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f?=^^
^^
THE
LECTURES
OF
SIR ASTLEY COOPER, BART. F. R. S,
SVRGEON TO THB KINO, &c. Sec.
ON THE
PRINCIPLES AND PRACTICE
OF
* Wflergi ;
WITH
ADDITIONAL NOTES AND CASES,
BY
FREDERICK TYRRELL, ESQ.
SURGEON TO ST. THOMA»'s HOSPITAL, AND TO THE LONDON
OPHTHALMIC INFIRMARY.
VOL. III.
LONDON:
PRINTEJ) FOR W. SIMPKIN AND R. MARSHALL,
stationers' hall court. 1827.
PRIMTBD BY 8. H0LD8W0RTH, 60, PatCroofter Row, fiOndoo.
CONTENTS.
LECTURE.
XXXI.
XXXII.
XXXIII.
XXXIV.
XXXV.
XXXVI.
XXXVII.
XXXVIII.
XXXIX.
XL.
XLI.
XLII.
XLIII.
XLIV.
XLV.
PAGE.
On Hernia 1
On Irreducible Hernice . . 17
Account of the Operation continued ..... 48
On Femoral Hernia ... 84
On Umbilical Hernia . . 107
On Wounds 149
0;^ Contused Wounds . .162
On Wounds of Arteries .181
On Wounds of Veins . . 205
On Wounds of Joints . . 250
On Dislocations .... 270
On Dislocations of the Elbow 326
On Dislocations of the Hip 363
On Dislocations of the Kiiee 43 1
On Dislocations of the Ankle 47e3
ERRATA.
Page S, line 28, /or lamina, read lamina.
Page 64y line 24 au<l 25, for the seat of strictare, read the stricture.
Page 80| line 15, for pioas, iliacas interaas, remi pectineiu,
adductor longus. Pago 118, line 16, for round, r«a<f wound. Page lt4| line 22, for mniclet, read muscle. Page 101, line 8, for head, read hand. Page lOS, line 0, for ulcerated, read ulcerative. Page 802f line SO, for can, read cannot. Page 817, line SO, for scapaln, read scapula. Page 820| line IS, for crepitas, read crepitus. Page 80P| line 20, for faeture, read fracture. Page 470, line 1, for Bayer, read Boyer. Page 4749 line It and 90, for maledns, reitd malleolus. Pagi 478, line 8, ditto ditto.
LECTURES,
SfC.
LECTURE XXXI.
ON HEKNIA.
This, of all the diseases to which the human import- body is liable, demands, upon the part of subject, the surgeon, a large share of anatomical knowledge, great promptitude and decision, and the utmost s|e91 and dexterity in ^tfae performance of ?in jB^ieration, when it is ren* dered necessary,' by a defeat of the means employed {0 its deduction. In other impor- tant cases; ^coilsultations may be held, or the patient he sient to a distance to obtain the advantage of the test opinions ; but in hernia the fate of the patient is decided almost upon the instant, and an hour's delay may turn the scale of success against the surgeon, and % destroy the prospect of safety on the part of the patient.
VOL. iir. B
DtfiniUoB. A hernia is a protrusion of any viscus from its proper cavity ; but the term is pryicipally applied to the protrusions of the abdominal viscera, to which it is at present my intention to confine my description. Abdomen The abdomen is particularly liable to such lyiuweto protrusions, on account of the moveable state traiiont?' of its viscera, of the natural openings from it to give passage to blood vessels, and unna- tural apertures from deficiency of structure, and from the great changes in bulk to which the omentum and mesentery are subject; so that instead of being surprised at the fre- quency of its occurrence, it might be expect- ed , from a knowledge of anatomy, that it would occur in many more instances than it does. iMiril* ^^ There are several genera of abdominal hernite; four of which, however, are more frequent than the others ; viz. the inguinal, the femoral, the umbilical, and the ventral ; but bcfiide these, there is a hernia through the iMchiatic notch, one through the fora- men ovale, a pudendal, a perineal, a vagi- nal, occraNionally a protrusion takes place thrr)Uf(h tho diaphragm, die kidneys have heon (bund in a swelling in the loins, mul thc) NniiiU intestines have been seen lietwtidu tho laminit' of the mesentery and ninNocutlon ; but, to tho two latter, the term \umm IN NiJurooly Ntriclly applicable.
Of Inguinal Hernia.
Of this hernia, there are four different onngamai
hernia.
species : —
1. The oblique taking the course of the Spedcs. spermatic cord.
2. The direct descending from the abdo- men immediately through the external abdo- minal ring.
3.. The congenital, or a protrusion into the tunica vaginalis.
4. The encysted hernia, composed of a* bag and protrusion suspended in the tunica vaginalis.
Before any hernia is formed, unless in contained wounds, laceration, or deficiency of structure, a bag of peritoneum precedes the protruded viscera, and forms a sac in which they are contained, and which is usually called the hernial sac. This protrusion is somewhat thicker than the natural peritoneal lining of the abdomen, the pressure of the viscera leading to an interstitial deposition into the membrane ; it is not placed loosely in the parts into which it is protruded, but it ad- heres by cellular tissue to all the surrounding structures.
B 2
in a sac.
/
/ t
Of the Oblique Inguinal Hernia.
This is also called bubonocele when seated in the inguinal canal ; and, when it further descends, is named scrotal ; as it takes the course of the spermatic cord, it might well be denominated spermatocele.
Before I describe the course and dissec- tion of this hernia, it is necessary that I should say something on the structure of the inguinal canal, and of the course of the sper-^ matic cord« e The spermatic cord first quits the abdo* h men mid- way between the anterior superior spinous process of the ilium and the sym- phisis pubis; it here passes between two layers of the fescia transversalis, the anterior layer of which is fixed in Poupart's ligament, whilst the posterior layer descends behind Poupart s ligament, and assists in covering the femoral artery and vein, and in forming the crural sheath ; above the passage of the spermatic cord, the tvro planes of this fascia unite, and form a lining to the transversalis muscle, extending as far as the diaphragm. As the cord penetrates between these two planes, which form the internal ring, a thin layer of fascia unites it to the edge of each. No part of importance is situated between
the anterior superior spinous process of the ilium, and the point at which the spermatic cord passes through the fascia transversalis ; but between the latter place and the pubes, the epigastric artery takes its course. This Epigastric artery is situated from one-fourth to one- ^^' half an inch upon the inner side of the inter- nal abdominal ring, or passage of the sper- matic cord, from the abdomen> and it passes to the inner part of the rectus muscle. The external iliac artery and vein are directly behind this internal abdominal aperture, and this opening is the beginning of the inguinal canal, in which the spermatic cord is next continued. j
The inguinal canal is bounded anteriorly Bounda-
rics of the
by a superficial fascia from the abdominal ingainai
canal
muscles, and by the tendon of the external oblique ; posteriorly, by the fascia transver- salis, and by the tendon of the transversalis muscle ; above, by the edges of the internal oblique and transversalis muscles, and be- low by Poupart's ligament; the canal is about two inches in length, and terminates at the external abdominal ring.
The external abdominal ring is formed External by two columns of the tendon of the external °^' oblique muscle united by fibres from Pou- part's ligament; the upper column is in- serted into the symphisis pubis, the lower
B 3
6
column into tiie tuberosity of the pubes, the pubes bounds the opening below; between these columns the spermatic cord passes; and from the edge of the ring, as well as from the surface of the tendon of the exter- nal oblique muscle, a thin fascia descends, uniting the cord to the edges of the opening, and passing down upon it to the tunica vagi- nalis; this fascia is then situated between the skin and the cremaster muscle ; which muscle arises within the inguinal canal from the internal oblique muscle; it descends with the spermatic cord, and passes through the external abdominal ring ; spreading over the fore and lateral parts of the cord as far as the tunica vaginalis into which it is in- ' serted. sperniaUc Behind the fascia and cremaster muscle
coro.
the spermatic cord is found passing to the testis ; it is covered by the tunica vaginalis, and is composed of the spermatic artery and vein, absorbents, and nerves, with the vas deferens and an artery accompanying it. Origin and The obliquc inguinal hernia first enters
coarse or ,
the hernia, the Upper Opening of the inguinal canal, or internal abdominal ring, so that at its com- mencement it is placed just mid-way be- tween the anterior superior spinous process of the ilium and the symphisis pubis, and close above Poupart's ligament; it has the
I
I
I
spe^au^ord behind it, and the epigastric artery to its inner side : when in the inguinal canal it is about two inches in length, and is covered anteriorly by the superficial fascia of the external oblique muscle and by the tendon of that muscle, the inferior edges of the internal oblique and transversalis muscles form an arch over it ; the cremaster muscle covers it partially; it has a thin slender covering ft'om the edge of the internal ring ; the fascia transversalis, strengthened by the tendon of the transversalis, is situated behind it, and to its inner side \ and Poupart's liga- ment is placed below it.
Having descended through the inguinal AppeBmi canal, it next emerges at the external abdo- nai ring. minal ring, and it is then usually denomi- nated scrotal hernia.
Its increase being then much less re- i strained than before, it descends on the fore r part of the spermatic cord to the testicle, at the upper part of which it usually termi- nates.
Upon dissecting this hernia below the ex- ' ternal ring, there is found covering it ;— ' first, the fascia of the spermatic cord, de- rived from the external oblique tendon and the edge of the abdominal ring; this substance is dense, and forms a strong covering, which often been mistaken for the hernial sac ; II 4
L has ofte:
8
when this has been divided, the cremaster muscle becomes exposed, covering the fore and lateral parts of the hernial sac. The cre- miaster muscle is thicker than the fascia of the cord, and its muscular texture is easily distinguished in the living body. On cutting through this muscle, and a dense cellular tissue, the hernial sac is laid bare, united on the fore part to the cremaster muscle, and on the posterior part to the spermatic cord, rest- ing below upon the tunica vaginalis of the testicle. Usual con- The usual contents of the hernia are either
tents of the . , -i* , i. . .
•«c. mtestme or omentum; if the former, it is
called enterocele ; if the latter, it is denomi- nated omental, or epiplocele. In the young, omental hernia is rarely met with, it being generally intestinal, for this obvious reason, that the omentum in the young subject covers only the superior iabdominal viscera.
Varieties of Obtiqtie iHguiiml Hernia.
UkiP^Uk Prom the description which I have given of thiiA hornia» it is clear that it may vary in longtht tVom the upper ring to the testicle, luul couHoquoutly that it is sometimes seen (UHMipyinp: only the inguinal canal.
*m^Mmi»« ill Ht>uic cases the hernia is so large as
reach the knee, but in ge does not exceed two fingers' breadth, and barely reaches to the upper part of the testicle ; its bulk depends considerably upon the time which it has existed, upon the degree of relaxation of the patient, and upon his inattention to the disease.
tl have seen the pylorus descend to the Umuuii tnouthof the hernial sac. The urinary bladder sions. is also occasionally situated within it;* and we have an excellent specimen in the col- lection at Guy's Hospital, of an inguinal hernia in the female, where the ovarium and falopian tube are protruded into the hernial sac.f
The spermatic cord is usually situated usuai
Biliiation ■
behmd the hernial sac ; but m one of the oftiie«per. i
• nr . r^. rr« • n<aticCOrd,J
preparations m the Museum at St. Ihomass "
Hospital, the cord is divided, the vas deferens passing upon one side, and the spermatic artery and vein upon the opposite side. I have seen also the spermatic artery and vein
■ passing over the fore part of the sac, while
I the vas deferens passed behind it.
When the cacum or urinary bladder are protruded, re is not a complete peritoneal sac ; but it is deficient !jlt that part of cither viscus not naturally covered fl
t See hernia in the female.
10
Symjrioms of Inguinal Hernia.
DistiitcUon It is discriminated from other diseases by diseases, the following marks : — it gradually descends from the abdomen in the course of the sper- matic cord : it usually protrudes in the erect, and retires when the patient is in the re- cumbent posture : it dilates upon coughing, and upon all exertions of the abdominal muscles : flatus may be often felt in it when it is intestinal, and it retires with a gurgling noise : when omental it has a doughy feel, is much less elastic than the intestinal hernia, and retires into the abdomen more slowly ; the intestinal is accompanied with costiveness, and with pain across the abdomen; the omental rarely produces any disturbance of the abdominal functions, when in the re- ducible state ; the hernia of the bladder is distinguished by the diminution of the swelling during the evacuation of the urine. The following are the principal marks of distinction from the diseases with which it is most likely to be confounded. From hy- From hydrocele, by that disease beginning
urocele* ^
below, and gradually ascendmg, by its trans- parency, by its fluctuation, its pyriform shape, its involving the testicle, and by the want of dilitation from coughing ; however, there
II
is an exception to this, if the hydrocele enters the upper part of the scrotum, when it sometimes dilates upon coughing, and the only means of distinction are in its history, its transparency, and its fluctuation. From hydrocele of the spermatic cord, it From hy-
drocclc o^
is with great difficulty distinguished, unless the cord, the hydrocele emerges from the external ring, when its transparency indicates its true nature. Hydrocele and hernia are sometimes com- Hemia &
. . . hydrocele
bined in the same individual, of which there sometimc|i
combined.
is a beautiful specimen in the collection at St. Thomas'sHospital ; a caseof this kind occurred to Mr. Thomas Blizard, on which he operated, and a similar one to Mr. Henry Cline ; in each case the water was in the first instance dis- charged, and then the hernial sac became exposed behind the tunica vaginalis.
Hydrocele is also connected with hemia, when there is water in the abdomen ; and I have tapped a hernial sac in ascites for the discharge of the accumulated water, and it is the best mode of operating in such a case, when it is quite certain that neither the omentum or intestine are descended, and that you can decide by the transparency.
Hemia is known from haematocle, by the From hie.
•^ matocele.
latter being usually the result of a bloy, and by the ecchy mosis which at first accompanies
12
it, by its not extending to the inguinal canal, by its not dilating upon coughing, by the bowels being undisturbed, and by its not returning into the abdomen. Fromdis- Hemia is little liable to be confounded
eased tes- ticle, with disease of the testicle, the history of the
swelling, its form, the distinctness of the spermatic cord, the want of intestinal obstruc- tion, the absence of dilitation on coughing, and its not returning into the abdomen, are sufficient marks of the latter disease. Hernial I havc sccu, howevcr, diseased testicle
sac con- ^ '
nected to complicated with hernia, and have twice been
the sper- *
maticcord. imdcr the necessity of dissecting the hernial sac from the spermatic cord, during the extirpation of the diseased testicles. In one case I opened the sac unintentionally in the operation, but it did not prevent the patient from doing well.
Acute in- The acutc inflammation of the testicle is the
flammation i • i t t
of the tea- only State which I have known confounded
tide, mis- .11.1 1 r ^
taken for With hcmia ; the tenderness of the part, the
hemia
swelling extending up the cord, and the vomiting accompanying the disease, led to a doubt which could only be removed by a knowledge of the history and progress of the complaint. Fronivari- The discasc with which hernia is most frequently confounded is varicocele, or en- largement of the spermatic veins ; this is a
13
very common complaint, it occurs most fre- quently upon the left side, and is supposed to be founded in the termination of the left spermatic vein, at right angles with the emulgent. It sometimes dilates upon cough- ing; it appears in the erect, and retires in the recumbent position. It is distinguished from hernia by its feel, (which resembles that of a bag of large worms,) by its being unattended with intestinal obstructions, by placing the patient in the recumbent posture, and empty- ing the swelling into the abdomen; then pressing the finger upon the external ring to prevent any visceral descent, by which the free return of blood by the spermatic vein is, obstructed, and the swelling re-appears when no hernia could escape.
I have more than once known a truss ap-. Tnis« ap- plied for this disease, and in one instance to varicocele, the «on of a medical man, by his father.
Inguinal hernia occurs more frequently This hernia upon the right side than the left, probably qnent on because the greatest exertions are made of sWe. the right side, from the preference we give to the use of the right arm, two-thirds of inguinal hernia are upon the right side.
Causes of Heimia. The loose connections of the jejunum, \III^q^^^{
viscera.
14
ilium, colon, and omentum, giva a proneness to the disease. The other viscera are rarely found in hernia.
^enures. '^^^ natural apertures for the passage of the blood vessels also lead to the ready production of hernia.
Maiforma. Malformatious also give rise to hernia, as when the abdominal ring is unnaturally large. Some species of hernia are originating en- tirely from malformation, as the phrenic and ventral.
Increase of Great incrcasc of the omentum or mesentery
omentum ^ ^
ormesen- Jn obcsity Icads to hernia. Pregnancy pro- duces it. Violent exercise frequently occa- sions it, by forcing the viscera through the apertures. Great exertions of the abdominal muscles in lifting weights, more especially in the stooping posture, is a common cause of this disease, as also coughing or straining violently. Flatulent food, and food difficult of digestion, tends to produce hernia. Great wasting of the body, by leaving the abdominal apertures relaxed, is also a cause.
Thus, then, the parietes give rise to hernia, by their formation, malformation, and con- traction ; and the viscera by their pressure, and from the changes they undergo, espe- cially in old age.
cumate. The lax state of fibre, induced by a long residence in warm climates, may also be
15
mentioned as pre-disposing to the formatioa of hernia.
Of the Reducible Hernia.
A hernia is said to be reducible when it can be returned into the cavity of the abdo- men.
In order to put the patient into a state of Treatment, safety, and to prevent a future descent, a truss is to be applied. A truss is required for the smallest hernia, as the danger from this disease, is in an inverse ratio to the size of the tumor.
Salmon and Ody's truss is most easily Salmon 4c
^ , ^ Ody's
worn, and most appropriate for recent and truss, small hernia; but the objection to it is, that it cannot be worn during the night, and there- fore the patient requires one of a different kind in bed. They are, however, excellent trusses. Egg's truss, and those of the common kind. Egg's
, truss.
are worn day and night, and make a steady pressure on the part. Hernia, very difficult to support, are best P»ndin's
iriiss*
prevented protruding by Pindin's truss, which has no springs ; I have seen it succeed when no other answered the purpose.
To obtain a truss, it is only necessary to send the measure of the pelvis to the instru-
Effect of a truss.
16
ment maker. The principle upon which the pad of the truss is to press, is the whole length of the inguinal canal ; that is, to reach from the upper to the lower ring.
Will this cure me ? the patient inquires : Yes, if he be young, assuredly ; if old, I have known it do so in a few instances. How long must I wear it ? to which the answer is, A year after the hernia does not appear when the truss is removed for a few hours, the patient at the time taking his usual exercise. Am I to wear it at night as well as by day ? Yes, or you have little chance of being cured ; and there is otherwise danger of strangula- tion.
In consequence of wearing a truss, the sac falls into folds, and gradually contracts ; but more particularly at its orifice. If hernia be complicated with hydrocele from the abdo- men, both diseases are cured by wearing a truss. 1
Danger of Giving up the use of a truss before the
leaving off . i ^ • j p
the truss, cure IS Complete, is very dangerous ; as from the contraction and thickening of the mouth of the sac, there is more liability to strangula- tion. The shut sac of a hernia will sometimes produce hydrocele by the secretion from its inner surface.
17
LECTURE XXXII.
IRREDUCIBLE HERNIA.
It is SO called when it is uninflamed, but does not return into the cavity of the abdo- men; and it acquires this state from the following causes : —
1st. Growth of the protruded omentum or Cansc*. mesentery, rendering it too large to return through the orifice of the hernial sac.
2nd. Adhesion of the omentum, mesentery, or intestine, to the inner surface of the sac.
3rd. Membranous bands formed across the sac by adhesion.
4th. Omentum intangling the intestine.
6th. . A protruded ccecum, in which the in- testine adheres by cellular membrane behind, and the sac exists only on the fore part.
6th. A portion of omentum suddenly pro- truded, of too large a size to be immediately returned.
Danger of Irreducible Hernia.
If intestine be protruded, it is sometimes Rupture of
-if 1-1 1 X intestine.
ruptured from a blow upon the tumor.
VOL. III. c
18
UabiUty There is a constant liability of strangula-
ution. tion from any slight additional protrusion.
Formatioii I havo known an abscess form in the pro- of abuceu. , *■
traded omentum, and prove destractive.
Treatment of Irreducible Hernia.
Nothing can be done in some of these To give cases, but to give support to the part by the application of a laced bag truss. When itarises from obesity, attention to diet, and to the means of reducing the patient, may sometimes succeed, for I saw a gentleman v^ho be- came reduced from dropsy in his chest, and had a hernia return, which had been for a long period irreducible.
Apparently in irreducible omental hernia of recent formation, I have known the application of ice succeed when there was not any inflam- mation proceeding, as far as could be ascer- tained by the pain.
A physician who had an omental hernia irre- ducible for a fortnight, had ice applied to it tfarough the medium of a bladder, for four days, during which period it gradually re- turned. In another case the same treatment was successful ; and it appeared to me that the ice was serviceable, by occasioning a con- stant contraction of the skin, and supporting moderate pressure on the part.
Use of Ice.
OftkeStranvtiiated Oblique Inguinal Hernia.
When the parts protruded into the hernial ■?' sac cannot be returned into the abdomen, and the pressure is so great as to prevent the free circulation of blood through the vessels of the protruded viscera, the hernia is said to be strangulated, and the following symptoms are usually present.
The patient directly feels violent pain in s; the region of the stomach, as if a cord were bound tightly round his body ; and this is followed by frequent eructations wlilch con- tinue until the strangulation be removed ; — there is a great desire for a fcecal discharge ; but the person only passes a small quantity of foeces from the large intestines. The tumor feels hard, and if it be intestine which has descended, it is often extremely tender to the touch. Vomiting soon occurs; first the patient throws up the contents of the stomach, afterwards bile, which is regurgitated from the duodenum ; and if it be a portion of the large intestine which is strangulated, fiscal matter is sometimes discharged from the stomach, as the symptoms become more urgent. The pulse is at first hard, and rather quicker than natural.
On the next visit to the patient, the vomit- p jog is more urgent, the coRtivcness remains, t
20
the abdomen is tense from flatulence, the tumor is harder and more tender, the pulse is more frequent, smaller, but still hard. Peritoneal Strangulation still continuing, the abdomen tion. becomes extremely tender to the touch, on account of the peritoneum becoming inflamed, at the same time the pulse is very small, thready, and frequent: in addition to the other symptoms, hiccough occurs, the vomit- ing and costiveness continue, the tumor be- comes more tense, often is inflamed upon its surface, and now and then the marks of the fingers, when pressed upon it, remain. Laststage. In the last stage, the pulse frequently intermits, the patient is covered with a cold perspiration, but his mind appears less de* pressed, and as his pain is less, he has more ^expectation of recovery. Expiaiia- With rcspcct to thcsc symptoms, the pain symptoms, in the abdomcn, and the vomiting, are at first sympathetic ; and the discharge of bile and foeculent matter afterwards is kept up by the anti-peristatic motion, which takes place above that portion of intestine contained in the hernia ; perhaps the valve of the colon may in some instances be imperfect, by which the vomiting of foeculent matter may be accounted for ; the obstruction to the passage of the foeces by the usual course, is prevented
21:
by the strangulation of the intestine; ^e tension of the abdomen arises at first from accumulation of flatus, and subsequently from peritoneal inflammation, which also occa- sioDs the tenderness of the abdomen ; the hiccough has been considered as an indication of gangrene ; but I have known operations performed in many cases, after its appearance, and the patients have done well, the contents of the hernial sac not being found in a gan- grenous state ; the tension of the tumor is caused at first by accumulation of blood from obstructed circulation in the part ; afterwards it increases from effusion into the hernial sac, in part of serum, and part of fibrin.
It sometimes happens just previous to the Evacuaiioni patient's death, that he has evacuation from •'^»'''- his bowels, and this probably takes place from the tension of the aflTected parts being lessened by the approach of dissolution.*
* I have iotroduced the following oase as presentiDg; some unusual peculiarity respecting the evacuation from llie bowels, during the continuance of the symptomH of 3trtnguiation.
Thomas Davis, a porter, aged tifty-nine, (who had for two years been subject to hernia,) on Saturday, the ISth of March, 1825, after making some unusual exer- liODs, found that the swelling formed b^^the hernia had much increased in dize, and resisted his repeated at- tempts to reduce it. On Sunday morning, the 13th, he experienced pain in (he tumor, unA in the abdomen,
22
va»^ The symptoms of strangulation do not al¥fays continue equally severe; but for
which was soon followed by vomiting. In the erening, as he did not get better* he apjdied to a sargeon in hia neighboorhoody who for some time tried the taxis, but ineffectoally ; in consequence of which he was taken to St. Thomases Hospital. On examination, a femoral her- nia was discovered on the right side, about the size of aa egg, hard, and tender to touch. He was bled, and placed in the warm bath, and when he appeared hkat, the taxis was again employed, under which the hernia became a^arently lessened, but not completely di^ersed. As he was not perfectly certain of its being quite rednoble before the existing symptoms, I was in- dueed to nder an enema; and directed, in case of a free disdiarge from the bowels after its use, that some purgative medicine should be given by the month. He had a copious motion from the enema, and in conse- quence some |m11s of cathartic extract and calomd, were given, after which, during the night, he had three more abuidant motions. On the following morning, (tiie 14th,) however, I found that the tumor had regained its former magnitude and tension ; that it was very tender, as also the abdomoi, and that he had hiooough, with occa-
lal vonuting. Under these curcumstances, after » lurtlMr short trial of the taxis, and which made no im- presaion upon tiie swelling, I performed the <yeratkMi> The hernial sac was surrounded witii enlarged glands ; it contained a little fluid, and a portioa of mtestine, which was highly inflamed and peifectly incarceralBd. This was bbe^iled and leplaeed in the cavity of the abdoHMn without much dittculty, and the wound was dressed as Qsuai.
In consequence of much tenderness of the abdomen.
23
short intervals the patient is often nearly free from suffering, and then again the symptoms become violent.
Dissection of the Hernia.
If gangrene has not taken place, a small Before the quantity of serum is found under the skin, ment of
gangrene*
and in the hernial sac a coffee coloured effu- sion of the same nature ; this is usually more
on preasure, in the evening, I ordered, Hirud, xxiv. abdom* 7ot. Papavei is, et Tinct. Opii guU. xxr.
16th. Less pain and tenderness of the abdomen. He had slept comfortably, (pulse 80, and feeble,) but he was troubled with occasional sickness; the hiccough had sabsidedr ordered. Mist: Efferr: pro re nata. c Tinct : Opii gutt v« Sin. dos, tf the sickness continued. At two o'clock he was seized with dyspmea and more frequent vomiting, but had no increase of tenderness. Ordered enema commun. c Oleo Ricini, and to continue the mixture. The enema was repeated in the afternoon, but did not produce any evacuation, and late in the erening he died.
On examining the body after death, I found the pe- ntoneum much inflamed^ and exhibiting marks of pre- vious disease, there being old and firm adhesions. The portion of intestine which had been strangulated con- sisted of a complete fold of the ilium, including the idiole diameter of the gut; it had still the mark from the stricture upon it, and was ranch more discoloured than any other part.— T.
c 4
24
abundant when intestine has descended, than when omentum alone is protruded. The intes- tine is of a dark chocolate brown, and has its surface covered by a coat of adhesive matter, by which it is in part glued to the hernial sac, but not very firmly. Directly under the seat of stricture, the intestine has suffered particularly, and often gives way to very slight pressure of the fingers. If omentum has protruded, it is found red, and somewhat harder than natural, ^irin^f*!!" W^^^ gangrene has taken place, the skin iuH'Mrro«j. Qvcr the tumor is emphysematous, and retains any marks made by the pressure of the fingers. When the sac is opened, a highly offensive wmoll is omitted, and if intestine be protruded, it In of a deep port wine colour, and has on itn Nurfuce numerous greenish spots, and its tdxturo ifi so altered, that its surface looses \tn brllliuncy, and it gives way to very slight prc^NNUre. Omentum, when gangrenous, is of li (Ittrk colouri easily breaks, and feels some- whftt liko a portion of lung, crackling under I hit prcsuNurc of the fingers. AiMiKNf <J" opening the cavity of the abdomen, the fftlli* p^irltorieum i« found inflamed, red lines can "*•"** hit trWJCcl on the intestines, where they are lyhiK In (sontact^ and here adhesions are forifiiid fVoni cfiusion of fibrin. The intes- Uui'f* u\v lmnu»n«ely distended with flatus.
25
If omentum alone has descended^ the Symptoms symptoms are usually much less severe, and from the patients live longer than when the hernia heraia. is intestinal.
Seat of Stricture.
In old and large hernia, the seat of stricture External is at the external abdominal ring, but in by far the greater number of cases, the stricture is seated at the orifice of the hernia from the abdomen, at the internal ring, and here it is Most fre- occasioned by the semi-circular edge of the thelnter- tendon of the transversalis becoming thicken- °* "*^' ed, as well as that portion of the hernial sac pressed on by this tendon.
I have also seen the stricture mid- way ^". ^f *"■
•^ gmnal ca-
between the two rings, and it appeared in n**- these cases to be occasioned by a thickening of the sac, which, by the exertions of the patient, had been frequently forced down to the external ring, and had again retired into the inguinal canal. There is also a beautiful specimen in the stricture
*■ from mem-
collection at St. Thomas's Hospital, showing bnmons
a stricture formed by a strong membranous
band within a hernial sac ; the patient, from
whom it was taken, had been operated on by
one of the surgeons of that Hospital ; and
26
although the inguinal canal had been freely opened, yet the surgeon could not return the intestine without doubling it back, which he did, and brought the integument together over it by sutures* On the day following the operation, the intestine peeped^ out between the sutures, and was in a gangrenous state, and the case terniinated fatally* Omentom Another occasion of stricture is from omen*
entanpuiig
intestme. tum entangling the intestines, an excellent example of which I operated upon in the case of a patient of Mr. Richard Pugh, of Grace- church Street.
s^tSSgiSl. The cause of strangulation is generally a
^on* sudden protrusion of an additional pcMrtion of intestine or omentum. The eating of vege- table food so as to produce flatulence, or very indigestible animal matter, is a frequent cause.
Danger in A Small hernia is much more easily stran-
hernia, gulatcd than a larger one.
Of the Treatment of Strangulated^ Oblique, ^
Inguinal Hernia.
Danger ef As the danger is entirely consequent on the
tion. ^ pressure of the stricture upon the protruded
viscus, the great object of. the surgeon is to
return the protruded part into the abdomen,
as quickly as he can with safety.
27 The operation for effecting this reductioil TaiLU,and
_ . mode of
is called the taxis, and it is performed m the employing following manner : — ^The patient is placed in a recumbent posture, with his head and shoulders a little elevated, and his thighs at right angles with his body. His bladder should be previously emptied. The surgeon^ standing on the right side of the patient^ passes his right hand down between the thighs, to grasp the swelling, and with his left thumb and fingers he kneads the hernia at the upper part of the inguinal canal. Slight pressure and elevation of the scrotum, with a kneading of the upper part of the hernia, are used for the purpose of returning a small portion of the protruded parts, when the whole usually follows without difficulty. The pressure should T)e continued a quarter of an hour, at least, for I have known it succeed after a trial of twenty minutes. The object is to use a continued steady pressure, and not violent means ; which, in several instances which have come under my obseryatioji, have caused a rupture of the intestine, so that, in the operation, as soon as the sac has been opened, fceculent matter has escaped. If the strangulation has been long continued,the em- ployment of force becomes doubly dangerous. The intestinal hernia is more easily reduced [ntestinai
*^ hernia
than the omental, it returns more suddenly, mostcMUy
28
aad with a gurgling noise^ but sometimes the f tenderness of the part is such as to forbid the immediate employment of the taxis. Case. I attended a young man, with Mr, Croft,
in the city, who, from tenderness, could not bear the swelling to be touched. I ordered ice to be applied, and in seven hours the hernia returned without the aid of the taxis.* Bleeding, If the taxis does not succeed, bleeding of. from the arm should directly be had recourse
to. In all cases it is best to employ it, on two accounts. First. — By the faintness which it produces, it frequently becomes the means of assisting the return of the hernia. Second. — If the hernia be not reduced, it saves the pa- tient from the danger of peritoneal inflamma- tion, which an operation is tikely to produce. I never saw it do harm ; and have in many cases witnessed its extreme efficacy. In
* In the month of May last, I was requested to see a publican in the Borough, who was suffering from the strangulation of a ventral hernia, about the size of an orange, seated in the linea alba, between the ensiform cartilage and umbilicus. The tumor was so extremely tender, that he could not bear me to make the slightest pressure upon it. I directed ice to be applied, which was kept on for three hours; after this period I succeeded easily in reducing the hernia, which had been strangu- lated nearly two days. — T.
29
strong athletic persons it should be carried to a very great extent ; in the old and infirm^ little need be taken away.
From neglect in bleeding, the patient very conae- often dies, four or five days after the opera- not bleed- tion,from peritoneal inflammation. The object *"** is to produce a fainting state, otherwise the bleeding does very little good.
Persons are very often deceived in peri- PuUe de-
. ceptive.
toneal mflammation, on account of the small thready pulse with which it is accompanied ; but this, instead of being a bar to the abstrac* tion of blood, only indicates a greater ne- cessity for it. I shall have occasion to mention the great benefit derived from it, in a case in which hiccough was extremely violent.
The next object which the surgeon has in ^^ view, when bleeding and the taxis fail, is to put the patient in the warm bath, which is of no use unless it occasion faintness ; and since I wrote my work on hernia, I have had several opportunities of witnessing its effi- cacy in assisting the reduction. If there is not immediate convenience for its use, no time should be lost in procuring it, as there are other and more powerful remedies.
The most powerful agent in the treatment Tobacco
. . glyster.
of Strangulated hernia, is the tobacco glyster ; for if when the patient is under the influence of this remedy, the hernia cannot be returned
30
by the taxis, there is but little chance of any mode short of an operation succeeding. The manner of making it is to infuse one drachm of tobacco in one pint of water, and of this one half should be first thrown up, and ac-> cording to the efiect produced in twenty minutes, or half an hour, the other half may be injected, or not. This is the safest plan of administering the tobacco, it produces ex- treme languor and relaxation of all the fibrous structures, and is certainly the most potent remedy which is employed, but at the same time requires the utmost caution in its use. Fatal ef. I havc sccu a paticut with strangulated ueco. hernia expire under the effects of tobacco, which had been used in the quantity of two drachms, without reduction of the hernia ; he was placed upon the operating table, but as his pulse could scarcely be felt, his coun- tenance showed extreme depression, and as he was covered with a cold sweat, the opera- tkm was not performed, and the patient died, as the assistants were removing him.
A girl who was sent to Guy's Hospital, by Mr* Tumbull, surgeon, had a single drachm of the tobacco in infusion injected, to assist the reduction of a strangulated hernia. She M>on after its being administered complained of violent pain in the abdomen, and vomited. Thft berDia was reduced, but she died in
Case.
31
thirty-five minutes after the use of the tobacco^ and evidently from its effects.
Mr. Wheeler, senior, of St. Bartholomew's Hospital, told me he had known it destroy life, but prudently employed it in the way that I have recommended ; it is the most efficacious of the remedies proposed for the reduction of hernia.
The effect to be wished for from the use of Beneficial
etfecU of
tobacco, is a universal relaxation, so that the tobacco. patient has not power to exert any of the voluntary muscles ; when this is produced, a hernia may be sometimes reduced with very liUle force, after having previously resist- ed a firm and continued pressure. Under the influence of tobacco, hernia, which has before its employment felt tense, will be- come soft, and this is not occasioned by any partial reduction of the hernia, but only by the force of circulation being for a time greatly diminished.
I have several times known the application coid. of cold succeed in reducing a hernia, and it has this great advantage ; — ^that it arrests the progress of the symptoms, even when it does not ultimately succeed; therefore, when an operation cannot be immediately performed, it should always be employed. Ice broken into small pieces and put into a bladder; or water cooled by adding equal parts of
32
muriate of ammonia, and nitrate of potash to it, are the most convenient modes of pro- ducing the desired effect. I have known the cold produced by the evaporation of spirits of wine and water, succeed in reducing a hernia.
Caution iu It is very improper to apply ice in such a
ice. manner that the patient or his bed clothes
become wet as the ice melts ; it is also wrong to continue it upon the part for a long time together, as it may occasion sloughing, as occurs from the eflfects of frost bite. A case in which sloughing was produced in this way, was attended by Mr. Sharp, and Mr. Cline, who had directed the application of ice over a strangulated hernia, and continued it for thirty-six hours. The part, to the extent of four inches, froze, became hard and white ; the hernia was reduced, but soon after the removal of the ice, the part thawed, becoming red and inflamed ; in about ten days it assumed a livid hue, and sloughed to the extent that it had been frozen.
Purga- Purgatives used formerly to be very much
given, but are now little employed. Calomel given by the mouth, and a strong enema of the compound extract of colocynth, sometimes are useful.
Fonienta- If the parts be exquisitely tender, fomen- tations may be employed, which if long
tives.
tioiis
33
continued, may by their relaxing effects an- swer the same purpose as the cold.
Of Direct Inguinal Hernia.
Sometimes a hernia protrudes nearer to the pubes than that I have just described, des- cending from the abdomen immediately behind the external abdominal ring, and having the epigastric artery situated on its outer side.
Mr. Cline first observed this species of First ©b- hernia, in opening the body of a Chelsea MrCWn/ pensioner, with Mr. Adair Hawkins, on the 6th of May, 1777. The hernia was on the right side, and the mouth of the hernial sac was situated an inch and a half on the inner side of the epigastric artery. I have myself witnessed several cases of this description.
I have carefully dissected this herriia, and course of. found that it passed on the inner side of the epigastric artery, and protruded through the external abdominal ring, under the fascia of the cord, pushing the spermatic cord to the outer and upper part of the tumor. I traced a covering upon it, formed in part by the tendon of the transversalis muscle, and in part by the fascia transversalis; beneath which is situated the hernial sac. The coverings of this hernia are, therefore, the integument,
VOL. Ill, D
34
the fascia of the cord, a part of the cremaster crossing obliquely the outer part of the swellings then the fascia and tendon of the transversalis.
r^^the '' ^^^^^® ^^^^ *^® oblique inguinal hernia obUque in not taking the course of the inguinal canal,
hernia. ^ ^ ^
but m protruding directly through the external ring^ and having the epigastric artery to its outer side, and in having but an im- perfect covering from the cremaster, and d, perfect one from the fascia transversalis and tendon of the transversalis united.
^ufhin "^^^ distinguishing marks between the
markf. direct and oblique inguinal hernia, are the situation of the spermatic cord, and the direc*' tion of the tumor ; in the first, the spermatic cord is on the outer and upper part of the swelling, and the swelling may be traced in a direction towards the umbilicus : — ^in the latter, the spermatic cord is situated behind the hernia, and the inclination of the tumor is towards the spine of the ilium.
Causes. The direct inguinal hernia may be produced suddenly from a laceration of the tendon of the transversalis, in which case the covering from this tendon will be found wanting.
Case. A gentleman applied to me, having a direct
inguinal hernia, which had appeared imme- diately after he had been thrown firom his
35
liorse, and had fallen with the lower part of the abdomen upon a post, by which accident I imagine the tendon of the transversalis might have been ruptured.
I have never seen this hernia acquire the size of the common inguinal hernia, and in most of the cases 1 have witnessed, the patients have had some disease of the urethra.
In a patient of Mr. Weston's, of Shoreditch, who had for a long time laboured under difficulty in passing his urine, 1 found six hernia of this description, of which I have given a plate. I also found several strictures in his urethra, and a stone lodged behind one of them.
Splclom
Treatment of Dii'ect Inguinal Hernia.
When reducible, the truss employed should i be longer than that applied for common in- guinal hernia, as the part at which the hernia quits the abdomen, is an inch and a half nearer to the pubes. The pad of the truss should not rest on the pubes, but press prin- cipally a little above the abdominal ring, otherwise the general form of the truss may be t^ same.
L hernia be irreducible, the means \ :
36
recommended for the oblique irreducible hernia will be proper.
stran^uia- When Strangulated, the reduction must be
ted, taxis, attempted in a different direction to that re- quired for the oblique. The tumor is to be grasped as in the oblique hernia, with one hand, while the fingers and thumb of the other hand are to be placed over the abdominal ring, to knead the neck of the swelling, and the pressure must be directed upwards and inwards, instead of upwards and outwards.
Case. In this manner I quickly succeeded in
reducing a direct hernia which had become strangulated, in a patient who was admitted into Guy's Hospital, for some other complaints. The hernia was small, it had the cord to its outer side, and could not be traced higher than the abdominal ring.
Hernia This hemia may apparently be reduced by
apparently , ./ i x .^ w
reduced, the employment of the taxis, and strangulation still exist; a case of this kind occurred a short time ago at Guy's Hospital. A man applied at the surgery, having a direct hernia strangulated, and the taxis was had recourse to, by which the gentleman in attendance thought he had succeeded in reducing the hemia, as he had pushed it through the abdominal ring. The symptoms of strangula- tion, however, still continued, and in two or three days the man died. On examination of
37
hi^ body, the hernia was found placed im- mediately behind the external ring, with a stricture still existing at the mouth of the 8ac.
Operation for Strangulated Inguinal Hernia.
When the means I have recommended when ne- cessary.
have been tried, without enabling the surgeon to reduce the hernia, or relieve the strangu- lation, it becomes necessary that an operation should be performed, to liberate the strangu- lated viscus.
There is but little danger attending this Butiituc operation, if the person upon whom it is to be performed be free from other disease. The cause of persons who have undergone this operation, so frequently dying, is not to be attributed to the operation, but to the degree of mischief which has taken place previously to its being performed.
When strangulation has existed for a long Gangrene, time, the contents of the hernia either become gangrenous, or in a state so nearly approach- ing to it, that they do not recover their proper 'functions, otherwise inflammation extends from the strictured portion to the viscera, within the cavity of the abdomen, and thus the surgeon has to combat with a
D 3
3g
severe di&ease after the removal strangulation. The danger is therefore in the delay, and not in the operation. Danger of Very frequently much time is unnecessarily lost, before an operation is proposed ; and too much cannot be said in condemnation of such practice. Apatient is submitted againand again to the taxis, and the swelling is rendered extremely tender, by being so often com- pressed, in the hope of avoiding an operation, until at length the rapid increase and urgency of the symptoms point out the impropriety of such delay ; and an operation is performed when but little prospect of success remains.
It is extremely important that the opera- tion should, if possible, be performed before the abdomen becomes tender under pressure. Distension of the intestines from flatus, often produces tension of the abdomen, soon after strangulation has occurred; but still the patient can bear pressure without experienc- ing pain ; but when he does complain of pain under pressure, it indicates the extension of inflammation to the cavity of the abdomen, which is likely to be much increased by the operation.
The progress of inflammation, and extent of mischief, are not always in proportion to the time that strangulation has existed, for the period between the commencements
J
tlOI
39
tlie symptoms, and the fatal termination, varies exceedingly.
A large hernia when completely strangu- lated, is more quickly fatal than a smaller one ; but the latter more frequently requires the performance of an operation, on account of the greater firmness of the stricture.
A hernia containing a portion of strangu- lated intestine alone, is more rapidly fatal than one containing omentum only ; and that containing both intestine and omentum, takes a middle course between the two above mentioned.
When a hernia has existed for a long time, and becomes strangulated, the attempts at reduction will be more likely to succeed than if it were of recent formation ; in the first instance, the parts are more easily relaxed, having been accustomed to repeated dilita- tion ; while in the latter case, the powers of
listance are much greater.
Also in very young, or very old persons, strangulated herniEe are more frequently re- duced, than when they occur at the middle period of life, during which the fibrous struc- ture is firmer, and the muscular strength greater than at any other period. In very old persons, also, the strangulation is not so rapidly fatal ; as long a period as twenty
lys have been known to elapse between
very old or young
^vdays have
40
the commencement of the symptoms, and the death of the patient.
Of the Operation for Inguinal Hernia.
Bladder to Prcvious to the Operation, the patient should
ed^and be directed to empty his bladder, and the
doused, integument upon the tumor and surrounding
parts, must be cleansed from the hair usually
covering it.
Position The patient is then to be placed upon a
tient. ^* table, about three feet six inches in height,
on his back, the shoulders should be raised,
and the thighs a little flexed towards the
body, so as to relax the abdominal muscles ;
the hams are to be brought to the edge of
the table, so that the legs may be allowed to
hang over it.
Operation. The surgcou should now place himself
between the patient's thighs, and grasp the
tumor with his left hand, so as to put the
integument covering it upon the stretch, and
then having a scalpel in his right hand, he
should commence the operation by making
an incision through the skin, on the anterior
part of the swelling, which incision should
be begun opposite the upper part of the
external abdominal ring, and carried down
to the inferior part of the tumor, unless the
swelling be of a large size. Besides the skin and
41
cellular substance,the external pudendal artery may be divided by this incision, as it alwayd crosses the sac near the abdominal ring. The hsemorrhage from this vessel may usually be stopped by pressure ; but if very troublesome, it will be necessary to put a ligature upon it. By this incision the fascia of the cord be- Fa»cia of
the cord
comes exposed, which generally forms the exposed, thickest covering of the hernia. This must be carefully cut through in the centre, so as to admit the entry of a director which is to be passed under the fascia, upwards to the ring, aod downwards to the extent of the external incision, that the fascia may be safely divided upon it.
«
Thus the cremaster muscle is brought into Crcma«tcf view, forming the next covering, which must"^ be opened and divided in the same manner as the fascia, and with equal care, and the cellular tissue beneath must be cautiously cut through.
When this has been completed, the hernial Hernial sac itself is laid bare, and the surgeon must ed. proceed with the utmost caution to open it in the following manner. He first nips up a small portion of the membrane on the anterior and inferior part of the tumor, between his fore-finger and thumb of the left hand, and slightly rolling the membrane between them, he easily distinguishes if any intestine or
omentum be included ; and if so, he r fresh portion. Being satisfied that he has only a part of the sac raised, he is to place the edge of the knife horizontally against it, and make an opening of sufficient size to admit the end of a director, which is then to be introduced, that the sac may be opened upon it. " In dividing the different coverings, a very - cautious operator will make more layers than I have described, being fearful of doing mischief which might be irreparable.
When the hernial sac is exposed, it has usually a bluish tint, and is semitransparent. If the contents be not adherent to the sac, it generally contains a quantity of fluid, and a sense of fluctuation may be usually per- ceived at the inferior and anterior part of it, for which reason this part should be first opened, as the intestine is there in the least
Immediately the sac is opened, this fluid escapes. If the strangulation have not ex- isted long, it is occasionally of a serous colour, but more frequently of a darker, or coffee colour, and sometimes it has an oflFen- sive smell.
This fluid is most abundant in intestinal hernia, and is in quantity in proportion to the bulk of intestine strangulated. If, how-
43
erer, the hernia be omental, or if the intestine adhere to the interior of the sac, little or no 8uid is found, so that it must not always be looked for as an indication of the sac being opened.
The sac being opened, the surgeon is en- abled to see its contents, which he must attentively examine. If both intestine and omentum have been strangulated, the latter is found above and anterior to the former ; in some instances covering the gut partially, in others completely.
If the hernia has not been long strangu- lated, the omentum has much of its usual charactef, being only a little darker than natural, and having its veins distended; but the intestine is found covered with a thin coat of adhesive matter, and is of a red colour. When the strangulation has existed for a long time previous to the operation, or when the stricture has been unusually tight, the intestine presents a dark brown chocolate colour.
The surgeon should now pass his finger into the hernial sac, and examine accurately the seat of the stricture, which he will find in one of the three following situations ; —
First.— At the internal abdominal ring, in the mouth of the sac. ^^ Second. — In the inguinal canal, an inch,
»
How eX' posed.
44
or an inch and a half within the external ring.
Third. — At the external ring.
ternSring] '^^^ ^^^^ frequent Seat of stricture is at the internal abdominal ring, from an inch and a half to two inches above, and outwards from the external ring, and it is occasioned by the pressure of the internal, oblique and transversalis muscles upon the mouth of the hernial sac, which becomes thickened, more especially on its pubic side.
Should the stricture be situated at this part, it has been thought necessary to divide the ex- ternal ring, and to slit up in part the inguinal canal, by dividing a portion of the tendon of the external oblique muscle, in order to give the operator a distinct view of the protruded parts, and to enable him to divide the stric- ture without danger to his patient. This may be done by passing the finger into the sac, through the external ring, as far as the seat of stricture, and then introducing a curved bistoury with a probed extremity between the upper part of the finger and the sac, and cutting through the tendon, superficial fascia, and integument, forming the anterior bound- ary of the inguinal canal.
Having thus exposed the contents of the hernial sac as far as the seat of stricture, the operator should insinuate the point of his
45
finger, or a director, under the stricture, between the sac and its contents at the upper part, carefully keeping the latter from turning over the finger or director. He should then nivWonof pass the knife for dividing the stricture upon tare, the finger or director, und^r the stricture, and by a gentle motion divide the stricture in a direction parallel with that of the linea alba, and to an extent sufficient to allow the finger to be easily passed into the cavity of the abdomen. The knife thould then be with- drawn in a careful manner. In this case I have adopted with advantage the following plan : — The sac being opened to the external ring, I have put my finger into it, and hooked down the sac ; I have then directed an assistant ^ to draw up the tendon of the external oblique at the ring, and hare thus been able to bring the stricture into view without cutting the ten- don of the external oblique to the upper ring.
The knife best adapted for dividing the Knife for stricture is blunt at its extremity for about a the stric- quarter of an inch, sharp for half an inch, and then again blunt, only cutting so far as is necessary to divide the stricture, without endangering the neighbouring parts.
The second seat of stricture is in the in- stricture
• • • •
guinal canal, and is formed by the sac itself guinaV"a.
nnl
in the following way:— a person becomes the subject of oblique inguinal hernia, and
the pressure on the neck of the hernial sac at the internal ring, creates a thickening of the sac at this part. From any sudden exer- tion or straining, which occasions a further protrusion, this part of the sac is forced into the inguinal canal, and when the patient is in the recumbent position, part or the whole of the contents of the sac being re- turned into the cavity of the abdomen, the portion of the sac which had been previously situated at the interna! ring, and had been thickened, again takes its former position. This occurs again and again ; but at length the sac becoming elongated, the thickened portion which had been originally placed at the internal ring, no longer returns to this situation when the contents of the sac are reduced ; but it remains in the inguinal canal, and may here at any future time be the cause of strjtngulation. How ex- When the stricture is thus formed, the
poied and ,
divided, surgeon should freely expose the contents of the hernial sac as far as the stricture, and then divide it in the same manner, and in the same direction as before described.
girictiirp Sometimes, but rarely, the seat of stricture
of the rx- II-
ciwii ring, is at the external abdommal ring, in which case the same plan of dividing the stricture should be adopted ; but it is not necessary to make so large an opening.
47
If the hernia be direct, it is to be re* membered that the spermatic cord is placed on its outer side. It is covered by the fascia of the cord, by the cremaster partially, and is contained in a sac formed by the tendon of the transversalis muscle, assisted by the &scia transversalis, beside a peritoneal sac, as in other hernia.
The division of the stricture directly up- Bcstdirec-
^ ^ tion for di-
wards is then applicable to every common vidingthe
stricture.
case of strangulated inguinal hernia whether oblique or direct ; it is equally safe with any other division that has been proposed, and the operation is by it more simplified than by adopting a different mode of dividing the stricture for each variety.
4S
LECTURE XXXIII.
tiiJ^^*' After having sufficiently divided the stric- viscera. tare, the surgeon should carefully examine the protruded intestine, particularly that part which has been immediately under the stricture, and ascertain whether the circula- tion becomes restored, which he may do by employing pressure to empty the vessels, and then observe if they be again immediately filled.
Should the circulation be free, he should then gradually and very carefully return the intestine by small portions at a time, until the whole is reduced. At this time the patient should be placed much in the same position as when the taxis is employed. Adhewons. When adhcsions have taken place between the intestine and sac, great care is required in opening the latter, as little or no fluid exists in it, to separate it from the intestine, which may be in consequence easily wounded. The sac being opened, if the adhesions be found long, and not very numerous, they may be divided to allow of the return of the protruded part. Sometimes these adhe- sions are only found at the mouth of the
, or are otherwise ]
irtial ;
1 either case-
they should be carefully separated, that the hernia may be completely reduced ; but the division of such adhesions, particularly at the mouth of the sac, is attended with con- siderable danger. Sometimes the sides of the fold of intestine which has been strangu- lated are found glued together : in this case it is best to separate such adhesion, if it can he easily done, as the free passage of the faeces is afterwards interrupted, if the intes- tine be returned doubled back into the abdo- men with such adhesion remaining.
Should the intestine be in a state of gan- Jnteitioe grene, it will have a foetid smell, the peritoneal «"»>■ surface will have lost its brilliancy, and be of a dark port wine colour, with greenish spots on it ; it will not possess any sensibility, and will easily give way under slight pressure.
Under these circumstances, the stricture Trcaiment
ofgaiigre-
should be divided in the manner I have de- nomime.. scribed, after which a free incision should be made into the gangrenous intestine, to allow of the escape of its contents, and then it should be returned to the upper part of the £ac, the wound should be left open, and a poultice applied ; but if the portion of intes- tine which has descended be not large, it should not be disturbed from its adhesions to the sac.
VOL. HI. E
50
Case. I was requested, during the absence of
Mr. Chandler, to operate upon a woman who had been admitted into St. Thomas's Hos- pital, under his care, with strangulated hernia. From the examination of the part, and from the history of the case previous to my seeing the patient, I imagined that gangrene had commenced, and I soon found this opinion to be correct; for before I had opened the hernial sac, there was a highly offensive and putrid smell. On opening the sac, I found the intestine in the state I have before described ; I therefore divided the stricture, and then made an incision of about an inch and a half in extent, on the anterior part of the gangre* nous intestine, through which the faeces readily escaped. I afterwards directed that a poultice should be applied. Feeculent matter continued to be discharged through the wound; but nine days subsequent to the operation she had a stool, per anum, after which the patient passed her stools by the natural passage, occasionally at first, then more frequently, as the artificial anus and wound closed, and she completely recovered. This patient was confined five months after the operation, and delivered of a full grown but dead child, by Mr. Brown, a respectable surgeon at Rotherhithe. It is extraordinary; that being considerably advanced in her
m
Hppgnancy at the time of tlie operation, she
^B^ not miscarry.
EiiWtea a patient with strangulated hernia Terminii- ■will not submit to the operation necessary oiitnnope- for his relief, or if the proper assistance can- not be procured, and gangrene takes place, the hernia sometimes suddenly returns into the cavity of the abdomen, and the patient survives only a few hours. Sometimes the y-r^ skin and other coverings inflame and .slough, /^^^^ when the fseces are discharged through the ^^^ opening thus produced, and the symptoms ^^^^-^ of strangulation subside, after which an arti- ficial anus is formed, rendering the remainder of the patient's life miserable.
Occasionally, however, it happens that the Artificial external wound and artificial anus are gradu- ally closed, and the patient entirely recovers.
A case of this kind occurred under the ca5e. care of my friend, Mr. John Cooper, surgeon, of Wotton Underedge, Gloucestershire. He was requested to attend a poor woman, aged sixty, who was the subject of strangulated ^^H crural hernia. When he first saw her, she had ^^| been labouring under symptoms of strangula- ^^| tion for a fortnight, and the hernia was ^^| evidently in a state of mortification. Thinking, ^^H therefore, that there would not be any chance I
of saving her life by an operation, he only
^ directed that her strength should be sup-
L
5S
ported, and the part poulticed. In a few days the mortified parts began to separate, and the fjeces were discharged through the wound. This continued for three months, during which period several inches of one of the small intestines sloughed. After this, a small quantity of faeces began to pass by the natural channel, and in six months the woman had perfectly recovered. 'f- The formation of an artificial anus is dan- gerous, according to its situation in the intes- tinal canal. If the opening be near to the stomach in the jejunum, the patient will die in consequence of the small surface for the absorption of chyle being inadequate to pro- duce sufficient nourishment. If the opening be in the lower part of the iUum, or in the colon, then the patient may recover, as there is but little interruption to nutrition.
A man about fifty years of age was admitted into Guy's Hospital, with a strangulated umbilical hernia, which sloughed, and oc- casioned an artificial anus. As he was re- covering from the effects of the strangulation and sloughing, and was allowed to take food in any considerable quantity, it was observed that part of what solids he ate passed out at the artificial anus, within half an hour after he had swallowed thetn, and that fluids passed out in ton minutes after they had been taken
63
3 the stomach. Although he took sufficient
I to support a healthy person, he wasted
pidly, and died in three weeks. On ex-
(nining his body after death, and tracing the
jfejunum, the lower part of that intestine was
found entering the hernial sac, and in it the
opening was situated. The other viscera were
healthy.
When an artificial anus has been formed, From in- ,
, veiiiou of
care must be taken to guard against any in- the inte*. version of the intestine at the artificial open- ing, as such an occurrence will most likely prevent the perfect recovery of the patient, by rendering the false opening permanent.
A patient of Mr. Cowells, in St. Thomas's c«se. Hospital, underwent the operation for a strangulated hernia ; the intestine was found to be gangrenous, and the consequence was the formation of an artificial anus. For three weeks after the operation, the fgeces passed in part by the artificial opening, and in part by the natural aperture, but most by the latter; at this period the intestine became inverted, and protruded at the artificial open- ing; after which the faeces were entirely discharged by the false passage. The man lived eleven years after this, but always dis- charged his stools by the artificial anus. I If a portion of the colon has been stran- Appendicai I ^gulated, and the patient be fat, the appen- remM"
54
dices epiploicse are sometimes found much more diseased than the intestine, so much so that it becomes necessary to remove them, which I have had occasion to do. ' ' SJiTo? *' Having returned the intestine, the surgeon omentum, should Carefully examine the omentum; and if it be not in a large quantity, or of an un- healthy appearance, it should be returned into the abdomen, with as gentle a preissure as possible. If a very large portion of omen- tum be protruded, a part should be removed, which may be done without any danger to the patient by means of the knife ; and; if any arteries sufficiently large to afford a troublesome haemorrhage, are divided, they muHt be secured by fine ligatures; th^" di- vided surface should then be returned to the mouth of the sac, so as to form a plug, and tho ligatures should remain hanging from the external wound. •u^ #rr Mm 'f|i(3 old mode of applying a ligature AtntniuM^il around the protruded portion of the oinen- turit to occasion it to slough off, is now, I liolicv(% entirely abandoned; and it appears i^xtniordiuary, that it should ever have been ndoptod, ttH it is the object of the operation to romovu the stricture, which would be lliuN innnediately restored with increased
Ncwority. ihiiiiihim ll'ilu* omentum be in a state of mortifica-
IIHilllHliff.
may generally be known By'ife crispy feel, and tlie distension of its veins by coagulated blood ; or even if any suspi- cion arise of its being in an unsound state, it should be removed by excision at the Bund part. In doing this, the strangulated jortion should be drawn down a little, so as I expose some of the sound part, which diould be held by an assistant to prevent sudden retraction into the abdomen, while tlie surgeon cuts off the diseased and when this has been completed, any bleeding vessels should be secured as before directed. Should the omentum, in an nnsound state, approaching to gangrene, be ^umed into the cavity of the abdomen, be danger of the patient will be much in-
lased. kl have, however, known a patient recover, siougiiiog
whom sloughing of the omentum took tum. lace after it had been returned into the ^vity of the abdomen. This occurred in a man who had undergone the operation for a strangulated hernia in Guy's Hospital, jhe sac contained both intestine and omen- a ; and the latter, although much changed ( appearance, was returned into the abdo- men. Some days after the operation, the lan appeared to be dying ; the ligatures, ijOlding the edges of the wound together,
L 4
56
were removed, and poultices and fomenta- tions employed, when, on the following day, a portion of gangrenous omentum was found protruding from the wound, and for several days more continued to present itself, mitit the whole of the portion which had been previously strangulated was exposed, and gradually sloughed off; after which the patient recovered. OMMtmii When the omentum atone adheres to the *'*" * sac, it may be freely separated and returned, any vessels likely to afford a troublesome httmorrhage being previously secured, omniiittttt Should the protruded omentum be much Mirrkui. hardened, or have a scirrhus feel, it should sImo be removed in the same manner as t have already described.
Ti'tatmcnt after the Operation.
» . ^ When the contents of the hernial sac have •"••*• "•* liftrn ruturnod into the cavity of the abdomen, thn wound should be well cleansed, and its (idKrM sliould be afterwards brought into roll tacit by means of sutures, in order to itrotiioto ndhodion, two or three sutures ImliiK uciccmsary, according to the extent of Ihft wouiidi Cure »hould be taken in passing
!ae sutures only to include the mtegumei otberwise, by penetrating the sac, much subsequent mischief may arise.
The approximation of these parts should he assisted by the application of slips of soap plaister, and a compress should be placed over the wound, and retained there by means of a T bandage, to close the orifice of the sac, and prevent any further protru- sion into it, and at the same time the scro- tum should be well supported.
The patient should then be carried to bed in a horizontal position, and placed with his shoulders a little elevated, and the thigh, on the same side as the wound, moderately flexed towards the abdomen.
As it is perfectly necessary that the patient should keep the recumbent position during the cure, a folded sheet must be placed under him, into which he should discharge his stools, otherwise should he rise to use the night-chair, much mischief may arise from the effort. Mr. Cline had operated upon a patient for strangulated hernia; and some hours after the operation the patient got out of bed to use the night-chair, and from the exertions he made in getting up and in passing his motion, the intestine, which had been reduced, again descended the sac : Mr. Clinc again reduced the
of the re- cambent
Bkto the s;
58
I
intestine, and gave strict orders for the man to keep the recumbent position, and the patient ultimately did well.
Usually, if the patient be left to himself, he will have some natural stools in a few hours after the operation; but, if several hours elapse without an evacuation, either castor oil or sulphate of magnesia should be given, or a purgative enema, containing colocynth, or castor oil, should be thrown up, and the abdomen should be fomented with spirituous fomentation, which will assist the action of the bowels, and jEifford much comfort to the patient.
Medicines. As the Safety of the patient depends much upon procuring evacuations from the bowels, the exhibition of opium soon after the ope* ration should, if possible, be avoided; but if the irritability of the stomach continue, or if the patient have a troublesome cough, it should be administered in conjunction with calomel.
Purgatives. It is uot Only hcccssary to procure eva- cuations from the bowels soon after the operation, but it is extremely desirable to keep up a free action upon them for several days following ; as I have frequently known patients die in a few days after the operation with constipation and peritoneal inflamma- tion, although they had passed several stools
69
within twenty- four hours after the strangu- lation had been relieved.
Should the patient go on well, die wound sotores shoiild be' dressed on the third day, and "^**^® * afterwards daily. The sutures may be re- moved on the fourth and fifth day ; but the patient must be kept in bed until the wOutid is entirely closed. '
When the operation has been perfofmed operation at any early period after the strangulation has taken place, the patient generally does well ; but when much time has elapsed fVoni the strangulation of the herniai before the performance of the operation, dangerous symptoms frequentiy arise.
Sometimes the intestine does notrecoveif sometimes its furiiction, Vh^en the vomiting and consti-> patron continue, and the patient dies.
Sometimes peritoneal inflamniation con-^ Peritoneal
, * •■ inflamma-
tinues, in which case the abaomen is ex- tion. tremely tender and t^nse, although thib bowels are open, and the life of the patient is soon destroyed. The best means of re- lieving this inflammation are by local and general bleeding, fomentations, purgatives, and extremely low diet.
Occasionally the patient is attacked with Diarrhaea. a violent diarrhaea, which continues for many days, producing so great a ^ state of debility as to prevent recovery: In such
60
cases, the treatment I have found most ous, consists in exhibiting small doses of opium frequently, and the employment of injections of starch and opium, with a light but nutritious diet, as gruel, or milk, with isinglass, &c.
Hiccough. In a few instances I have known a trouble- some hiccough continue for several days after the operation, but entirely unconnected with gangrene, being the result of peritoneal inflam- mation.
vm. The most remarkable example of this kind
I ever met with, was in a gentleman at Maid- stone, for whom I performed an operation upon a large strangulated intestinal hernia. 1'ho symptoms had been unusually severe,^ find inflammation had taken place in the poritonoum. The abdomen continued tender to pressure for several days after the opera- tion t and the hiccough continued until the Mixth day. The patient was bled and purged IVi^dly, And he eventually recovered* As this symptom depends upon inflammation of the prritonoum when gangrene has not taken pltuii^i the proper means of relieving it are the sMirifi IIS <lirocted for the inflammation of this mi»fnhriinr, ns local and general bleeding,
IMirtrntlvMi &c. HiH«i*fM 'I'lift pcirformance of the operation for stran-
!«'•»* I*"*-* iiHltttpH luirnlu docs not prevent the future
Ml III M III
\m m (litMUUtl uC tho intestine or omentum, but pef-
mm
Iltips renders the patient more liable to its recurrence, as the mouth of the sac is by the operation considerably enlarged. It is, there- fore, perfectly necessary before the patient be allowed to get up, or use any exertion, that he should be fitted with a truss, which will effectually prevent any protrusion, by keeping the mouth of the sac closed, other- wise he may in a short time again become the subject of strangulated hernia.
When the truss is first applied, a dosil of Trrwxiab* I lint should be placed under the pad, to pro- pfitti. tect the recently healed wound.
In consequence of a radical cure not being Removal produced by the operation I have described, some persons have recommended the removal of the hernial sac by excision or ligature, or that it should be returned into the abdomen.
In a patient of Mr. Holt's, at Tottenham, ( I had an excellent opportunity of seeing the efiects of removing the sac by excision. A woman, who, for several years, had been sub- ject to a femoral hernia, applied to Mr. Holt, on account of the swelling having become so painful and tender as to prevent her from following her ordinary occupations, although the bowels appeared to act very regularly. Mr. Holt requested me to visit the patient with bim, and I made many ineffectual at- tempts to reduce the hernia, and in a few
62
days afterwards I recommended Mr. Holt to operate^ as the symptoms had not in the least subsided. On opening the hernial sac, . ft small portion of intestine was found at the mouth of the sac, inflamed^ and adherent to it« Mr.HoIt carefully separated the adhesions, and returned the intestine into the abdomen/ The sac itself being but little attached to the surrounding parts, I requested Mr. Holt to allow me to remove it, which I did, close to the mouth of the sac. I then closed the orifice by sutures, and the external wound was treated in the usual way. On the sixth day, the ligatures came away, and the wound was closed on the tenth. I saw this woman a niontli after the operation, when she had a hernia nearly as large as the one for which tlie operation had been performed, and at the same s{)0t ; she was subsequently obliged to wear a truss constantly, to prevent the pro- trusion of this hernia. \^^mi\%\ From this it appears that the removal of Hl.il!mHMv»t the sac will not prevent the re-formation of a *^** horuitt, nor do I think, upon reflection, that it
scarcely could be expected to do so, as the nporturo from the abdomen remains equally largo, and the peritoneum alone oflFers resist- unco to the formation of another hernia, and this had been insufficient to prevent the pro- trusion of the fii^st*
63
The removal of the sac by ligature is equally ^^^^^ objectionable, even • if it could be done with- J^ ^\^^, out risk, which it hardly could, more especi- ^""^c- ally in oblique inguinal hernia, as the ligature ought, in such cases, to be supplied close to the internal ring, which could not be done without a very tedious and hazardous dissec- tbn; besides, the spermatic cord is some* times divided by the sac, which would in- crease the difficulty and danger of such an operation.
The great danger of this operation is in the Danger of. inflammation, which is likely to be induced by the action of the ligature upon the peri- toneum, and in this inflammation extending to the cavity of the abdomen.
Of Large Hernia. In very large inguinal herniae a very difierent Different
operation
mode of operating i^ required, to that which required. I have already described, for the following reasons : —
When a large hernia has existed for some Difficulty time, the cavity of the abdomen becomes ing. diminished, from the habitual loss of a large portion of its natural contents', and such a resistance is offered when any attempt is made to return the contents of the hernial
sac, that the intestine sometimes gives way, or is lacerated from the violence employed in attempting to reduce it, and even if it can be returned, the slightest exertion will occa- sion a further protrusion.
Also, in large hernia, a considerable extent of protruded intestine being submitted to much violence in the attempt to reduce it, often gives rise to inflammation, which may produce fatal consequences.
Sometimes extensive adhesions have been formed between the sac and protruded in- testine, or the portion of peritoneum which has descended, and is forming part of the sac, may have brought with it a portion of the intestine, to which it is naturally closely con- nected, as the ccecum, and which thus be- comes irreducible: in either case the reduc- tion of the hernia is of course prevented.
Instead of performing the same operation, as in other cases, I should, under these circum- stances, merely expose the upper part of the hernial sac, and divide the stricture without opening the peritoneum, unless the irtil iif stricture happened to be seated in the mouth of the sac itself.
The first time that I had an opportunity of performing the operation in this manner, was upon a patient of Mr. Birch's, in St. Thomas's Hospital. The man was between
J
G5
■ and sixty years of age, and had been X from Ills infancy, which, jecoming strangulated, and not yielding to the usual measures, rendered an operation necessary. From the size of the hernia, which
tsached halfway to the knees, and its dura- on, I conceived that such adhesions might ave occurred as would render its reduction impossible, and that the ordinary mode of operating would be extremely hazardous, on account of exposing so large a surface of intestine; I therefore determined upon trying ^bhat could be effected by a division of the ^Hricture, without opening the hernial sac.
I commenced by making an incision, be- <
ginning about one inch and a half above the
^external abdominal ring, and terminating
^Ebout the same distance below it ; this ex-
Hnsed the tendon of the external oblique,
and the fascia of the cord. I then carefully
made an opening into the latter, large enough
to admit a director, which I introduced, and
upon it divided the fascia so as to expose the
cremaster muscle as far as the external ring ;
after this I passed the director between the
cremaster and edge of the external ring, and
introducing a probed bistoury, I cut through
a part of the tendon of the external oblique,
so as to enlarge the external ring. On passing
I my finger into the inguinal canal, to the edge
L VOL. III. t
66
of the transversalts muscle ; I felt some further resistance, and again introducing the director, I carefully separated some fibres of this muscle. The contents of the hernial sac were then reduced, and the edges of the wound being approximated, the patient was put to bed.
The wound healed kindly in about three weeks, although the hernia was protruded upon the slightest exertion, which would have occasioned much irritation, had the sac "been opened. The patient was subsequently obliged to wear a laced bag truss. Division of Should the stricture be seated in the neck
the stric'
inr«. of the hernial sac itself, of course the division of the parts exterior to it, will not relieve the strangulation ; in this case the sac must be opened carefiiUy at the upper part only, k) as to allow of a division of the stricture. Care in Haviug divided the stricture, the surgieon tbeTi^^ qiust avoid ^dolence in attempting to return the protruded parts, for the reasons I have before mentioned. I have known the: intes- tine ruptured in forcibly endeavouring to effect the reduction after the liberation of the stricture. The case occiurred in St. Thoma&'s Hospital, and terminated fatally. The ruptured intestine is preserve^ \n the collection at that Hospital.
Some surgeons object to the division of
cera«
67
ft stricture without opening the hernial sa6> \ iirging that the intestine or omentum may bf) 1 a gangrenous state, and that this cannot be ^certained unless the sac be opened ; but I ihould imagine that a very limited experience would enable the surgeon to form an accurate ppinion in this respect.
I
0/ Hernia in the Inguinal Canal.
The oblique hernia is sometimes confined Appesr- entirely to the inguinal canal, and does not emerge through the external ring. It is often difficult to detect in the living subject, as there is no distinct tumor perceptible, but merely a fulness above Poupart's ligament. When strangulated, the usual symptoms are 1 present, and the part is very tender on pres^ sure, or during coughing.
This hernia is covered by the superficial Cohering*. \ fascia, the tendon of the external oblique muscle, by a thin fascia from the edge of the internal ring, and in part by the cremaster muscle, the spermatic cord and the epigastric artery lie posterior to it.
These herniae, when strangulated, are often MisukM!.!
mistaken for cases of peritoneal inflammation,
as the patient is not conscious of having a
swelling ; and thus he may fall a victim to
F 2
Blizard, for the following curious anil mtercrt- ing case of hernia, descending behind the spermatic cord, which had been accompanied with hydrocele, in the tunica vaginalis of the same side.
The patient had been the subject of hernia on the right side, for six years, for which be had worn a truss ; and from his own account a hydrocele had formed on each side, two years previous to his coming under the care of Mr. Blizard ; but that on the right side had gradually disappeared, leaving the testis wasted and drawn up to the groin.
The hernia becoming strangulated, and not yielding to the usual means employed for reducing it, Mr. Blizard performed the ope- ration about twenty-four hours after the com- mencement of the symptoms. Having laid bare what he thought was the hernial sac, he punctured it, and then freely opened it upon the director. It extended through the ex- ternal ring, into the inguinal canal, which Mr. Blizard in part cut open, in order to make the necessary examination of what he conceived to be the hernial sac ; this, how- ever, proved to be the tunica vaginalis, which had formerly been distended by the hydrocele, having the hernia seated behind it. The pos- terior part of this tunic was then cut through, exposing the hernial sac, which was found to
71
contain a portion of intestine nearly of a black colour, from strangulation. The stricture which was seated at the mouth of the sac was divided in the usual manner, and the intestine returned. The patient did well. Mr. Henry Cline had occasion to operate upon a similar case.
Of Inguinal Hernia in the Female.
^L^ The structure of the inguinal canal in the stracture 1 ^Hemale is very much the same as that which \1 have described in the maJe, only that the round lijjament in the former takes the place of i^the spermatic cord existing in the latter. ^L. The round ligament, which commences Round ^■jlft the fundus uteri, passes from the abdo- """"^ ' ^ftaen midway between the anterior superior ^H^inous process of the ilium to the outer ^*«de of the epigastric artery, above Poupart's ligament, and below the transversalis and internal oblique muscles, as the spermatic cord in the male; it takes a course obliquely downwards, and inwards to the external labdominal ring through which it passes, and s lost upon the pubes. This round ligament, however, being much Ismaller than the spermatic cord of the male, Ipasses through openings corresponding to \its size, which are consequently much less
72
than those for the spermatic cord, and' 3n this account the formation of inguinal hernia in the female is of comparatively rare oc- currence. Course of When this hernia does occur in the female,
the beruiB,
it takes the course of the round ligament, is at first confined to tlie inguinal canal, where it is covered by the tendon of the external oblique, and subsequently it pro- trudes through the external ring, and forms a swelling at the upper part of the labium, which seldom acquires a large size ; here it is covered by a superficial fascia given off from the tendon of the external oblique. Cansci. It is pioduced by the same causes in the
female as in the male, and presents the same symptoms. The sac usually contains either intestine or omentum, or both, but some- times the appendages of the uterus are found in it. Less liable As the round ligament in the female is than in tiie not liable to the same affections as the sper- matic cord of the male, the hernia in the former case is not likely to be confounded as it frequently is in the latter case with such diseases. I have, however, known this form of hernia in the female mistaken for a femoral hernia, which may readily be ima- gined when we recollect the proximity of the parts concerned.
J
^
A careful examination will readily enable "o* <ii«-
tinguished
the surgeon to distinguish between the two, iromfcmo- as in the inguinal, the neck of the tumor is above Poupart's ligament and in the femoral below ; in the former, also, the spinous pro- -cess of the pubes can be readily felt outside l&e swelling, which it cannot be in the latter.*
When this hernia can be reduced, a truss, Rcdocibie. similar to that necessary for a mate, is to be employed.
When irreducible, the same treatment as > recommended for the male will be proper. If intestinal and small, a truss with a hollow pad; if omental, a common pad; and when the hernia is very large, a T bandage, to give support, and prevent increase.
Should this hernia become strangulated, strsngn- .fiie taxis should be first employed in the same way as in the other sex ; and should this not succeed, bleeding, the warm bath, ice, the tobacco enema, or other means to assist reduction, should be had recourse to.
The usual means having failed to relieve the strangulation, an operation becomes ne-
* Another good diagnostic mark is in the direction o^he impetus giveu to the swelling, when the patient <^otighs or sneezes; in inguinal heniia bein^ downwards, Md ill femoral, upwards from the thigh, — T.
ceasarjr, which should be performed in the following manner.
The hair having been removed from the surface of the tumor, and the patient being placed in the same position that I directed the male should be under similar circum- stances, the surgeon should make an inci- sion through the integument, commencing a little above the external abdominal ring, and terminating at the lower part of the swelling. This exposes the fascia covering the hernial sac, which should next be care- fully divided to the extent of the first in- cision. The sac, being thus laid bare, should first be cautiously punctured as before men- tioned, and then should be further opened upon the director.
The portion of the hernial sac below the external abdominal ring may perhaps con- tain only a quantity of the dark serum usually found ; in which case the operator must introduce his finger into that part of the sac which is in the inguinal canal, and there he will feel the portion of intestine or omen- tum which is strangulated. He should then slit up the canal and sac towards the ante- rior superior spinous process of the ilium, so as to expose the strangulated parts ; and, ascertaining the seat of stricture, he should pass a small director under it, ami carrying
berdia knife upon the director", the stnc-' ture should be divided upwards, or upwards and outwards, after which the protruded |»8rts are to be returned, if they be not in a state of gan^ene.
The last case of inguinal hernia in the female, in which I had an opportunity of witnessing the operation was under the care of Mr. Forster, in Guy's Hospital.
Upon opening the sac below- the external Cai. ring, a quantity of fluid escaped, but there was not any appearance of intestine or omen- tum. However, upon passing the finger into the sac, through the external ring, a portion of intestine could be distinctly felt, which Mr. Forster subsequently exposed, by slit- ting up the inguinal canal. The stricture, iwhich was seated at the internal ring, was ■divided upon a director in the usual manner, and the patient did extremely well.
The after treatment does not differ from After ,that I have directed for the other sex. ■ "
When the inguinal hernia in the female i" u>e
iDgnlna)
not descended through the external ring, canal, it may become strangulated, and occasion fatal consequences, as in the male, without its existence having been recognised during the life of the patient.
A patient was admitted into St. Thomas's case. Hospital, under the care of Sir Gilbert Blane,
^
t^
with symptoms of strangulated hernia ; but, upon being closely questioned by Sir Gilbert, she denied the existence of any tumor at the groin, navel, or elsewhere, and the case was consequently treated as one of inflammation. The woman died; and Sir Gilbert, supposing that some concealed hernia might have been the cause of her death, inspected the body, and found a small strangulated inguinal hernia on the right side, which did not protrude an inch from the internal ring.
When necessary, the operation in this case is similar to that required for the same disease in the male.
I have never seen direct inguinal hernia ia the female.
Of Congtnital Hernia.
r In this hernia the protruded parts have not any proper peritoneal sac, as the common inguinal hernia, but are contained in the tunica vaginalis of the testicle. All herniae seated in this cavity are not, however, con- genital, as such protrusion may occur at the adult period for the first time.
This hernia is originating from the descent of the testicle in the foetus. Usually about the seventh month, the testicles, which are up
y?
to that period seated upon the loins, begin to descend into the scrotum. At this time, a strong ligament is found connected with the inferior part of the testis and epididimis, and passing to the scrotum in the same direc- tion as the spermatic cord is afterwards placed ; it is called the gubernaculum, and appears to guide the testicle into the situation provided for it.
The testicle and its vessels are covered by peritoneum, except just where the latter enter at the posterior part of the former.
In its descent, the testicle takes with it a De* portion of peritoneum, which afterwards be- comes the tunica vaginalis ; and it is usually found in the scrotum at the ninth month ; but there is considerable variety as to the period when the descent is complete, some- times being earlier or later than the ninth month, sometimes one testicle comes down first, and the other does not descend until some time afterwards. In some cases, the testicles never quit the abdomen, and in others they only descend to the groin.
When the testicle has reached the scrotum, the opening through which it quitted the I abdomen generally closes, but at what period I is not precisely ascertained. If, however, it ^L should remain open at the time of birth, the ^■efforts of the child in breathing or crying
78
cause the protrusion of a small portion of
intestine into the cavity, and thus the tsoo-*
genital hernia is formed. , ;; ,:
Called the From its appearance and feel, more paf ^
rupture, ticulaxly when the child cries, the uursei^ oaU
it the lYindy rupture, in opposition, to .th^
term watery rupture, which they apply .to
an hydrocele, when it occurs in the infaAfe^
and this is not very unfrequent. . - j
Sometimes I hstvc fouud the tuuica vaginalis sufficiently
occurs &t
the adult opcu at the adult period to admit the introf ^^"^ ■ duction of a female catheter; and I have known hernia, similar to the true congenital form, occur in persons between twenty ian4 thirty years of age. In these cases I imagine the opening at first to have been so small <w not to admit the descent of a hernia undst ordinary circumstances, but that when the patients have been under the necessity of doing very laborious work, or during ^: state of great relaxation, the protrusion has taken
place. jiiin.:
Course. The Congenital hernia must necessarily take the course of the spermatic cord, passing in the same direction as an oblique ingumal hernia, from which it is to be distinguished by the following marks. In common oblique inguinal bemia, the testicle is perfectly disf* tinct from the hernial sac ; whereas, m the congenital disease, the testicle is confounded
with the sac. In the latter case, also, the appearance of the part very much resembles that of a hydrocele ; more especially if, as sometimes happens, a quantity of fluid de- scends into the sac with the intestine or omentum which, upon a close inspection, gives a irsuisparent appearance to the swell- ing. To distinguish these joint diseases, the contents of the hernia should be returned into the cavity of the abdomen whilst the patient is in a recumbent posture ; after this, a moderate pressure is to be made against the abdominal ring, with the finger, so as to prevent the descent of the intestine or omen- tum ; if the patient then assume the erect position, the water will escape into the tanica vaginalis, but the intestine or omen- tum will be felt pressing against the finger above.
Sometimes the testicle does not descend to the bottom of the scrotum, and then, if a congenital hernia form, the tunica vaginalis becomes elongated, and reaches considerably below the situation of the testicle.
In the congenital form of hernia, also, the Division oi Cord is occasionally divided, the artery and win being on one side, and the vas deferens taking its course on the other side.
When the congenital hernia is reducible, Redin:ible.J it requires the use of a truss, as the common
80
inguinal hernia; provided tiiat the testicle^ completely descended into the scrotum, or does not rest at the groin. For the first three months, perhaps a pad and bandage may be sufficient to prevent the descent of the hernia; but after this period a truss with a spring may be employed with safety, or- even at a younger period if necessary.
> If the testicle be seated in the groin, a truss canuot be worn without risk of injuring the gland, and it is better to allow of such a protrusion as will assist the complete descent of the testicle, before any truss or other means of suppressing the hernia be resorted to.
A young man who now holds a situation of importance, and who is the father of several children, was brought to me formerly by his father, on account of his having a congenital hernia; but because the descent of the testicle on the same side was incomplete, I directed that the protrusion should not be retarded. The testicle afterwards descended into the scrotum, a truss was then applied for the hernia, and the disease was ultimately subdued .
;■ After the truss has been worn for some time, the tunica vaginalis becomes closed at the upper part, and near the testicle, but sometimes remains open between, allowing a space for the deposit of fluid which occa-
81
i
ly takes place, forming hydrocele of the cord, and for the cure of which 1 have had to perform an operation on several oceasiona.
With regard to the treatment of this hernia irredncibwll in the irreducible state, the same as directed for common inguinal hernia, is here applica- ble; and when strangulated, the same means as recommended in the latter case, should be employed for the relief of the patient.
When an operation is required, it should Operfltioa. j differ from that described as necessary for common oblique inguinal hernia, in the follow- ing particular. Having laid bare the tunica vaginalis, it should not be opened low down on account of exposing the testicle, but a sufficient quantity of the tunic should be left whole to cover this gland.
On opening the tunica vaginalis, a much i-»fpe
t^ O D miaiUlIJ 01
larger quantity of fluid generally escapes ""id- than is found in the sac of a common inguinal Jiernia.
The seat of stricture will be generally seat or found under the edge of the transversalis muscle, or at the internal ring, when it should be divided in the same manner as in other cases of hernia ; after which, the pro- truded parts, if not adherent, should be returned. If extensively adherent, the stric- ture should be divided in the same way, but the surgeon should not attempt to separate
VOL. iir. i:
82
the adhesions, unless very few and slight, in order to allow of the return of the parts ; but they should be left ; and after the wound has healed, a bag truss will be required, as for other irreducible scrotal hemiae.
In operating for this form of hernia, the testicle is sometimes found in the inguinal canal in contact with the intestine; in i^diich case the intestine only should be returned into the abdomen, the testicle being left in the canal. The stricture in this case is at the orifice of the tunica vaginalis.
Of Encysted Hernia of the Tunica Vaginalis.
How formed. This is a particular species of hernia, which occurs in the following manner. The tunica vaginalis becomes closed, by adhesion, op- posite the abdominal ring, but remains open above and below it ; and when a protrusion of intestine occurs, this adherent portion of the tunic becomes elongated^ forming a dis- tinct hernial sac within the proper tunica vaginalis. Case. I had an opportunity of witnessing the fol-
lowing case, under the care of Mr. Forster, in Guy's Hospital. A man was admitted into the house with symptoms of strangulated hernia, which the usual means failed to re^ lieve, and the operation was proposed and
83
urged; but the patient would not submit, choosing rather to die. On examining his body after death, a sac was found within the tunica vaginalis, descending from the abdominal ring towards the testicle. This sac contained a portion of one of the small intestines which had become gangrenous^ The stricture was at the mouth of the sac.
In operating upon a case of this kind, the Operation, tanica vaginalis should be opened freely, to espose the sac, otherwise some difficulty may arise.
Mr* Hey, in his surgical observations, has related 9. casie swilv tp that of Mr^ Forster,
G 2
84
LECTURE XXXIV.
On Femoral Hernia.
Anatomy BEFORE I proceed to describe the symptoms
parta. of femorial hernia, I shall give an account of the anatomy of the parts directly or indi- rectly concerned.
saperfidai The superficial fascia, which covers the external oblique muscle, is continued down over Poupart's ligament upon the thigh, where it is found of considerable density, and serves to keep the superficial veins and absorbent vessels in their proper situations.
cnirai Under Poupart's ligament, which stretches
from the anterior superior spinous process of the ilium, to the spinous process of the pubes, is a space called the crural arch, which gives passage to the femoral artery and vein, the anterior crural nerve, and psoas and iliacus intemus muscles, with absorbents, &c. o^ernafa From that portion of Poupart's ligament which is inserted into the spine of the pubes, a process is given ofi*, extending downwards and outwards, and attached to the ligamept of the pubes over the linea-ileo-pectinea ; it presents a concave edge towards the femoral
85
vein, and is known under the name of Gimbernat's ligament.
Two fasciae are given off above from Pou- part's ligament, one passing upwards between I the peritoneum and transversalis muscle, which is called the fascia transversalis; a second fascia extends between the perito- neum and iliacus, and psoas muscles, called the fascia iliaca. From another part of the fascia transversalis, a process passes down under Poupart's ligament, through the crural . arch, to the sheath of the femora! vessels, form- ing its anterior part, and the fascia iliaca forms the commencement of the posterior portion.
In this sheath are situated the femora! i artery and vein, the anterior crural nerve > not being included. The vein is placed most internal, and about five-eighths of an inch to the outer side of Gimbernat's ligament ; the artery lies outside of the vein, and the nerve still more exterior. The artery and vein are separated by a septum.
Under the superficial fascia of the groin, i and extending from the inferior part of Pou- part's ligament, is a strong fascia, called fascia lata, which has two attachments above, but becomes united below. One portion is joined to Poupart's ligament from the spinous process of the pubes to the an- terior superior spinous process of the ilium ; G 3
86
and, paMwng downwardi^ coren the femoial artery and reiiiy the anterior cmal nerwey aad the nraidcs on the outer and fare part of the thig^
From its origin at the q>ine of the pubea^ a defined edge passes a little oatwards and downwards, in a ciescentic fiimij over the sheath of the fenKHral yessels, then eunres inwards, and a little upwards, under the saphena majw vein, and is united to the second portion. This seocmd portion is caor nected above with the ligament oi the pubee^ close to the inserticm ci the external oblique muscle; it then passes inwards ai^ down- wards upon the psoas, ifiwui iiitiinus,yanQ other muscles, to join that part which I described as passing undet the saphena major vein. From the union of these two portions, the fascia lata of the thigh results anteriorly.
Between the free internal edge of the firsts and the origin of the second portions^ as low down as their junction under the saphena major vein, an opening is left, exposing a part of the femoral sheath. This space is filled above by absorbent glands; the ab- sorbent vessels from which, here perforate the sheath of the femoral vessels, to pass Xi& the glands in the abdomen. At the lower part of the space, the saphena major vein
penetrates ttte sheath to enter the femoral vein about an inch below the crural arch.
If the fascia lata be entirely removed from the upper part of the thigh, the muscles and anterior crural nerve are exposed, but the femoral artery and vein remain enclosed in their proper sheath.
On opening the femoral sheath, the artery siieaoi
[d vein are exposed ; the former situated shaped. clo the outer side of the latter, and about three inches from the symphisis pubes. The sheath, about two inches downwards, be- comes intimately connected with a portion of the fascia lata. It has somewhat a funnel ^ape, heiag larger above, and contracted lelow, where it joins the fascia lata. t The epigastric artery, in its course up- EpigMitU wards and inwards from the external iliac,
isses from one-half to three-fourths of an inch from the opening where the absorbents enter the abdomen. There is, however, considerable variety in the origin of this
from above, the peritoneum, which covers it, must be taken off, when the relative situations of the vessels, entering the sheath, will be distinctly seen, as also the descent of the two portions of fascia to form the sheath, that from tlie fascia transversalis
88
above the vessels, and that fAm the fascia iliaca beneath them. Difference Ffom the difference in the formation of the
in the male . _ i c t i.
»nd female pelvis HI the male and female, the space form- ing the opening to the femoral sheath is largest in the latter, on which account they are more hable to the formation of femoral hernia.
ConHDence- When a femoral hernia commences, the
ment of the . , ■ i
herwi. patient's attention is first directed to the part on account of experiencing pain on suddenly straightening the limb, as in rising from a sitting posture. This is occasioned by the extension of the fascia lata, and its pressing on the protruded parts. Appear. On examining the seat of pain, a fulness hernia. is discovered at the upper and inner part of the femoral sheath, which disappears on pressure, or when the patient is recumbent. This fulness soon increases, so as to foiiB a tumor about the size of a small walnut, which is situated immediately below Poupart's ligament, to the inner side of the femoral vessels, and to the outside of the spine of the pubes. As the swelling enlarges, it pro- jects more forwards and upwards, turning up over Poupart's ligament; as it meets with the least resistance in this direction. ^j^aiged When the tumor is small, from its situa- gland. ^[qu ajj^ circumscribed feel, it has much the character of an enlarged inguinal gland.
89
The direction of this hernia is at first a little downwards in the femoral sheath, then obliquely inwards and forwards, and lastly upwards ; sometimes, however, instead of turning up over Pouparfs ligament, it takes a course downwards, in the direction of the saphena major vein; but this very rarely happens.
On dissecting a femoral hernia, the fol- lowing appearances present themselves. On cutting through the integument, the fascia superficialis is exposed ; this, in its natural state, is thin and delicate ; but frequently, when hernia exists, the fascia becomes dense and tough from pressure. Under this fascia a portion of the sheath of the femoral vessels 13 found, which closely envelopes the hernial sac itself; it is that portion which is per- forated for the entrance of absorbent vessels.
This covering I first became acquainted with in examining a patient in St. Thomas's Hospital, in the year 1800, and have since invariably found it, when operating for this form of hernia. It may be termed the fascia propria of the hernia.
Beneath this covering, and between it and ihe sac itself, there is generally some adipose matter situated, on separating which the sac
is laid bare. This layer of adipose matter I
liavc known to be mistaken for omentum.
DirecUoD of the
L
90 Miitake» The femoral hernia i8 much less likely to
for other "^
diseases, be confounded with other diseases than the inguinal^ on account of the much m,ore fire** quent formation of various tumors in the fiitua,tian of the latter; but still there are some diseases which I have known to be mistaken for femoral hernia, apd in the discrimination of which much care is re<- quisite.
Enlarged In Several instances, an enlarged gland in
^'"•'- the groin has been mistaken for a femoral hernia ; and, on the contrary, the hernia has been treated as an enlarged and suppurating gland ; but such mistakes must arise from inattention to the previous history of the case.
Case. Some years ago, a man was admitted into
Guy's Hospital with a strangulated henm, over which a poultice had been applied fw three days before his admission, under the supposition that it was a bubo. The opera-^ tion was performed, and the intestine found gangrenous.
Case. Mr. Bethune, surgeon, at Westerham,
in Kent, assured me, that he saw a patient who had been the subject of a strangulated femoral hernia, which had been poulticed for some days, and at length opened, when air and feculent matter escaped, and the patient died ten days after.
oi
I When a femoral hernia and enlarged HemiB iaud exist at the same time, an attentive 'arged I minute examination is sometimes requi- site to ascertain the existence of the former.
I once saw a lady with Mr. Owen, sur- caae geon to the Universal Dispensary, who had Buifered from symptoms of strangulated hernia for nine days, and had been treated for inflammation of the intestines, as she had not mentioned the existence of a swelling in her groin. Mr. Owen discovered this swelling, and in consequence requested me to visit the patient, at the same time in- forming me, that the tumor had not the feel of a hernia, but that he supposed it must be one from the symptoms. Upon examining the part, I found an enlarged gland, about the size of a walnut, very hard, and moveable ; but beneath this gland, and separate from it, was an elastic tumor, which I succeeded in reducing by the employment of the taxis; and this relieved the patient from all the symptoms of strangulation.
Some of the symptoms attending psoas P'"*" abscess resemble those of a femoral hernia, and might lead to mistake. Psoas abscess makes its appearance in the groin in the same situation as a femoral hernia; it dilates when the patient coughs, and is less apparent when the person is in a recumbent posture.
02
than when he is erect. It may, howerer, be readily distinguished from hernia hy the pain in the loins, which precedes the ap^ pearances of the swelling, by the general constitutional derangement attending it, by its more rapid increase, and by the absence of intestinal derangement. •
he^** The error of most consequence respecting femoral hernia, is, that of mistaking it for in- guinal hernia. Danger arises under such cir-^ cumstances, from the operation of the taxis, the direction to make pressure in the femoral being quite different from that proper in the inguinal ; but the most serious mischief is likely to arise, if an operation be necessary, in the division of the stricture. *
caac. I was ouce sent for to operate on a patient
for a strangulated inguinal hernia, which, on examination, I found to be femoral, and succeeded in reducing it, by making tiie pressure in the proper direction ; and I have known operations performed as for inguinaT hernia, when the disease has been femoral. These mistakes arise from the femoral pro- trusion turning up over the crural arch or Poupart's ligament ; and much attention is often requisite in making an examination, before the surgeon can confidently decide on the true nature of the disease. The best marks of distinction which I have observed.
93
are, that the neck of the femoral hernia is below and to the outer side of the spine of the pubes, while that of the inguinal hernia is above the spine; also, by drawing down a femoral hernia, Poupart's ligament may be traced above it, which it cannot be, if the disease be inguinal.
I have seen a case of enlargement of the varico« femoral vein, which had somewhat the ap- pearance of a femoral hernia, but it was rea- dily detected, by pressing on the iliac vein above, while the patient was recumbent, when the tumor immediately appeared.
Femoral hernia is most frequent upon the *"''* ^^"''"■ right side, probably on account of the most iient on persons employing that side in the greatest side. degree.
Women who have borne many children Mother are more liable to this disease than others, i which arises from the extension of the ab- dominal parities during gestation, causing a move relaxed state of the parts ; also, old persons are more frequently troubled with this disease than the young.
Most frequently the protruded part in Mo.t fre-
ooral hernia is small intestine, very rarely tcstuial'"' Twily omentum, but occasionally both intestine and omentum. I have seen the coecum in a femoral hernia on the right side, and the ovaria have also been found in the hernial sac.
94
The femoral hernia is produced by ■ same causes as occasion the formation of inguinal hernia, except that I do not recol- lect a single instance in which this disease lias been originated by a blow.
Treatment of the Reducible Femoral Hernia.
From the small size of the opening through which femoral hernia passes, the patient is in great danger from strangulation, unless proper means be adopted to prevent the descent of the viscera.
The employment of a truss is the only method by which the safety of a patient can be secured ; but the truss required for fe- moral hernia must be of somewhat different construction to that which is required in inguinal hernia.
The pad, instead of being continued nearly in a straight direction with respect to the spring, as when required for inguinal hernia, should project downwards, nearly at right angles, to the spring, that it may effectually press upon the opening through which the hernia protrudes under Pouparfs ligament, and also upon the upper part of the thigh.
The truss should be constantly worn, as for inguinal hernia, to prevent the protrusion
95
of the hernia, and also with the view of obliterating the mouth of the sac, and curing the disease.
It is very rare, however, that a cure is domhi effected in femoral hernia by means of the truss, but still it is right that it should be constantly kept on. I have known many instances in which the constant application of the truss has not produced the smallest apparent alteration in this hernia ; the reason is, because Poupart's ligament, and tlie fascia lata, support the pressure of the truss, and the constant variation in the tension of these parts on every movement of the body, prevents the steady pressure necessary to produce a gradual closure of the opening.
In some cases, when the opening of the femoral sheath is large, it will be necessary to have a larger pad, and a stronger spring to the truss, and the pad may be more effec- tually kept in place, by means of a strap passed from it round the upper part of the thigh.
If a hernia exist on both sides, a double soubif truss will he required, made upon the same principles as the single one.
The truss made by Salmon and Odv's, Salmon a I have generally found best adapted to these trms.
96
Of the Irreducible Femoral Hernia.
caiiies. Femoral hernia may become irreducible
from adhesions of the protruded parts to the interior of the hernial sac ; from a growth of the protruded parts within the sac, so that they cannot repass the opening into the abdomen, or by a contraction at the neck of the sac itself, producing the same con- sequences.
Treatment. In either case, a truss should be applied with a hollow pad, which is to receive the tumour, and prevent its increase.
Case. A gentleman consulted me, in consequence
of his having an irreducible femoral hernia, which, upon examination, I thought only to contain omentum ; I directed him to wear a truss, with a depression in the pad, just large enough to receive the tumor. Two- oi^ three years afterwards, I saw this gentleman again, when I was gratified in learning^, that his hernia had nearly disappeared. This was in consequence of absorption of the omentum having been produced by the pres- sure of the pad.
Truss can- If the hcmia be entirely intestinal, this
not always • i i n ••
be worn, form of truss^ With a hollow pad, cannot always be borne, as I have known it to create very severe suffering.
Of Stritngulated Femoral Hernia.
The symptoms of strangulation being the Sympio:
same as those I have already detailed in the
lecture on inguinal hemia, I shall not again
repeat them, but merely observe, that in
femoral hernia, they are usually more urgent
^Hi account of the smallness of the opening,
^brough which the protrusion occurs, causing
^Bteater pressure.
^ft The patients generally complain of more seTw. ■*1 Hpda from strangulated femoral than inguinal hernia in the same state, and they die sooner from the former than the latter disease. The medical treatment required for strangu- Medical b^ed femoral hernia, does not differ materially Hpom that necessary for the inguinal disease.
In the first place, the taxis should be Taxis, employed, but in a different mode to that ^J have described as proper for the reduction ^h|f mguinal hernia. The patient should be ^Waced on a bed, with the shoulders ele- i rated, and the thighs bent at right angles with the body, leaving only sufficient space between them to admit the arm of the operator. The tumor is first to be pressed downwards, until it be below the level of Poupart's ligament, when it is to be kneaded upwards towards the abdomen. The difficulty usually experienced iu at- uifficuiiy.
tempting to reduce this form of hernia, arises from the pressure being made at first in an improper direction, viz. upwards, so that the hernia is forced over Poupart's Hgament, instead of beneath it, and in this way the hernia never can be reduced.
As in the reduction of inguinal hernia, the pressure should be gentle and continued, avoiding violence, which may be productive of the most serious consequences.
Should the taxis fail, the same general treatment as that directed for inguinal hernia, should be pursued, as bleeding, the warm bath, opium, the application of cold, and the injection of the tobacco glyster. These reme- dies, however, have much less beneficial influence in femoral, than in the other forms of hernia ; which I imagine is owing to the nature of the parts through which the pro- trusion occurs, and the smallness of the aperture through which it descends.
As the symptoms are usually very urgent in femoral hernia, and as the disease more rapidly destroys life, there is the greater necessity for the early performance of an operation, when the usual means to effect reduction have been tried and have failed. I have known a patient die in seventeen hours after the symptoms of strangulation had commenced ; and on the contrary,^
»T^^
99
nve performed an operation with sucoess, fter the symptoms had existed seven days.; 'but in general, the patients lahouring under this disease do not survive the strangulation more than four days, if the stricture remain ; whereas, in inguinal hernia, under similar circumstances, they often live a week or more.
Of the Operation for Femoral Herni
The hair is to be removed from the sur- Prcpara. Yace of the tumor, and the bladder should be emptied. The patient should then be placed upon a table of convenient height, in a horizontal position, but his shoulders should be a little raised, and the thigh bent towards the abdomen, in order to relax the abdominal muscles, &c.
The first incision should commence a little OperaUon. ] above the superior part of the tumor, towards the umbilicus, and be extended downwards, somewhat to the inner side of the prominent part of the swelling, as far as its middle ; a second incision should then be made from the inner to the outer side of the tumor, at right angles with the first incision, and join-r ing it at the lower part, so that the two togetiier form a figure resembling an in- terted ± .
H 2.
The angular flaps should then be dissected up, to allow of sufficient space for the other steps of the operation. ii The superficial fascia which is thus ex- posed, should next be divided to the same extent as the integument, by which the covering formed of the sheath of the femoral vessels will come into view ;■ this should be carefully cut into, so as to admit of the intro- duction of a director under it, upon which it should be further opened, so as to freely expose the hernial sac.
If the patient is fat, a layer of adipose matter may be found between this covering, formed of the sheath of the femoral vessels, and the sac itself.
I have known this covering, which I call the fascia propria, to be mistaken for the hernial sac, so that the surgeon who ope- rated, supposed he had opened the peri- toneal covering when he cut into the sheath, and after considerable difficulty, he suc- ceeded in pushing up the protruded parts, but on the following day, the patient died ; and when examiniog his body, it was dis- covered, that the hernial sac had not been opened, but had been thrust up into the
• There is usually a considerable vein between the auperficial fascia, and the fascia propria, as well as sb^ Hoibent gtand)^.
ell aBM*|
idomen with its contents, which still re- i|nained in a strangulated state.
The surgeon having exposed the hernial i
should pinch up a small portion of its terior and lower part, between his finger and thumb, carefully excluding any portion of the contents of the sac, and then placing the blade of his knife horizontally, he should cautiously make a small cut into the elevated part, making an aperture of sufHcient size to *llow of the passage of a director, upon which he should further divide the anterior part of sac upwards and downwards,
A quantity of fluid usually escapes, when f the sac is first opened, which varies greatly quantity, and somewhat in colour, accord- ig to the period that the strangulation has ejdsted. It is not uncommon, however, for the fluid to be entirely wanting, even when Lthere are no adhesions. ^B If inflammation runs high, the peritoneal ^Piwrfaee of the intestine is covered by adhesive ~ matter.
The next and most important step in the i operation, consists in dividing the stricture, t the situation of which should first be dis- tinctly ascertained by passing the point of the little finger into the hernial sac, on the tore and inner part of its contents. li" the hernia be large, the scat of stricture s H 3
»
the
may be at or under the opening in the folscm lata, through which the covering formed by the sheath of the femoral vessels is pro- truded ; but generally, the stricture will be found immediately beneath Poupart's liga- ment, in the mouth of the sac itself, where the hernia quits the abdomen.
In either case, a director should be very carefully introduced into the sac, anterior to its contents, and gradually insinuated under the stricture, and upon its grove the hernia knife (before described) should be passed, with its cutting edge turned upwards, and a little inwards, towards the umbilicus, in which direction the stricture should be divided.
In some cases when the hernia is large, strictures may be found both at the cres- centic margin of the fascia lata, and under the crural arch of Poupart's ligament, and each will require division, that at the fascia lata must of course be first libe- rated.
When a stricture, therefore, exists at the crescentic margin, the surgeon, after dividing it, should make a careful examination, to ascertain if the passage to the abdomen be free, before he attempts to return the pro- truded parts, for should a second stricture exist, he may rupture the protruded intes-
103
tiiie ki the* vidence he must employ in en-* dewQwingitQ return iti.
In drn^^fif^ihe ^iner stricture^, it has been Direetioii recprnmendjod t9 cut in the direction of Gimr bemtit's ^gam$nt^ inwards towai^ds the jHibea,; but as the stricture is not occasioned by this ligament, there cannot be any ueees- sity fcMT dijiriding . it ; I have known Gim- b^mat'$ ligaraesit divided, from an idea that it iormed thQ stricture, but the strieiiure still remained at the orifice of the &scia fMX>pri9,, or in. &e mouth of the ssic itself, and the patient died.*
Great caution is requisite in dividing the Great sti^turie, if the protrusion be entirely in- Mry. testinal, and the operator should not intro- duce the knife, until the int^tine hu been carefully placed out of danger by an as- sistant
. Sometime ago, a case occurred in one of Cue. the Bqrough hospitals, in which the intestine was wounded, when the operator was dividing
* It is curious, that Gimbernat's ligament should e^r have been supposed to be the seat of stricture, as it exipli only upon the inner side of the mouth of the WnialsaiB, and therefore could not influence the outer portion. If strangulated femoral hernia be examined in the dead body, and Gimbernat's ligament be cut through, the hernia is not liberated by such a division, for the orifice oE-tiie fascia propria, or the neck of the sac itself, still girt the viscera as much as ever.
H 4
104
the stricture^ which he did inwards^ tc^ardiEr Gimbernat's ligament ; feculent matter was extravasated into the catity of -the abdomen^ and the patient died. On exa^ mining the parts after deaths two openihgs were found in the intestine^ close to fhe mouth of the sac*
Adhesions, fhe treatment I have directed as proper in' inguinal hernia, when the protruded parts adhere to the sac, or when the intestine or omentum are gangrenous/ is also proper under similar circumstances in femoral^ hernia.
After After the operation, the same mode of
treatineoi' . , ir i '
closing the wound, and indeed the after treat- ment generally, should be the same as in the inguinal disease. But little Very little variety is met with in femoral'
variety. , '' "^
hernia, - the most important one is that • in which the obturator artery arises from the epigastric, and surrounds the neck of the sac. 51* ? *V . ^^* Barclay, a celebrated teacher of paraUon. auatomy at Edinburgh, was kind enough to send me a specimen of this variety, which was taken from a patient, whose previous history could not be ascertained.
* Cutting directly inwards is a most dangerous operation in femoral hernia, as the intestine is very likely to be wounded.
. Wardrop has also met with this variety.
Although the obturator artery frequently arises from the epigastric, it is Tery rarely found passing before the sac in femoral hernia, but usually takes a course to the outer side, and beneath the sac, as I have often witnessed when dissecting the parts of femoral hemiae. My mode of avoiding iDJury to the epigastric or obturator arteries, is to make a very slight division of the stric- ture with the knife ; and then, by pressure of the finger or of a director, to enlarge the opening.
In one instance I have met with a large quantity of fluid situated between the fascia propria and the hernial sac. The following is a short account of the case : —
Miss , Bet. 20, had been the subject
of a femoral hernia on the right side for three or four years, which had acquired about the size of a pullet's egg. In June, 1825, the hernia became strangulated, and increased to a very large size. As she did not mention the existence of the hernia to her medical attendants, it was not discovered until the third day from the commencement of the symptoms, the continuance and severity of which led to an examination. Mr. Wakefield, of Hatton Garden, who had attended her.
Fluid be- neUh the fascia pro-
L
106
immediately requested me to visit her; wken, after trying, without effect, the CNndinary means to reduce the hernia, I cq^arated. On opening the fiisda {HPf^na, I was astonished at the escape of nearly a {ant of tianspar^it fluid, resemUing that nsoally drawn off in hydrocele. The hernial sac, which then be- came exposed, was smaQ ; and, chl opauqgt it, a little of the usual dark-coloured flaiA was discharged. A small portion of omes-f turn, with a fold oi small intestine, were pro- truded. After dividing the stricture^ and returning the viscera into the cavity of the abdomen, I removed a large part of loose bag exterior to the sac. The patient, reeo- vered rabidly. f. ?. r.
.■ ':0-
' r - .' .
■ • at
LECTURE XXXV.
On Umbilical Hernia.
This form of heniia, which is also termed syoo^ exompbalos, is next in frequency to the inguinal.
The protrusion takes place through the Nitiirai opening in the linea alba, wliich is formed in the foetal state for the passage of the ves- sels of the umbilical cord.
After the funis has been tied, this opening How dosed
'^ " usually.
usually becomes closed by dense cellular tissue, and the remains of the umbilical . vans and arteries, but not by a tendinous Btracture. The integument over it is adhe- rent, and generally drawn in, forming the navel.
Behind the navel, when these parts are DSe'ecUon dissected, the peritoneum is found, which parn. adheres more firmly at this part than any other of the linea alba ; it is connected above to the remains of the umbilical vein, and below to the ligament of the bladder and feniEdna of the umbilical arteries. There is lot any perforation in the peritoneum behind '^^ navel, as the vessels do not penetrate
108
it, but pass between it and the abdomimd parietes. Commence. Umbilical hernia commences in a small
ment of the
disease. protrusion about the size of a nut, which can be easily reduced, but which again appears immediately the patient coughs <Nr exerts himself. If neglected, it soon increases in bulk ; and, as it augments, it grantateii ^ so I that the. larger part of the . swelling .^ia below the orifice of the sac, and in some instances it acquires so great a size as., to reach to the upper part of the thighs. }.; .
Creates This discasc, if intestinal, and hot imp-
moch sat- ^ . » r
fering. ported, is attended with much danger, aadt creates a considerable degree of sufferings The patient frequently feels so.much.weid&t ness and sensation of sinking, as to be ine|4 pable of making an exertion. The^-boweif: are very irregular in their actions, and'tl)y» > patient is much troubled with flatulenoe, and nausea. ■ '/»*'- .
symptons Besides the frequent occurrence of- these
when in- - ,
testinai. . symptoms, the intestinal protrusion may be distinguished by its elasticity, its unifcmn feel, and by the passage of the air, &€*' through the canal, producing, a gurgling noise.
When When the protrusion is entirely omental,^
omental. *^ . ^ f i
the patient experiences but little uneafianesa or irregularity of the bowels. The feel of the
and doughy, ana is but
sweUing IS nneven
little tender under considerable pressure- Sometimes, if both intestine and omentum wiicnboth. are contained in the hernial sac, they can be distinguished from each other by the above-mentioned marks. The omentum is in these cases usually above, and the intes- tine below. But, most frequently, the quan- tity of omentum protruded is much larger than that of the intestine, and the latter is covered by the former, so that it cannot be at Brst distinguished.
The umbilical hernia is very common in ^ infants soon after birth. Intestine is then generally protruded, and the shape of the swelling somewhat resembles the distended finger of a glove in shape ; the hernia is easily reduced, unless the opening in the tinea alba is very small.
Children, subject to this disease, suffer from griping and a very irregular state of bowels, sometimes being constipated, at others being violently purged.
When this hernia occurs in the adult, if Appe»r- the patient be thin, the shape of the tumor adoit. 18 pyriform and defined ; but in fat persons, the hernia is sometimes scarcely perceptible on a superficial inspection, as it extends upwards and downwards, is flattened ante- riorly, and has its circumference blended
no
Sac in part deficient.
Two sacs.
Case.
Most fre- quent in women.
Causes.
with the adipose matter, so as not to present any defined edge. The tumor may be flat- tened in thin persons, but when so, its eldtent is always evident. j :
Although, generally, the hernia has a peri- toneal coveripg, or proper sac, yet^ in a 'few instances, when the disease has been of l6n||( standing, and , has acquired a very large sttMi I have seen the sac in part wanting.
I have also known two sacs to exist at the same time ; one protruded by the side of the other, and only separated at their origin by a thin septum.
Mr. Cline operated twice upon a womati in St. Thomas's Hospital, for strangulated umbilical hernia, in whom two hemies ex<« isted, having their commencement about haff an inch apart, but the sacs lying in contact. • • Women are much more liable to this disease than men, and the most frequent cause of it is pregnancy, the bowels being pushed up by the gravid uterus as it rises from the pelvis.
Another cause is the deposition of adipose matter within the omentum and mesentery, whereby their size is so much increased that the abdomen is hardly capable of containing them. Women who become corpulent after having had many children, are often subject to this disease, on account of the lax state
Ill
aomioal parictes, not affordit^ suffi- cient resistance to prevent such protrusions.
The distension of the abdominal parietes, and protrusion of the navel, which is some- times met with in ascites, is said to be a cause of umbilical hernia; hut I am inclined lo think that it is more frequently the conse- quence than the cause of this disease.
Treatment of Reducible Umbilical Hernia.
Id infants subject to this disease, the plan in inraDU. I usually adopt, is, after having reduced the hernia, to apply half of an ivory ball sufficient to cover the opening, and to confine it in that situation by means of adhesive plaistcr. A linen belt should be applied, and secured round the body, but as soon as the child begins to walk, two straps must be fixed to the lower part of the belt, which should pass under the pelvis, between the thighs, to prevent the belt from slipping.
For the adult, or even for children, when in aJuii>. the hernia is of small size, a spring truss may he employed, made on the same principle as that directed for inguinal or femoral protrusions. The pad of the truss should cover the opening through which the viscera escape ; and the spring should pass from the pad to the back of the patient, a little beyond
112
the spine ; and a strap should be continued
from the spring to the pad, to complete the
circle.
In very fat ' Whcu the patient is very corpulent, so
persons, ^j^^j ^^ navel is deep, the portion of ivoary
may be advantageously placed under the pad of the truss, the more effectuidly; Ob close the opening of the sac; and this is much better than having a conical pad, which is liable to shift its position when the patient is in motion; but the half globe of ivory does not follow the motion ,of the pad.* When very Very large herniae, accompanied witU & ^"^^' lax state of the abdominal parietes, require a different form of truss, as it. is necessary to make a more extended pressure. The pad of the truss, therefore, instead of being CMO^y of sufficient size to cover little more than the orifice of the sac, must be of considerable extent, so as to press upon a large space round the hernial opening, and thus support the parietes as well as the hernia, which will render the patient comfortable, although there is not any prospect of thus effecting a cure.
^ The ivory ball with the adhesive plaister, wrll, in the adult, prevent the increase of a small hernia, m> as to render a truss unnecessary.
Of the Irredticibk Uinbilical Hernia.
riy large.
Umbilical hernia becomes irreducible from c the same causes as the inguinal does; viz. adhesions of the intestines or omentum to the inner surface of the sac, or a growth of omentum, rendering it too bulky to repass the opening by which it escaped.
Under these circumstances, the hernia Bec-o sometimes acquires an enormous size, more particularly in women, whose abdominal parietes have been weakened by frequent pregnaQcy ; and I have in such persons seen the pudendum entirely covered by the hernial swelling. The umbilicus in these cases is brought nearer to the pubes than natural, by the constant weight and drag of the hernia.
With such a large hernia the patient is D.111 exposed to constant danger from blows or falls ; besides the weight of the tumor, and an ulcerated state of integument, which often occurs, renders the patient incapable of fol- lowing any employment requiring bodily exertion.
When the hernia is irreducible, and not of Tieaiment. very large size, a truss should be worn with a hollow pad, as recommended for irreducible inguinal hernise. The hollow should be just sufficient to contain the swelling, and the
114
edges should be rounded off so as to prevent any injury from pressure to the surrounding parts. The substance of the cup should be pewter, which should be covered with soft leather. The spring should be of the same kind as that of the common truss. When very Jq y^jy large hcmias of this description; a truss cannot be worn ; and all that can be done to relieve the patient is to support tfan swelling by bandages, passed over the shoul- ders so as to prevent the constant dragging of the tumor.
. ■ J
Of Strangulated Vmbilicai HemuB.
Vi
Symptoms. fhc symptoms, indicating strangulation in this form of hernia, are the same as those I have described as existing when inguinal or femoral hemiae are in the same state; but in the umbilical disease they^ are gene^ rally less urgent.
Caoses. Strangulation is frequently produced in
these cases by the 'patient taking food not easy of digestion, or such as occasions flatu- lency ; persons having this complaint should there^Dre eat sparingly, and be careful to avoid all food difficult of digestion, or likely to create flatulence.
lid
The seat of stricture is usually at the seat of tendinous opening through which the hernia fHTOtTudei, but sometimes the neck of the sac itself is thickened, and prevents the re* duction^of -the viscera.
When strangulation exists, the surgeon Treaiment.
" " Taxis.
should first endeavour to relieve the patient by emplojring the taxis in the follovring manner. The patient being placed on the baeky the shoulders should be elevated by pillows, also the pelvis a little raised, and the thighs bent at right angles with the body. The surgeon should then grasp the swelling with hil^ hand, and direct the pressure a little upwards as well as in- wards, because the opening to the abdo- men is not usually in the centre of the swelling, unless the hernia is small, or pro- jecting, when the pressure should be made dirediy inwards. If the neck of the sac can be distinctly felt, the surgeon should knead it with the finger and thumb of one hand, while he presses the hernia with the other.
In very large, flat, and spreading hernia, tn very when the tumor cannot be grasped hy the ifer'nl.. hands, the surgeon should make pressure by means of some broad surface, as the bottom * of a wooden platter, which he should place on the surfoce of the swelling, and keep up
1 2
116
a steady pressure upon it for twenty minutes or half an hour. General Should the employment of the taxis fitil ' in relieving the patient, the other nieans recommended for the femoral and inguinal hemise, under similar circumstances, should be tried ; but the remedy which I have found most successful in this disease, and on which I place the greatest reliance, is the tobacco glyster, as it appears to produce much more beneficial effects in this form of hernia, than in the others I have described. It should be used of the same strength, and with the same precautions I have before mentioned* In many instances I have known this re- medy successful, after repeated trials of other means had failed to relieve the patient.
Bleeding, and the application of cold, I have known to produce the desired effect aflter the taxis had failed ; but the surgeon must be careful how he takes away blood, as women of delicate constitution, and lax fibre, are often the subjects of this disease, in whom the loss of blood, in large quantity, might prove destructive.
Should the strangulation continue in spite of these trials to relieve it, the surgeon should proceed to liberate the hernia by an opera- tion, the performance of which is extremely simple, but requires a little caution.
The patient being placed upon a table of opemtion. convenient height, in an easy position, with the abdominal muscles relaxed, the surgeon should commence the operation by making an incision across the swelling, and then a second cut at right angles with the first, in the direction of the linea alba ; the transverse incision should be below, and should be joined at its centre by the lower part of the perpendicular cut, so that the two represent an inverted x ■
The two angles should be dissected up to expose the superficial fascia, which the sur- geon must next divide, but very carefully, as the hernial sac itself is sometimes wanting in part; and in such a case the protruded viscera would be immediately exposed. This covering should therefore be opened, as if it were the sac, by nipping up a small portion between the finger and thumb, in the manner I have already described.
If the peritoneal covering be complete be- \ neath the superficial fascia, it should be cut into, and divided further, upon a director, in the same way as when operating for other hemiEe. The escape of a small quantity of fluid usually indicates that the sac has been opened.
The protruded viscera being exposed, the DiviiioDof operator should carefully pass his finger over ture.
I 3 I
118
their upper part to the opening of the umbi- licus, and then introducing the hernia knife upon his finger, and insmuating it iiader ihe stricture, he should cut upwards towards the ensiform cartilage to such an extent as will make the opening suflSciently large to allow of an easy reduction of the protruded parts. Return of Haviug divided the stricture, the intes-
viscera. . .« . ^ i i •» i /•
tme, if m a fit state, should be first cau- tiously returned; and the omentum, if in large quantity, or if in a doubtful state, may be cut away, but if in a small quantity, and sound, it may be returned into the abdom^ok. Alter- The edges of the externaUiound should
'"''*'""'• be brought together by sutures, and the approximation completed by strips of adhe- sive plaister ; a compress of linen should be placed over this, and confined by means of a broad bandage passed round the body.
It is of much importance, after this ope- ration, to procure a closure of the wound by adhesion, as the direct communication with the abdomen increases the risk of peritoneal inflammation. Operation For vcry large umbilical herniae, when hwnia?^ strangulated, I should recommend a different mode of operating, which should be per- formed in the following manner. A small opening should be made over the neck of
119
ite swelling, ttirough the integument and superticial fascia, so as to expose the hernial sac at that part ; then the operator should pass his finger between the sac and edge of the umbilical opening, so as to guide the hernial knife, by which the umbilical opening should be dilated upwards without dividing the sac.
1 performed this operation upon a Mrs. Ca«. Aaron, who had long been afflicted with a large irreducible umbilical hernia, which became strangulated. When I had divided the tendon, I was able, by very slight pres- sure, to return a portion of the protruded intestine, anA«he rapidly recovered.
In some cases the intestine adheres so Adiiesious. firmly to the moutU of the sac, that great care is requisite to avoid wounding it. The sepai'ation of these adhesions in part must be effected with as little violence as [Xissible, by means of the finger, to allow of the safe division of the stricture.
In some instances, where there has been stranguii an opening formed by absorption, or lacera- opening™ tion of the hernial sac, tlie intestine, or ''"^" omentum escape from the sac through the aperture, and become strangulated by the pressure from its edge. lu these cases there is considerable danger, unless the operation be very carefully performed, as the viscera
120
are exposed immediately the superficial fascia is divided.
Should the adhesions be extensive asul
firm^ the surgeon must be content witii
liberating the stricture, and not attempt tO'
return the protruded viscera. >.
Pvtorthe The intestine generally protruded inumr-
colon pro- . . *
truded. bilical hernia, is a portion of the colon ;. the appendices epiploica^. of which become more quickly altered than the intestine itself; and if much changed, they should be cut off rather than any risk incurred by leaving, them to slough after the operation. S*"r'ra^ The danger in this operation is of wound- tion. ing the intestine, as there is not any vessel of importance that can be injured.
Of Ventral Hernia.
Like the This hernia only differs from the umbilical uni ihcai. ^^ j^ g^^^ which is usually at the linea alba,
or linea semilunaris; but any visceral pro- trusion at the anterior, or lateral parts of the abdomen, except those already described, may be called ventral hemise. symptoms. The symptoms of this form of hernia are usually the same as those of the umbilical, excepting when the hernia is formed be- tween the umbilicus and ensiform cartilage
121
in the linea alba, and contains a portion of the stomach, when peculiar symptoms will arise.
I once saw a gentleman with a hernia in cme. this situation, who suffered constantly from indigestion, flatulency, and a distressing sensation of sinking at the scrobiculus cordis. His hernia was, however, reducible, and the application of a truss relieved al! his unpleasant symptoms.
The following causes may give rise to this Came.. hernia : —
1. A natural deficiency of tendinous struc- ture, which I have known to a very consi- derable extent, in the linea alba or linea semilunaris.
2. The apertures for the passage of blood- vessels being unusually large.
3. Injuries by which the continuity of the parietes is destroyed.
The coverings of ventral hernia are gene- covetingji. rally the same as those of the umbilical disease; viz. the integument, superficial fascia, and peritoneal sac ; but in some in- stances I have found another covering con- nected with the edge of the opening in the tendon through which the hernia escapes.
When this hernia occurs in consequence of wound, the coverings must, of course,
122
Of the Reducible Ventral Hernia.
Triui. When seated in the linea alba» a tnisi^
similar to that employed for umbilical hernia^ should be worn ; but, when low down in the linea semilunaris, the truss applied shoiiUi resemble that recommended for ingninal hernia, only that the pad must be turned somewhat upwards.
When irreducible, the same form of tmss^ with a hollow pad, will be required.
/»,
Of Strangulated Ventral Hernia.
Symptoms. The symptoms indicating strangulatioB of this hernia are, in every respect; similari to those already described, as occurring when umbilical hernia is in the same state; and the means which should be tried, with a view of relieving the patient, should be of a like nature.
Treatment. As in the umbiUcal disease, the tobacco enema has here a more powerful effect than in the inguinal cur femoral herniee.
Taxis. In employing the taxis, the pressure
should be made a little upwards as well as inwards, for the swelling, like the umbi-
J23
lical, has the greater part situated below the opening from the abdomen.
If an operation becomes necessary for the operation, relief of the patient, it should be performed ia the ^same mode as that described for um- bilical hernia ; but when the disease is seated low down in the tinea semilunaris, the sur- geon must bear in mind the course of the epigastric alrtery, and divide the stricture so as to ayoid it.
In very large ventral hemiae, the operation For large I have mentioned before, of merely exposing the neck of the sac, and dividing the stric- ture, without opening the sac itself, may be adopted with advantage.
In the after-treatment of these cases, After- nothing of importance is necessary beyond ^®**"®"*- what I hav« already recommended for the other forms of h^mise.
Cf the Thyrmdeal Hernia, or Hernia ' Faramims Ovalis.
The 'first example of this disease which I saw, was accidentally discovered in a male subject, in whom an inguinal hernia also existed on the same side. The parts are preserved in the Collection at St. Thomas's Hospital.
124
courte. The hernia was protruded through the opening in the ligament of the foramen ovale, by which the obturator artery and nerve pass to the thigh; the pubes was imme- diately before the neck of the sac^ and the ligament of the foramen embraced the other portion about three-fourths. The obturstor vessels were situated behind, and somewhat to the inner side of the neck of the sac. The sac itself, not larger than a nutmeg, was placed under ^the heads of the pectineus and adductor brevis muscles. Two her- ^ lately had an opportunity of seeing two sme^^r- sp^cimeus of this hernia in the same subject, •^"- one existing on each side, which were .not
discovered during life.
Several cases of this form of hernia arc^ related in the first volume of the Memoirs of the Royal Academy of Surgeons at Paris. - Operation The depth at which this hernia is situated, ^" ** would render an operation, in case of stran- gulation, extremely difficult ; but, should such a step be necessary, I should recom- mend the division of the stricture inwards on account of the obturator artery, &c. Treatment. If rcduciblc, a truss, similar to that used for crural hernia, but with a thicker pad, would prevent its further descent.
Of the Pudendal Hern
This hernia appears in the external labium lu ««t. pudendi, about its middle.
It commences at the side of the vagina, count, and passes into the labium between the vagina and ischium ; it has usually a pyra- midal figure/ and presents the characters of other herniae, as elasticity, dilitation on coughing ; also appearing in the erect, and , disappearing when the patient is recumbent.
The situation of the swelling, and its want of connection with the abdominal ring, suffi- ciently distinguish it from inguinal hernia, which also appears in the labium, but at the i
upper part.
The increase of this disease may be pre- Treatmpnt. vented by the patient's constantly wearing a bandage to support the part ; but a partial protrusion cannot readily be checked, as from its situation, a pessary, unless of very large size, would not be of any service.
When strangulated, the usual remedies When before mentioned should be tried; and, if an operation becomes necessary, the sac should be carefully opened, and the stric- ture divided inwards towards the vagina, the bladder being previously emptied.
L.
126
Of the Vaginal Hernia.
lu teat. This hernia protrudes between the utenii and rectum, where the peritoneum is re^ fleeted from one viscus to the otiset, at die posterior part of the vagina; 8om;etimas; however, it appears at one side instead jrf the posterior part. It is only cciv^red by th€ lining membrane of the vagina.
Treatment. The uso of a pessaiy will prevent the protrusion of this disease. :)
Of the Perineal Hernia.
it4 teat. In the male, this hernia protrudes betweetl the bladder and rectum ; and, in the female, between the rectum and vagina.
Gate. I have only seen one instance of this
disease, which was in the body* of a male brought into the dissecting room. Dissection. The reflected portion of peritoneum be-* tween the bladder and rectum, was pro- truded as far as the perineum, but no elrter-^ nal tumor was perceptible; Mr. Ctitli£fej surgeon, at Barnstaple, has the parts pre^ served.
Anterior to the sac were seated part of the bladder, the prostrate gland and termi-
nations of the vesiculte seminales ; behind was the rectum, and the mouth of the sac was about two inches and a half from the
IDUS.
The following curious case is taken from Mr. Bromfield's Chirurgical Observations : —
"A lad, between six and seven years of Chbc age, was put under my care to be cut for the stone. The staff, in the attempt to in- troduce it into the bladder, met with resist- ance from a stone, which seemed to be lodged in the membranous part of the urethra, Or a little lower down in the neck of the bladder. I made my incision, as usual, through the integument and muscles, to get at the grove of the staff; and then pressed the blade of my knife into the sulcus, at the extremity of the staff, being able to divide only the membranous part of the urethra; Mid a very small portion, if any, of the pros- trate gland ; by the examination of the parts, with my fingers, I then found that this hard body was a process continued from the body of the stone contained in the bladder ; I therefore took the double gorgeret, without the cutting blade affixed, intending only to push back the stone, and dilate the neck of the bladder, which I did by getting the beak of the gorgeret into the sulcus of the staff, and pressing it against the point of the stone,
128
following its course with the instrument as the stone retired : but the direction that the gorgeret took alarmed me, as it passed under the ossa pubis with great obliquity. I then concluded that the instrument had taken a wrong route, as I could not, in this case, have the advantage of the grove of the staff farther than the extremity of the membra- nous part of the urethra ; but, on withdraw- ing the upper part of the gorgeret, I intro- duced the fore-finger of my right hand into the bladder, by the under part of the instru- ment, which remained in the bladder, and was now no more than the common gorgeret ; by which I was soon convinced that it was in the bladder, the situation of which was raised much higher in the pelvis than usual. I then introduced my forceps, and, while I was searching for the stone, a thin diaphanous vesicle, like an hydatid, appeared rather below my forceps, which, in the child's screaming, soon burst, discharged a cleetr water, as if forced from a syringe ; the next scream brought down a large quantity of small intestines. I need not say, that this was sufficient to embarrass a much better operator than myself; however, I proceeded in the operation with the greatest tranquillity, being convinced, that this very extraordinary event was not owing to any error in the
eratian::' but tlie difficulty was to keep the Intestine out of the cheeks of the Ibrceps, should again attempt to lay hold of the stone; the extraction of whicli would be very difficult to effect, from the unusual situation of the bladder in this subject. The lower part of the gorgeret remaining in the bladder, the forceps were again easily intro- duced, which being done with the fingers of ray right hand, I pressed back the intestines, while I laid hold of the stone ; but during the extraction the intestines were again pushed out by tlie child's screaming : never- theless, as I had the stone secure in my forceps, I proceeded to extract it, which I did very easily. Before I introduced the common gorgeret for the introduction of the forceps the next time, I got up the intestines again, and desired my assistant to keep them up till 1 got hold of a second stone, which, from its shape, appeared to be that which had got into the neck of the bladder. As soon as I was convinced by the examination, with my finger, that the bladder was freed totally from any pieces of stone, I again returned the intestines into the pelvis, and brought the child's thighs close together; a piece of dry lint was applied on the wound, and a pledget of digestive over it ; he was then sent to bed, witli no hopL- of his siir-
V o I, . 1 1 1 . Iv
130
viving till the next day; but, contrary to expectation, the child had a very good night, and was perfectly well in little more than a fortnight, without one alarming symptom during the process of cure ; neither did the intestines once descend through the rup^ tured peritoneum after they had been re- turned when the operation was finished/'
The following are Mr. Bromfield's ideas of the nature of this case : —
'* After the incision of the integument and muscles was made, as usual, there soon ap« peared in the wound something like an hy^ datid, which proved afterwards to be that part of the peritoneum which is extended from the left side of the bladder and intes^ tinum rectum to its attachment on the inside of the left OS innominatum ; preventing th^ intestines from falling down too low into the pelvis ; therefore, in this case, this expansioii of the peritoneum must have been forced out of its usual situation.
^* Suffering daily more and more extension, it will at length permit the intestines to fall down to the very bottom of the pelvis, be- tween the bladder and the rectum; there- fore, when in the case above related, the resistance of the integument and muscles was taken off ^by the operation, the perito- neum was forced out, and at first was fiUed
\3l
Oily with lymph, which gave it tbo apjiear- ance of an hydatid ; but its thinness not being able to resist any longer the force of the abdominal muscles, pressing the viscera downwards, it burst, and the intestines soon followed through the aperture. If this is allowed, we can easily account for the ob- lique course that the gorgeret took when first introduced, as the intestines had raised up the fundus of the bladder against the back part of the ossa pubis, so that my forceps could not be conveyed into the bladder, but almost in a perpendicular direction ; and I was obliged to press with my hand on the lower part of the abdomen, just above the pubes, to bring the bladder and its contents sufficiently low for the laying hold of the last stone with my forceps."
Scarpa met with a case in which this hernia formed a tumor in the perineum.
This form of hernia, and the vaginal, may become dangerous during gestation, and some cases illustrating this are related in Dr. Sraellie's cases on midwifery.
Of the Ischiatk Ha
This is an extremely rare form of hernia ; very n indeed, I have only seen one specimen of it,
K 2
132
for which I am indebted to my friend Dr. Jones, whose name is well known by his excellent work on haemorrhage. Case. Dr^ Jones having told me that he had inspected the body of a patient who had died in consequence of the strangulation of a portion of intestine in the ischiatic notch, I became very anxious to obtain the parts ; and, after considerable difficulty, we obtained permission to open the body a second time, when I removed the hernia and surrounding parts.
Dr. Jones had been requested to visit the. patient, a young man, about twenty-seven* years of age, in consequence of his suffering from symptoms which resembled those pro- duced by strangulated hernia. The patient stated that he had experienced a simitar! attack before, which had been relieved by opium, followed by a dose of castor oil. Dr. Jones, therefore, gave him some opium, and directed that he should take some pilla composed of calomel and scammony, as soon as the stomach appeared tranquil.
On the day following, Dr. Jones found that the patient had experienced relief for a short period after taking the opium, but that the pills had been thrown up, and no evacuation had taken place from the bowels. The patient was also much troubled by eruc-
133
■
tations and flatulence, for which he took some spir: ammoniae comp: and spirit: lavendulee, with good effect.
Dr. Jones, feeling confident that the symptoms were produced in consequence of the strangulation of some portion of the intestines, now examined the man carefully ; but could not detect any protrusion; nor did the patient complain of any local pain, which could induce Dr. Jones to inspect the ischiatic notch.
As no stools had been procured, some purgative glysters were thrown up, but with- out producing the desired effect. Other purgatives were subsequently given, and glysters were again thrown up, but without affording relief; also leeches and blisters were employed, but they produced only temporary benefit. On the sixth day from the commencement of these symptoms, they suddenly subsided, excepting that no eva- cuation from the bowels took place ; and the patient felt himself so well, that he was de- sirous of going to business; but Dr. Jones advised him to remain quiet for some days. Early on the morning of the seventh day ^ the patient got up, and went down from his bed-room, which was in the fourth story, to the ground floor, but he soon returned, complaining of being very unwell; after
K 3
134
which he gradually sunk, and expired on the same evening. DLuection. Qn examining the body after death, % portion of the ilium was discovered pasBing by the right side of the rectum to the is* chiatic notch, through which a fold of the intestine was protruded into a small h^nial sac, to the inner surface of which the intes- tine was adherent. The strangulated part of the gut, and about three inches of it on each side of the stricture, was very much discoloured. The intestines between the stomach and protruded portion were dis- tended with air, and had a few livid spots upon them. The intestines from the stric- ture to the rectum were very much con- tracted, particularly the arch of the colon.
On carefully dissecting the parts after I had removed them from the body, I found a small orifice in the pelvis, anterior to, but a little above the sciatic narve, and on the fore part of the pyriformis musclef • This opening led to the hernial sac, which was situated under the gluteus masimus muscle, and in which the intestine had been strangulated.
The orifice of this hernial sac was placed anterior to the internal iliac artery and vein, below the obturator artery, and above the obturator vein; its neck was seated before
135
the sciatic nerve, aiid its fundus was covered by the gluteus maximus muscle. Below the fundus was the sciatic nerve, and behind it the gluteal artery ; above, it was placed near the bone.
Should the existence of such a hernia be Treatment.^ ascertained, it might, if reducible, be pre- vented from protruding by the application of a spring truss ; but, should it become strangulated, and an operation be deemed advisable, I should recommend the division of the stricture to be made directly forwards.
Of Ike Phrenic Hern
^ Protrusions of the abdominal viscera in through the diaphragm, may take place either at the natural apertures framed for the passage of the (Esophagus, vena cava, aorta, &c., or through unnatural openings, t|ie consequence of malformation or injury.
When this hernia exists, the patient suf- .sy. fers much from interrupted respiration and cough, besides experiencing the symptoms of hernia already enumerated.
This hernia has, or has not a proper sac. He according to the circumstances of its for- mation; when protruded through one of the
^■Mttural apertures, it has a proper sae ; when
136
occurring from malformation, it someliiiies has a peritoneal covering, and aometimei this covering is wanting; when the conae- quence of laceration or injury, the hemid sac is always deficient. Csie. I have never seen an hernia protruding through any of the natural openings of. the diaphragm; but several cases are related by Mortgagni, in which this form of hernia existed. He mentions the case of a young man who was attacked with symptoms of acute cardialgia and constant vomitinjg, v. under which he expired. On examining his body after death, the omentum, with part of the colon, the duodeum, some portion of the jejunum and ilium were found in the cavity of the thorax, having passed through the same opening by which the oesophagus descends; the lungs and the heart were compressed into a very small space. Fioiiimai. The occurrence of phrenic hernia frmn
formHtion. , , *
malformation is not very uncommon. There are two preparations in the Museum at St. Thomas's Hospital exhibiting this disease. In one instance the opening is of sufficient size to admit nearly the whole of the small intestines through it ; in the other specimen the large portion of the stomach was pro- truded through a much smaller aperture.
137
In both cases the unnatural openings al-e m the left muscular portion of the diaphragm.
Some cases of this form of the disease are also related in the first volume of Medical Observations and Inquiries, by Dr. G. Macauley.
When the unnatural aperture is small, the Daiigar patient suffers frequently from the usual symptoms of hernia, and is in danger of being destroyed by a strangulation of the protruded parts as in other hernia.
In the year 1798, I published the history of an interesting case of this description, which I shall take the liberty of relating here.
Sarah Homan, set. twenty-eight, had, from c«e. ber childhood, been afflicted with oppression in breathing. As she advanced in years, the least hurry in exercise, or exertion of strength, produced pain In her left side, a frequent cough, and very laborious respiration.
These symptoms were unaccompanied with any other marks of disease ; and, as her appetite was good, she grew fat, and, to common observation, appeared healthy. The family with whom she lived suspected her of indolence, and her complaints being considered as a pretext for the non-perfor- mance of her duty, she was forced to under- take employments of the most laborious kind.
138
This treatment she supported with pa- tience, though often ready to sink under its consequences. After any great exertion, she was frequently attacked with pain ia the upper part of the abdomen^ with yomif*- ing, and a sensation, as she expressed it,, of something dragging to the right side; which sensation she always referred to the region of the stomach.
The cessation of these sj^ptoms used to : be sudden, as their accession. After suffer- ing severely, for a short time, all the pain and sickness ceased, and allowed her to resume her usual employments.
As her age increased, she became mem liable to a repetition of these attacks ; and, as they were also of longer continuance tbaa in the early part of life, she was at length rendered incapable of labouring for her sup- port.
Some days previous to her death, she was seized with the usual symptoms of strangu- lated hernia; viz. frequent vomitings, coft^ tiveness, and pain ; the pain was confined to the upper part of the abdomen, which was tense and sore when pressed.
As these symptoms were unaccompanied with any local swelling which indicated the existence of hernia, they were supposed ^to be produced by an inflammation of the ia^-
139
testines; tut there were other symptoms that could not be attributed to this cause, which occasioned much obscurity with re- spect to the true nature of the complaint, and seemed to iadicate a disease in the thorax. She was unable to lie on her right side, had a constant pain in the left, a cough, difficulty of breathing, attended with the same dragging sensation of which she had formerly complained.
The signs of inflammation of the intes- tiues, with the addition of a troublesome cough, continued without abatement for three days, when she expressed herself better in these respects ; but the morbid symptom in the thorax remained as violent aeat first; and in the fourth day from their commencement she expired.
On examining the body after death, when Dissection, the abdomen was opened, there appeared a rery unusual disposition of the viscera. The stomach, and left lobe of the liver, were tliriKt from their natural situation towards the right side. On tracing the convolutions (rf the small intestines, they were found to retain their usual situation ; but lines of inflammation extended along such of their surfaces as lay in contact. This appearance tile adhesive inflammation assumes in its early stage ; and it is highly probable, that,
140
if the approach of death had been less twpk these surfaces of the intestines would- ban been glued together by the effusion of coagti- lated lymph. ♦;
When the large intestines were examined^ the great arch of the colon, instead of beiog stretched from one kidney to the other, wai discovered to have escaped into the left caxntf of the chest, through an aperture in the diaphragm. The coacum and beginning'^, the colon were much distended with aiv^ and appeared therefore larger than natural ;. bit the colon, on the left side, as it descend toward the rectum, was smaller thap it is commonly found.
A small part only of the omentum i could be discovered in the cavity of the abdolnen, . a considerable portion of it having^ be^n fBO^ traded into the chest, through the same opening by which the arch of the colon had passed* The displacement of the stomach, and left lobe of the liver, had arisen/ from the altered .position of the colon and omen- tum; which, in their preternatural course towards the diaphragm, occupied the situa- tion of each of these parts.
When the chest was examined, the left lung did not appear of more than one third of its natural size ; it was placed at the upp^ part of the thorax, and was united to the
141
pleura costalis by recent adhesions. The protruded omentum and colon were found at the lower part of the left cavity of the chest, between the lung and the diaphragm, floating in a pint of bloody-coloured serum. The colon, in colour, was darker than usual ; } in texture, softer, and distended with fecu- lent matter mixed with a brownish mucus. The portion of the intestine contained within the chest measured eleven inches. The omentum was also slightly altered in colour, being rather darker than natural; but, in other respects, this viscus was not changed ; it adhered firmly to the edge of the aperture, and more than half of its substance was con- tained within the chest.
The opening thix)ugh which these viscera had protruded, was placed in the muscular part of the diaphragm, three inches from the oesophagus ; it was of a circular figure, and two inches in diameter ; its edge was smooth, Imt thicker than the other parts of the muscle.
The peritoneum terminated abruptly at the edge of this aperture, so that the protruding pairts were not contained in a sac, as in cases (rf* common hernia, but floated loosely, and without a covering in the cavity of the chest, of which' they occupied so large a space, as to occasion considerable pressure on the left
142
lung, and to produce the diminution I have before remarked.
The right side of the chest, also the right lung and the heart, were free from disease.
Gould the precise nature of this disease be ascertained during the life of the patient, but little could be done for his relief; no more, than, perhaps, his own feelings would dic- tate, the refraining from all kinds of bodily exertion. From lace- The third cause of this form of hernia \i I
ration.
woimd, or laceration of the diaphragm, and the former inflicted with the small 6Wotd, has been the most frequent. The opening is at first prevented from closing, by the pressure of the abdominal viscera, which frequently protrude through it, in small quantity at first; but at length, should the patient survive, very large portions escape.
The only instance in which I have known this disease produced by accident, has been from laceration of the diaphragm, in conse- quence of the fracture of several of the ribs. Case. William Rattley, aged thirty, was admitted
into Guy's Hospital. About one o^clock on February 6, 1804, having fallen from the height of about thirty-six feet, by which six of the lower ribs on the right side were fractured. When admitted, he breathed with great difficulty, and complained of excessive
14
' pain; the crepitus from the fractured ribs could be distinctly felt, and there was slight emphysema. Soon after his admission, he Tomited violently, had frequent hiccough, and expired about eight o'clock on the follow- ing morning.
The following appearances presented them- D'sseeiioi selves on inspecting the body after death. A small wound at the inferior and posterior part of the right lung, with some slight but recent adhesions between the two portions of pleura. On pressing down the diaphragm, i portion of intestine was discovered, in the cavity of the chest on the right side, of a livid colour. On examining the cavity of the abdo- men, this fold of intestine proved to be a part 1 the ilium, which passed upwards behind l&e liver, through the lacerated opening in ffte diaphragm, into the chest. The aperture in the diaphragm was situated about two iaches from the cordiform tendon on the right I side, in the muscular structure ; it was filled Ihy the intestine, which was confined by a ffinn stricture. The laceration had been oc- casioned by the fractured end of the tenth rib. The other viscera of the abdomen were otherwise but little altered ; but near a quart of bloody serum was extravasated into the cavities of the chest and abdomen.
144
Of the Mesenteric Hernia.
\\\
Cause. This hernia occurs in consequence of 4
natural deficiency of one of the layers com- posing the mesentery, or from an accidentd aperture being made.
Formation. fhc intcstincs forcc themselves into such an opening, and, quitting the proper cavity of the peritoneum, form a hernia, which may become of very large size, as the cellular union of the two layers is not sufficiently firm to ofier much resistance to the pressure i of the protruding viscera.
Case. Mr. Pugh, of Gracechurch Street, afforded
me an opportunity of examining a hernia of this kind. The subject in which it was found, had been brought for dissection to St. Thomas's Hospital ; and the man had been a patient under Mr. Forster, in Gruy's Hos- pital, just previous to his death.
Appear- ^^ Opening the abdomen, and raising the omentum and colon, the small intestines were not to be seen, but a large swelling was discovered, situated over the lumbar vertebrs, and reaching to the basis of the sacrum; which, on further examination, proved to be a sac of peritoneum, containing the small intestines, and surrounding them completely, excepting at the posterior part, where the
anccs.
aperture by which the intestines had escaped,
was situated.
From what I could collect of the previous iistory of the patient, he did not appear to Aave been much inconvenienced by this Unnatural position of the viscera.
Of the Mesocolic Hernia.
The formation of this hernia is similar to that last described ; and the first example I had an opportunity of examining, was, as the former, in a subject brought to the Hospital lor dissection.
The abdomen having been opened, and the Appp«r omentum and large intestines turned up, a tumor was discovered on the left side of the cavity, extending from over the left kidney, to the edge of the pelvic cavity, the lower portion being situated in the fold of the sig- moid flexure of the colon. The large intes- tines took their usual course, only that the ccecum was nearer to the centre than in com- mon. On the left side, the colon was raised by the tumor. The duodenum, a small part of the jejunum, and teimination of the ilium, were the only parts of the small intestines to a, on first opening the abdomen, all ^ being situated in the sac, having
I VOL. III. L
^-*ic on its right side, _^i 10 admit two folds MCiAxed state. cau9P. ^^^ J y the peritoneal layers
j^iriuloes, sent me a drawing,
^ iipir part of the moveable
*"*''"= '•'■ . ^ w J iie layers of the peritoneum,
^K,a examining the body of a &u ictonded.
:^^i»^muCMi of t/ie Intestine withm the
Abdomefi.
SIB. w bave known to occur in several j^tfUw ways.
;n>i. From the intestine protruding^ uwn^^ jin aperture in the omentum^ mesen— ^,%. ^i mesocolon.
>«W«h1. — From the same circumstances*^ vvuittnjt when small openings are left in the - .vtlKv^^H^ formed in consequence of inflam-
I'hml.- From a membranous band formed ,t; iho mouth of a hernial sac, becoming elon- >;;iUHl, and entangling the intestine when it !k^s Ihhmi returned from the hernial sac.
Fourth. — From the appendix vermiformi& ^ uian^liu^ the intestine.
!n;ikes, surgeon, of Barnstey, in casc. . sent me the accoHiit of a case in I portion of intestine had been pro- ■ through an opening in the omentum, iiatl become strangulated. The patient as eighty years of age, and had been l^reviously very healthy and active. The Ciase terminated fatally, two days after the com- mencement of the symptoms ; and on ex- amination after death, the intestine was found in a gangrenous state.
A case in which a portion of small intes- Case.
tine had protruded through an opening in the
meitentery, and become strangulated, occurred
QHder the care of Mr. Palmer, of Hereford.
The symptoms were severe, but the patient
3tirviv6d until the ninth day from their com-
^Hencement.
Dr. Monro has related a case of this nature *tt his wofk on Crural hernia.
IMfe. Rodsoh, of Lewes, attended a young Case. ^3aan who died in consequence of the strangu- lation of a fold of small intestine, which had Protruded through an aperture left in an ^hesion of the omentum to the peritoneum.
I have a very excellent specimen, showing case. the strangulation of intestine by elongated membranous bands. It was taken from the lx)dy of a patient of Mr. Weston's, of Shore- ditch. The patient was eighty-five years of
L 2
148
n Hozton Wcatiune.
He was seized with symptooiB hernia, in consequence of ipiiiidi llr.Wii was sent for, who, on examining At mHi found a hernia on the ri^t side, wiatk k soon reduced by the taxis. The synfttni^ however, continued, and the patient died. On examining his body after deatii, I find that the intestine had been retained into dn cavity of the abdomen, but that two CoUiaf it were entangled and strangulated by a kiy membranous band, spedmen la the Museum at Guy's Hospital i» t Mosemn. beautiful preparation, showing a constdeiaUfi portion of the small intestine, surrounded and strangulated by the appendix vennifimniii but I am not acquainted with the history of the patient from whom it was taken.
As the precise nature of any of the above cases could not be ascertained during the lives of the patients, no ben^t could te derived from surgical aid.
Ilk
tia
149
.s.v>
LECTURE XXXVI. On Wounds.
Solutions of continuity on the surface of 2^/!?'*' the body are of four kinds, according to the manner in which they are produced; viz. Incised, Lacerated, Contused, and Punc* tared.
Incised, when produced by a cutting in* strument; lacerated, when the parts are forcibly rent asunder; contused, when oc- casioned by some heavy body, or one pass- ing with great velocity ; and, punctured, if made by a pointed substance.
This division of wounds is attended with advantage in the description of their treat* ment, as it must in some degree vary from the mode of their production.
Of the Incised Wounds
The lips of the divided parts^ are more character, or less separated according to the extent of the injury ; and, the division of the mus- cles, which, by their contraction, lead to
L 3
150
u gaping state of the wound, as in tiie cheek, the lips, or in transverse incisions in the limbs.
The wound is covered with blood, which is florid or purple, as an artery or vein hu been injured. If an artery, the blood flows by jets rapidly, and is of a florid colour ; H a vein, the bleeding is slow, gradoaUy filling the wound, and the blood is of a pinrpl^ colour. Fainting is produced if an artery [)0 cut, but rarely, if the bleeding be venotti. Fainting also results if the wound extends to parts of vital importance, even although the haemorrhage be very slight. i.< tiMuiii. When you are called to a case of incised wound, you are to make pressure upcm its Hurface with a sponge to arrest the hsBmorr*> hage, and if the divided vessels be small, you will soon find it subside under a steady and continued pressure.' But if an arteiy of any magnitude has been injuied, it should be drawn from the surrounding parts by a pair of forceps, or raised by a tenaculum, and then tied with a very fine ligature ; one end of which should afterwards be cut off, that no more space than is absolutely neces- Hary may be occupied by the thread or silk.
So soon as the bleeding ceases, the coagu- hited blood is to be completely sponged away hfftn the surface and edges of the wound.
151
the edges are to be brought together, and a strip of lint or Unen moistened with the blood, is to be placed on the part in the direction of the wound, when the blood, by coagulating, glues the edges together in the most efficient and natural manner ; adhe- sive plaister is to be applied over the lint with spaces between to allow of the escape of blood or serum.
In a few hours, inflammation arises, and How fibrin becomes effused upon the surfaces and edges of the wound, by which they become cemented.
In a few days, vessels shoot into the fibrin, organwed. effused by the inflammation ; and it becomes organized with arteries and veins, and after a time, with absorbents and nerves ; thus the structure of the part is restored.
If the wound be in a muscular part, more wound of
■ 11 ■ IP muicle.
especially m transverse wounds of muscles, it is required that the position of the * iitnb be carefully attended to, that the wounded muscle may be relaxed as much as possible, and its separated portions ap- proximated. Thus, if the biceps muscle Were divided in the arm, the limb must be bent at right angles; and if the triceps be injured, extension will be necessary.
But if the wound has happened in a mus- t cillar part, which is not supported, as in the
.^k.
150
ji gaping state of the check, the lips, or in U. the limbs.
The wound is co\ . is florid or purple, been injured. If .. by jets rapidly, . a vein, the blcc the wound, r colour. Fai
r\ e ap
■-' >liould b'
iis many a
«> produce thi
iserted.
.:kI of considerabl
t .^le is desirable, o
re returned in thei
be cut, bill Faintinjr : * to parts the hiv
T.rjihiicnt. \VI WO I
A. X suppose that suturej
. zjLt they should be nevei
. . jtt -iiien heals better witl:
.^ua^ lotion, than with ad-
i^mieed, adhesive plaistei
= .i,riit*c to the edges of wounds.
j^u X produce erysipelas, and
St. ^ry^sipelas followed by the
wieat. After the removal of
jvia the breast, I often em-
^ajfu :^ keep the parts in exact
4Hi ji; pne'%"ent the edges from be-
g^,. :ic wound is healed, the parts ux ^Mierally reproduced. The
^••«
, oiv. .uccvc, easily ; the rete mucosum, ^^t- \. Vhe cellular membrane is for
.mt*»%.
itKij^TXicd. and requires the use
, » — —
.^^:vu .*t'" the [>arts, to be completely
..»;ll ,V'
%•
branches of arteries and
153
^! instead of the original
s are reproduced. Tendons
■ i formed. Bones are united by
lie parts are not reproduced. There Muscle vcimen in the Collection at St. Tho- dSced?'"^ ^ tiospital, in which a wound of a muscle f'cn united by a tendinous structure. i iicre is also a specimen of a cartilage of a rib united by bone, but in young persons eartilage is reproduced.
Parts which are nearly separated readily Parts x^inite, as the finger or the nose when it has parated^ l)een cut, or torn, and a suture is required readuy. tx) aid its union. >
Parts entirely separated in other animals Parts . -Mmetimes unite. Mr. Hunter removed the separated Spur of a cock, and placed it in the comb by ^ ""' ** incision, where it not only adhered, but grew. He also removed the testis of a cock, and ]daced it in the belly of a hen, where it ^ered. A tooth extracted from the human subject, and placed in the comb of a cock, ^eres there.
The only instance in which I have seen ^ part removed entirely, and afterwards ad- here, was in the following case : —
I amputated a thumb for a patient in Guy's Hospital; and, finding that I had not pre- served a sufficient quantity of skin to cover
154
the stump, I cut out a piece from the thum which I had removed, and applied it upoi the stump, confining it by stripes of adhesive plaister. On taking off the dressings a fe¥V days after the operation, I found, that the portion which had been completely sepa- rated, and afterwards placed upon the stomp, was fimly united and organized.
The most extraordinary instance of the union of a separated part has been related by Dr. Balfour, in the Edinburgh Medical and Sui^cal Journal, for October, 1814, from which the following account is taken: — - Case. " On the 10th of June last, two men came to my shop about eleven o*clocfc in the fore- noon; one of whom, George Pedie, a house carpenter, had a handkerchief wrapped round his left hand, from which the blood wa$ slowly dropping. Upon uncovering the hmd^ I found one half of the index finger wanting* I asked him what had become of the ampu-^ tated part. He told me that he had never looked after it, but believed that it would be found where the accident happened. I im^ mediately dispatched his companion «to look for it, and to bring it to me directly he found it. During his absence I examined the wound, which began near the upper end of the se- cond phalanx on the thumb side, and termi- nated about the third phalanx on the other
Uillbe^ inflicted
pieew.itf the
cold, BvA
oandle.
^o a
. off
.idhere
with as
:c wounded
sing a confi-
ould take place.
■ 1 re the patient with
V did not appear con-
)ility of sueh an odcw*
. Iiim, that, unless pain or
should occuF> I would not
dressings for a week at least.
him to keep his arm in a sling,
. to attempt any kind of work ; to
a he promised pbedienc^. He called on
0 the next day, when be was quite easy,
but the wound had bled a little. Although
he prqn^sed to call on me daily, I did not
see him^again till the fourth of July. I had
concluded that he hnd applied to some other
jHactitioner ; but, on the second of July, a
gentleman called on me, and gave me the
^wing account of the patient : —
"Two days after the accident, the patient.
154
Case.
the stump, I cut out a piece from which I had removed, and applif the stump, confining it by stripes plaister. On taking ofi* the dre.' days after the operation, I fbi portion which had been con rated, and afterwards placed u was firmly united and organi?
The most extraordinary union of a separated part by Dr. Balfour, in the F and Surgical Journal, f from which the following
"On the lOthof Jun^ to my shop about elevo noon ; one of whom, < carpenter, had a hand ^ his left hand, from slowly dropping. U' I found one half of I asked him what tated part. He t looked after it, b found where th(
mediately dispr for it, and to b^ it. During hisi which began cond phalan^ nated about
ritf
ly, how-> >v even iier pnrpMNIJl'
• ■
informatiMf-I^ ..und out 'dift pcitidlV . mion of tte'peltB yhU 7 was in fitBt tiicf ' hadtf :. and bid tteoVered bctf 7 In As- 'j^0{gf6M of tb «:tf ^MVedf^fd ><>on aA fiBoir.
of persons prew ^flieted, I am satisfi [re elapsed bef
-ni4W
iie
iS can Adhesion prevents ceases, danscr.
>
iiien, ex-
L followed
\e to unite.
iplicated with
be dangerous
. Wounds of the
jii, and the patient
is prevented by the Adhesion
, J preYented.
s in incised wounds : —
uction of many, and of Bysutnrei.
is therefore necessary to
threads, and to cut off one
lat they may occupy as little
ijle ; and in, from four to six
juld be removed; thus they are
om producing suppuration and
he inflsunmation being suffered to By too much
inilammation.
c
i:
158
run too high from want of bleeding generally, Of, locally, by leeches ; or, front not eittploy- ing cooling evaporating lotions. Spirits ctf wine and water, or acetate of lead and wtttet*, should be applied upon the wound, and arotind it. Purging is also often required.
The adhesive inflammation is but a slow degree of action, and if it be not kept itf bounds, suppuration will occur.
By poisons. If poisous be inti^oduccd into wounds, it will be wrong to attempt to produce adhesionfi' thus the bite of a rabid animal should be eir- cised, as well as c&uterized afterwards, to prevent the terribly dangerous consequ^mc^ of such an injury.
Bycaus- The usc of caustic applications, wheth^
tics
by potash, nitric acid, the actual ' cautery, &c. will necessarily prevent adhesions. When an When mauv absorbent vessels are divided,
absorbent •' '
is divided, the lymph poured out by them prevents adhesion^ as I have seen in a transverse w6und in the groin.
oiasecre- When the secretory glands are wounded,
orygan . ^^^^^ secrctiou prevents union.
Case. I was Called to a gentleman who fell ufjon
his face on an earthen plate, which he broke ; his face was dreadfully wounded ; I brt)ught the parts together, and in ten days they ap- peared to be united, when I allowed him to ' eat ; but the result was a profuse discharge
I
159
of saliva from the wound, which was a very long time in healing, on account of the paroted dHct having been cut across. Union by adhesion, is often frustrated by By the
, ... , . . surgeon'*
the surgeon s impatience ; he is anxious to impiudence. see if union be effected or not, and most absurdly and mischievously raises the dress- ings, disturbing, and often breaking, the adhesions, and thus rendering the process of granulation necessary, when it might have been avoided.
The adhesive inflammation is often pre- bv sute vented by the state of the constitution ; if tation. the patient be much out of health, or if he be extremely irritable, the inflammation . will proceed beyond the bounds of adhesion, and suppuration will take place. In such persons, evaporating lotions to the wound, and opium internally, are the means of arresting the nuschief which will otherwise ensue.
It is not always an object to endeavour to Adhesion produce adhesion ; when there is much loss desirable." of substance, and the parts must be forcibly drawn together, much additional pain and irntation are occasioned by the attempt at ^hesive union, and this is more especially the case in children^ when the skin cannot ^ell bear the application of the adhesive plaister. I therefore, when I remove those ^arks which are called nevi matemi, I do
^
158
run too high from want of bleeding or, locally, by leeches ; or, from ■ ing cooling evaporating lotion^ wine and water, or acetate of If should be applied upon the woi it. Purging is also often re( The adhesive inflammat' degree of action, and if ' bounds, suppuration will By poisons. If poisons bc intfodv will be wrong to attemp thus the bite of a rab' cised, as well as c prevent the terribly of such an injury The use of ca'
By cans tics.
by potash, nitr" &c. will necess When man^
iiL'OUgh
uccurring. ■o differ from incii iiung eictraneous boidilto^ lip are frequently filled w^{^ head ploughing the gvouiii^) their seer. .::;ost care is required to cleaiuiiii ^ I was 1 ^\ Ann water, and to remove yriAm ^ his fiaec j^ extraneous matter, as I have seea his fkc^' «g«od adhere, and afterwards sup* the j^ ^ Mrious places, for the discharge of pear | bodies which the adhesive matter m
^^^^ Hi confined.
When an absorbent
is divided, the lymph ] adhedion, a w6und in '
<) r a secre- W^hcn 1 ■ tory gland. , ,
tneir seer.
Case. I Was .» «
_ disposed to Moredls-
suNKthey require inflame, uisli^f evapo- ippreas it.
^ suff'ers Affect the
nervons ms of •y»tein.
Oil
.an at ^^' tge and ; he died .Gin lacerated jy machines for i al times known te- aons and fascia in these i exposed and injured. I an unusual effect of lace- Prodnce
erysipelas.
more especially if they are die scalp, and they therefore .at attention, although they at first 1 trifling importance. c treatment of these wounds is the same Treatment, that which has been described for incised wounds ; but more care is required in the use of cooling lotions,and the application ofleeches, in quiet, and in. the exhibition of opium under tiie first appearance of spasmodic symptoms. Patients with lacerated wounds^ should not be much reduced by-depletion^ as it disposes to. tetanic symptoms.
VOL. III. M
162
^ s.%;
LECTURE XXXVII.
Of Contused Wounds.
Character. These injuries differ from the incised ancf lacerated wounds, in being accompanied ^tfa disorganization: blood is extravasated, the cellular tissue is broken down, muscles are bruised, and many parts disorganized.
Procew of The process of restoration is therefore quite ' different to that which takes place after incised or lacerated wounds.
Sloughing. Inflammation to a considerable extent must be produced; the dead parts must be separated by a process of ulceration, and granulations will arise to fill up the cavities occasioned by these separations; The surgeon, therefore, who treats these wounds as he would the incised or lacerated, has still to learn the fundamental principles of his pro- fession.
Contused wounds bleed but little, from the organization of the parts being destroyed, and from the extravasation making pressure upon the vessels which are divided.
Treatment. The treatment of the contused wound in principle, consists in facilitating the separation
163
"Stead of approximation,
i lacerated wounds. To
Liul to expedite the process,
I poultices are to be used,
-tii iaHammation when too violent,
i the suppurative and ulcera^eS^ro-
1 1 the inflammation be still consider-
ii leeches should be applied ; but bleeding
:^^ht not to be had recourse to from the
arm, for all the powers of the constitution
are required to assist in the process of separa*
tion, and of granulation.
The bowels should be kept regular; but Medidnw, opium should be combined with the medicines given, to eflect that object. If the constitu- lioii become much debilitated, the sulphate of quinine may be given ; or ammonia, com- plied with opium.
'. When the sloughing, or separating process AppUca- ip completed, the fomentations and poultices He to be abandoned, and the parts may be ^roximated by adhesive plaister, or simple dressing be applied to the wound, treating it ^ a simple ulcer.
tions.
Of Punctured Wounds.
These wounds are produced by pointed Danger of. Wies, as needles, scissors, hooks, points of
M 2
i<;j
LECTTl...
- '.%
Of '
> ts which follow , us, by occasion- . . i^ rbents ; or when rres are injured.
'./I the Absorbents.
Clianuster. ThESE injlP
lacerated v disorgani?'^' cellular • brui."
Process of reparation.
ri'
i
•%:
k* ■>-
,^ onmsrh the skin iirto the ^ je sometimes followed . ,x uort, a blush around it, ayfMat vessels forming red ..uiid CO the absorbent glands,
di
i'i
Sloughinir.
^^i i have seen very many ex-
^ BLve been a sufferer from it
jgkrtfs^ scmetimes form upon the
.1 :netr course to the axilla, or to
j^ ^cmetimes in the glands in
B» trtmnate ; and in very irritable
^^1 sometimes ensues; and the
. .xampi^' ^* ^t ' ^^^ ^^ opportunity
Imiian- studying at Guy's Hospital,
%.< MiTt'r, the absorbents of his arm
iirfa:tte\l. and he laboured undet
^'^"'^ ^ . r.rji:ivo tever ; the veins seemed to
^^"^ ,, /^,t»* inflammation communicated
.*- •'^•^ limbs became almost incapa^
..- wm the violent pain produced
, , • «nv ot" the joints, and the super^
>66
were very tender when six days after the attack, <i.s arm. The absorbents of iiighly inflamed; and in the was effused, not in a separate I ill a sheet of suppuration in the . issue, between and around the ab- i vessels. I was not permitted to in- I the body further. After an inflammation of this kind in myself, ^*^' produced by wounding my finger when open- ing the body of a man executed on the same morning; my throat became sore as the inflammation in the absorbents of my arm subsided, and one of my knees became stiff firom rheumatism; when this was subdued by a blister, the other knee became similarly affected^ It would seem that under certain circum- ^^^ _,
absorbed.
stances a poison is produced sufficiently strong to excite inflammaticHi, even when there is no wound.
Mr. Cook, surgeon, at Marsh-gate, West- cue. fliinster Bridge, sent to me whilst he was la- bouring under the highest irritative fever, in consequence of having opened the body of a person who had died of puerperal fever. When I examined him, I foimd the extremities of bos finger, of both hands inflamed, as if they hd been dipped in scalding water, and the
M 3
8 of his arms red, bard, and knotted W the axilla ; yet he had not any wound or abrasion of any kind upon his hands; itud it would therefore seem, that the fluid produced in the ahdomen of this woman, in which his fingers had been frequently im- mersed, was of a highly stimulating nature.
The effect of punctured wounds depends, however, very much upon the form of the wound, and the state of the constitution. When punctures have been made, by a clean needle, the tongue of a knee buckle, a frag- ment of bone, &c., nothing can be introduced of a poisonous nature, and the effect must depend upon the form of the wound, and the structure injured. But the effect also depends upon the state of the constitution, as is evinced in our young students suffering in the Spring, after confinement in London, in the air of our dissecting room, and in the wards of our hospitals, and by their escaping these violent sjnuptoms in the Autumn, when they have just quitted the country.
I believe, therefore, that these effects arias (com the form of the wound, and the state of the constitution ; also occasionally, but rarely, from the introduction of an irritating fluids the result of pecuiia' inflammation, ot the production of the first stage of putrefaction.
1 have known the bites of cats, dogs, and
rats, followed by high inflammation, and ' congtitutional irritation, many days after the injury has been inflicted ; and these cases unite the symptoms of punctured and contused wounds ; the first effects upon the constitution arise from the punctures of their pointed teeth ; but when the symp- toms produced from this cause subside, from fifteen to twenty days after, 1 have known the injured parts inflame and slough ; the con- stitution, as well as the part, undergoes great changes, and the patient becomes excessively reduced.
The treatment of punctured wounds con- i sists in adopting the following plan ;—
First. — A lancet should be used to extend the puncture to an incision. Second. — The surrounding parts should be . pressed to remove, by the blood which issues, 11 any extraneous matter which may have been il introduced. If the finger is wounded, a piece ^ of string or tape should be bound tightly H lound the injured finger, from its junction W- with the hand, as far as the wound, so as to ■ force out blood from the opening.
Third. — The nitric acid, nitrate of silver, Of caustic of potash, should be applied to the I Wound.
Fourth.— A lotion composed of the subace- tale of lead ; spirits of wine and water should
168
be applied over the part, to prevent to6 mubh action when inflammation begins. . i .' = '•{!(> i
Fifth. — Leeches should be applied^ and fomentations with poultices employed, if die pain and inflammation become considerable.
Sixth. — Give calomel and opium at night; and a brisk purgative in the morning.
7th. — Let the limb be supported on an iiH clined plane, so that the blood shall gravitate towards the body; all stimulating food and drink should be avoided; a measure so absurd that a caution against it appears unnecessary $ but an anatomist . killed himself by taking wine to oppose the putrefactive influence of the matter he supposed to be absorbed; inflamma. '^'he inflammation from punctures of the uTrasr ^^^^ i^ dissecting, will continue a long time^ and be resumed when it seems to be at an end ; attention to the general health, and to the part, must be therefore regarded closely, for a considerable period after the injury.
Of Punctured Wounds of Tendinous Structure.
Danger of. If fascia be punctured, alarming symptoms will sometimes arise, in part from the form of the wound, from the feeble power of the structure, and partly from the confinement of matter beneath the fascia.
169
The formiof the wound produces these Pormoftue symptoms^ because the parts txe rather for« cibly separated than actually divided, and consequently the adhesive process does not readily succeed. • The structure of tendons and iascise, from their little vascular organic zation, and difficult restoration, leads to much constitutional effort ; and the form of fascia tends to confine the pus when it is secreted.
A gentleman sat upon a rail, from which case, alnail projected, and it entered the middle and back part of his thigh ; great irritative fever followed, with redness and swelling of the thigh; and, as fomentations and poultices, and calomel with opium, did not relieve him, I made an incision in the situa- tion of the puncture, and found that the nail had penetrated the fSeuscia lata; I divided it iBreely, when some pus, which had formed under it, was discharged. He quickly re- coveted.
When a puncture is made into a theca, Eariv
• . induons.
suppuration is apt to ensue, when an early incision, by allowing the discharge of the matter, prevents the greatest mischiefs.
If matter forms under the aponeurosis of the palm of the hand, an early incision ^ is the only mode of relief, if the puncture which occasioned the suppuration is too small to admit of the escape of the pus.
i7a
Treatment. The treatment, therefore, of these wounds, consists in endeavouring to prevent suppura- tion by leeches, and evaporating lotions, in the first instance ; but, if matter does form, to open the abscess early, both with a view of making the punctured an incised wound, and to give a free outlet for the escape of the pus«
On the Effects of Ptmctured Wounds on' the
Nervous System.
lymptoras '"^^^ spasmodic and tetanic symptontf, which follow punctured wounds, are the effects of injury to tendinous, rather than nervous parts. Most of the cases of tetanus which I have seen occur from punctured wounds, have been when the hand or £30t has been the seat of injury ; the aponeurosis of the palm, or sole, or the tendons being hurt. I will not deny that an injury to a nerve will produce the same effect; but I cannot help doubting its being the usual cause.
Case. I divided the posterior tibial nerve in a
Mrs. Sabine, the wife of a surgeon at Dun- church, for a painful tumor on it ; and Httle constitutional irritation was produced by tibe operation.
171
I removed a tumor from the median nerve case, of a gentleman, and cut away two-thirds of the thickness of the nerve, leaving one-third ; tingling of the fingers, with some partial numb- ness, followed, but no constitutional irrita- tion; and he did very well.
I cut out five-eighths of an inch of the ci»e. radial nerve, for aura epileptica; and no unpleasant symptom followed, but the pa- tient got well.
Mr. Key removed a portion of the cubital cue. nerve^ for aura epileptica; and, although it did not cure the woman, it produced no un- fiiToiiiable symptoms.
These instances, to which many more might be added, as well as the usual seat of the wound, which produces tetanus, lead me to believe that it is rather the result of injury to tendinous than to nervous structures.
Extensive injuries, by their sympathetic io^uence, and by their severe shock to the nervous system, produce the destruction of life, even without vascular reaction or in- flammation.
The symptoms which arise are sometimes only generi spasm, sometimes trismus, and sometimes tetanus.
I once saw a boy die, in a few hours, of cue. the most violent spasms of most of the muscles of his body, from the pointed extre-
172
mity of a broken thi^*- ''y pub-
trated the under sidt» '>y the
Cane. I saw a person d
by a punctured v -. \o(l by
ligament of the i> =^^^d shower
of wood; and 1 ^f^^- tincture of
of such cases ^^'^^'^ ^so known
foot. -^^ scarcely taken any
Degree of SoHietimi -"-^S ^ do^bt upoD the
2Sr "^ the influci. -^ had, in other cases,
felt in t;. -^ beneficial,
trismus, -"'*"* ^^^^^ ^ ^^^^ witnessed
the mi, ^ trismus, the patient hns
of re . .avflxel and opium are the best
tinv ., jua a blister to the head the
tr! .usvAiifc^ local remedy.*
t
^ a«i»t«^ interesting case occurred in St ^^ •iMMiai. Milder the care of Dr. EUiotaon
VI ««
*r»<u«r. ««. thirty-nine, of florid complexion,
, ^.•^•«ni;;isco. employed in the London Docks
t. ^dtf admitted December 10. There were
^,,.,^ ^^ *»*n lacerated wounds on the inside of
*^ * -'^' ^^'^ ?^^^ ^^' ^® crepitus indicative
^vti*» .vttvvl be discovered. There was a slight
. x^^cii'.Mjj:. attended with violent pain.
tc ^>*t^ «^*^ ^>=* ^^® ^^^ ^^^^ dislocated, and
,. ...4 .«.^j:v:*. across the other toes, by the fall of
.vvv H !^itt^«'r. ^^ l^ad been, however, forcibly
.i |K*r»o« present, while he was in a fainting
>.. >>
175
condition. He was brought to this Hospital immediately after.
The edges of the wounds were brought togetlier, a dossil of lint was placed over them, and afterwards covered by a light poultice: the foot elevated on a pillow.
Cap: haust: purg: statim.
December 11. Evening. He was restless, with a pain in his head, back, and loins. Skin hot and dry ; pdse full and hard, about eighty ; tongue furred in the eeatre, and red at the sides ; bowels costive. rVenesectio ad ^ xij.*— — Repet : haust : purg : ;The dressings were removed from the foot, which ordered to be fomented all night.
About. an hour after the bleeding, the violence of the symptonis abated, and the man said he felt relieved.
December 12. Slept comfortably last night. Skin laoist ; pulse full and soft ; tongue white ; bowels have been opened.
The foot is very, painful ; the wounds are beginning to suppurate ; the dorsum of the foot is red, tense, and swollen.
Applic: Hirudin: xij.
Capt: cal: gr ij opii gr ) o. n. inf: rosee c mag: sdph : t. d.
The blood abstracted yesterday neither cupped ^or iNUBed.
December 14. Was very restless. Skin dry; pulse ■nailer and quicker ; boweb costive.
Foot very painftd ; still red, tense, and swollen ; wonnd suppurating.
Bepet. hirudin, xij. Repet. haust purg.
December 19. Face flushed; skin moist; pulse amaU and quick ; tongue white and furred ; bowels relaxed.
176
Foot yery painful^ so much so as to disturb his test, the wounds suppurating, and the degree of inflammatidii less.
Omit : calomel and opium.
Capt. Tinct : opii gtt. xxx. Si opus sit.
Foot to be fomented and poulticed as before.
December 22. Diarrhaea subsiding ; but he laboured under great irritation both of body and mind.
December 24. Imperfect trismus came on yesterday afternoon, and increased towards this morning. Be could not open nis mouth more than three-quarters of tti inch, nor protrude his tongue farther than the teedi. Deglutition painful, and articulation difficult ; pain in the back of the neck, and a want of freedom id the motions of the head ; no rigidity of the muscles ; coun- tenance aniLious, and spirits very much dejected ; skia bedewed with moisture ; pulse quick, small, and com- pressible, 132 ; diarrhsea had ceased.
The wounds were suppurating healthily; granu- lations at the bottom ruddy ; but perhaps the discharge was somewhat thinner; tension and swelling on the dorsum of the foot remained, but the redness was less.
Capt. ol : terebinth : ^ij statim.
Ferri: subcarb : ^ ss. 2nd qque bora (in treacle.)
Applications to the foot as before.
December 25. Took the same quantity of ol. tere- binth, at 10^ last night, which was followed by five or m copious dejections, but he was not able to swallow more than one dose of the ferri subcarb. on account of its thickness. He therefore took five grains of musk every four hours ; this he commenced at twelve o'clock last night, and took four doses of it.
Mouth more closed; a perfect inability to swallow anything but liquids; complains of pain in Hie back; the other symptoms of trismus the same.
177
Did not rest last night; face flushed; skin very moist ; pulse the same.
The foot remained the same.
To omit the musk, and to take the iron mixed up with his beef tea every two hours, as befo|« ordered.
Capt. vin, rub. J iv. Strong beef tea, Ifeiv. daily.
December 26. Mouth more closed ; other symp(om« of trismus the same ; belly rigid in a slight degree.
Was restless last night; countenance anxious, and spirits much depressed ; face flushed and hot ; pulse the same ; boweb opened twice during the night ; troubled to-day with tenesmus and prolapsus ani.
Foot very painful, and appeared the same as yesterday.
December 27. The symptoms of trismus the same as fssterday ; the belly more rigid, and he complained of astiffiiess in the back, and a shooting pain through the lerobic : cordis. ; his face not so hot or flushed ; had no liool for the last twenty-four hours ; tenesmus and pro- lapsus ani continued; perspires a good deal at night, ttd doses a little.
Foot very painful. While removing the poultice tills morning, an abscess over the metatarsal bone of the great toe burst, and discharged an ounce or more of iKItter, of a greenish colour, streaked with blood. Enema commune statim.
This produced one or two small evacuations. Hi- tiitrtQ (according to the nurse's account,) the foeces We been of a natural colour, but to-day they presented Ike appearance of the ferri. subcarb. - December 28. Morning. Mouth more closed ; deg- lutition more difficult; articulation less distinct; the Mly rigid, and there has been during the night con- nlnve movements in the muscles of the neck. " Had no rest last night, and perspired a little ; his
VOL. HI. N
178
skin now cool ; pulse 112, very weak aod smaU ; tenes- mils has subsided.
About half-an-ounce of pus was eTacuated ffoan the dorsum pedis, (near the metatarsal bone of the little: toe,) there was a foetor arising from the wounds on the dcHWum of the foot, while the original wounds wece looking healthy.
Afternoon of the same day, all the alarming symp- toms abated; his skin became moist; hia pulse Adler and softer, and his mouth more open, with an unpiered countenance.
December 29. Mouth more open; awallawiig easier ; no pain in the back of the neck, noi: any ^aoie conTubiye movements about the muscles oi that part; belly soft.
Slept last night, and perspired a little, and had Awe motions from an enema; countenance improTeds fMse not so flushed ; skin, cool and dry ; pulse fiiUer and softer, but still weak; appetite beginning to mnnjftnl itself.
Tension on the dorsum pedis quite subsided. The surface is still inflamed, but the redness is of a daifcer colour. The two wounds on this part loddng very uur healthy, and the discharge foetid and rather thin. The original wounds on the side of the great toe are begin- ning to cicatriie.
December 90. Mouth more open ; less difficulty in deglutition, and a more distinct articulation ; no pain in the neck or back ; the belly however is rigid.
Was very restless all last night, his foot being very painful ; skin cod ; pulse contracted and more diatittct, about 120 ; during yesterday passed some small lumpy fceces*
Hie foot tense, red, and swdlen; the discharge has ceased,and there was a fioetor arising from the wounds.
179
whicb were looking unhealthy , accompanied -with severe laaeinatiag pains. The original wounds, however, were heafii^. Foot to be fomented.
Ci^ ol.'rieini fss. '
Enema cathart: siopvssit.
Beef tea, Ibvj, instead of ftiv.
December 31. The castor oil operated fire or six times, bringing away small lumpy fceces. The enema was not administered.
Opened his mouth readier, but not wider ; complained of pain running through the scrob. cordis, and of a di^ eeiig^, ^Huch arose, he said, from his not being able to bieirthe freely; deglutition and articulation better;
'Slept better last night, and did fiot perspire ; coun* teniUioe and spirits improved ; skin cool ; pulse 180, BoAer, land itot SO' eontnusted.
~***Foo€ less tense and' inflamed; discharge from the wMnrib returned, bet it is still too thin ; leg placed in «
frMStur^box; ' ■ •■
■ ■' January 1. Symptoms of tetanus quite subsided, those of trismus less violent.
Mudi the same as yesterday; pulse 108, soft and BM>re full; bowels relaxed, with tenesmus; motions come away of a dark colour, and in very small quan- tities.
Foot better ; discharge more copious and healthy.
Capt. ferr. subearb. ^ss. 4tu. q : q : hor^, (in powder.)
January 2. The same as yesterday; opened his mouth wider, but was still obliged to be very careful in swallowing.
Foot looking better; the excess of inflammation quite subsided; the suppuration free and healthy. It was painful last night, and this prevented his sleeping.
January 8. Much improved ; pulse ninety-nine, softer and fuller.
N 2
186
i
Suffers very much from a collection of ^ 1m8 reptum, a quantity of which was remor^ tially dry state ; this prevented his sleeping J Capt. ferr. subearb. 6ta. q : q: hora,(in.f Enema commune — pro re nata. (
Foot improving ; discharge healthy <^n4V^ The fracture box removed. . ^'X
January 4. Same as yesterday. .
January 6. Much improved; pube fi great deal softer and fuller; has reman ^k quantity of iron from his rectum. . '
From this period he gradually any further relapse; he continued, time, to piassi portions of the subcarhor' his stools. The sudden improvements ;€ the evening of the 28th, after the :em# , torn the donsum of the foot, camioMi^ one, who may carefully p^use and I think it will require further before its efficacy in this formidab «. relied on. — ^T. ■'';^
181
ladled.
LECTURE XXXVIIL
Of Wounds of Arteries.
These wounds we shall divide, as wounds in general, into the Incised, Lacerated, Con- tused, and Punctured.
When an artery is cut into, or divided, ike immediate effect of such injury is to occasion an impetuous hsemorrhage of florid blood, which, if the artery be large, whizzes through the wound. It flows in pulsation in obedience to the action of the heart.
If the wounded orifice, nearest to the heart, be compressed, the blood from the opening, most remote from the heart, flows in an uninterrupted stream, and is of a dark venous colour, owing to its having passed through capillary vessels.
The brain soon ceases to be supplied with Fainting blood, and fainting is produced: sensation p'<^"««**- ^d volition become suspended; and the action of the heart is in a great degree sup- pressed ; the flow of blood from the wound becomes much diminished, and sometimes ^^tirely ceases.
N 3
182 Recovwy In a few minutes the patient opens his
from funt- 11 /• 1
ing. eyes, and the power of the nervous system
is restored. Modes of The mode by which bleeding is arrested thTbie!^- may be either constitutional or local. Faint- *°^' ing is the constitutional mode, by suspend-
ing the voluntary and involuntary functions, more especially in the diminution of the action of the heart, so that the blood scarcely reaches the wound, but it undulates in the heart, and large vessels under the fluttering of the heart.* i^oeai T^^^ loc^l means consist in, first, the
"**"*• coagulation of the blood, which is effected in the cellular tissue around the artery, and .!»> in «.e extremity of the wo„«ied^, forming a plug ; so that there is a continua- tion of coagulum from the outer surface to the orifice, and this sufficiently opposes the issue of blood under the enfeebled action of the heart, contrac- ^^t this proccss IS also aided by the con- ▼cMch.*^^ traction of the artery, not particularly at the divided part, but also to a considerable ex- tent from the orifice.
If the carotid artery, on one side, be cut
* The brain and nervous system are, however, some- times so depressed, that without stimuli to the stomach and nose, the person will not recover.
183
across, and examined after the death of the animal, the artery is found much smaller on the wounded side than on the other which has not been injured. This state of the vessel lessens the influence of the blood upon the wound.
A. retraction of the artery also follows RctrMtion when the division of the vessel is complete ; sei. and, by withdrawing itself into the cellular membrane, the blood becomes effused around it, so as to compress its orifice. Thus, then, it . appears that coagulation with contraction and retraction of the vessel, all concur to put a check to the bleeding.
These, then, are the immediate means ; process of but it is required that a further process uoo. should take place, to render their effects permanent. Inflammation follows; and the clot of blood becomes glued to the inner surface of the vessel, whilst effusion into the surrounding parts creates pressure upon the artery so as to diminish its calibre ; this inflammation also usually produces a union of the edges of the wound, or otherwise granulations arise, fill it, and thus it becomes closed.
The treatment, when an artery of not a pressure, very large size, is divided in an extremity, is to apply a tourniquet to compress the trunk from which it is supplied ; this, with
N 4
184
gentle pressure on the wounds for a short time, will generally command the haemorr* hage, when the edges of the wound may be approximated, and union promoted, leaving on the tourniquet, so as to continue a mode- rate pressure on the trunk.
tioo dri ^^'» ^^ *^^ vessel be large, it is necessary ligatnre. jq make an incision in the direction it takes, so as to expose the wounded portions, when a ligature must be placed above and below on each portion of the vessel. The ligatures should be small, and one of the ends removed after their application. Dr. Vetch first recom-^ mended the removal of one of the threads.
When an artery is not completely divided, its retraction is prevented, and a coag^lum^ with diflSculty, forms in it, and, when formed, is easily forced off by the action of the heart. Hence, in a week or ten days after the in- jury, bleeding will sometimes occur; and repeated haemorrhage will destroy the patient if a ligature be not applied. I have known the temporal artery bleed eleven days after its partial division, and when the wound in the integument was almost closed.
The treatment of this injury consists in completely dividing the vessel, when its retraction enables a coagulum to form in, and around it ; but, if the artery be large, a ligature must be applied.
185
Lacerated Arteriet.
These bleed comparatively little.
A sailor, on board a Margate Packet, was caie. bringing up his vessel in the river, and hav- ing his leg in a coil of the cable, the anchor was unexpectedly let go, when the cable caught his thigh, and tore off his leg six inches above the knee, excepting thai a small podTtion of skin on the outer part still con- nected the parts; the bone was broken; the artery, vein, sciatic nerve, and muscles, were all completely separated. A handker- chief was bound around the wound, and he was brought to Guy's Hospital. The artery had ceased to bleed, but he had lost a con- siderable quantity of blood. I amputated his limb, and he proceeded favourably for ten days, when he was seized with tetanus, and died.
I have also seen the foot torn off above case, the ankle, and the bleeding stop without the aid of tourniquet or ligature.
The case, related by Cheselden, of the cheseiden's arm being torn off at the shoulder without *^***' much haemorrhage, is known to every sur- geon.
There are two causes which operate to ^^* prevent bleeding : — EteeSn
186
1. The cellular tissue is sometimes drawn over the mouth of the vessel, ^^d makes a ligature upon it, which stops the blood.
2. Another state of the artery produces the same result, and in which the mouth of the vessel remains open, the coats of the artery are excessively elongated, and its sides fall together so as to render its canals unpermeable.
Treatment The hidst treatment is to apply ligatures upon lacerated arteries, if they be large; otherwise, when the powers of circulation are restored, there is a danger of hsemorr* hage.
Of Punctured Arteries. conse. . They produce different symptoms from
qaences. J r ...
the other wounds of arteries in this respect, that the external opening being small, the blood does not readily escape; and there- fore coagulates in the cellular tissue, and forms a s^^elling there, which gradually in- creases in size as the blood issues from the wound in the artery; the impetus of the blood causes a pulsation; and the cellular membrane, around the extravasated blood, being condensed, form a sac, which impedes the evolution of the swelling. The external
187
wound heals, and* thus an aneurism is iormedi
It may be said that it differs from an aneu- rismal swelling in the mode of its production ; and this is true, but it still has the other characten^ of the disease, and requires the same treatment. . . P"??^
in bleed<*
I have several times known it happen from tqg. bleeding in the arm; in one case the radial arteiy was wounded, but in all the other caaes, the brachial artery. CMe.
The first case was in a patient at Guy's Hospital, a dresser of Mr. Lucas, senior, bled the man, and he came to me excessively alarmed, telling me what had happened, and that he had great difficulty in stopping the haemorrhage, but had at last succeeded, by applying a very tight bandage. A short time afterwards the man came to Guy's, and showed his arm to Mr. Lucas, who, seeing the aneurism, and hearing the cause, told the man that he must submit to an operation, which the patient refused. In walking home^ he met an old acquaintance, to whom he told the circumstances ; this friend, who occasion* ally bled and drew teeth, said he would cure him, and inviting him into his shop, he put 9, lancet into the swelling, and finding blood impetuously escape, he as quickly escaped * from his shop. The patient finding himself
188
ble^ng, fortunately put his hand upon wound, and called for assistance. A bandage was bound tightly round his arm, and he went to St. Thomas's Hospital, where Mr. Cline operated upon him, when the radial artery, in consequence of a high division, was found to be the wounded vessel.
One of the apprentices at Guy's Hospital had the misfortune to wound the brachial artery in bleeding, he immediately perceived the nature of the mischief, but before he could arrest the bleeding, thirty-seven ounces of blood were lost. He bound up the arm extremely tight, and when the bandage was removed a few days after, an aneurismal swelling appeared at the fore part of the elbow, for which an ope- ration was performed, of tying the artery at the part, an operation which was attended with great difficulty, and the patient died.
I once assisted Mr. Chandler in performing the operation for brachial aneurism, produced by bleeding ; the sac was opened, and the orifices above and below were secured by ligatures, but still there was a free hEemorr- hage, from an anastomasing vessel, which it ii. was necessary to secure.
The treatment of this injury consists in the immediate binding up of the wound, and applying a tourniquet to the middle of the arm, which should press upon the artery, and
189
upon the opposite side of the arm only, leav- ing the circulation by amastomasis as free as
possible. If aneiirlim
If an aneurism still follows this accident, the tourniquet is to be continued, as des- cribed in the lecture on aneurism. Oiieration.
Should the tumor still continue to increase after this has been fully tried, it will be proper to make an incision upon the brachial artery, about midway between the elbow and shoulder joints, and place a ligature upon it, but upon no account cut down upon the wounded vessel at the elbow.
In one instance, after I had applied a liga- ture to the brachial artery, I was surprised to find the thread completely separated on the fifth day; but the ulcerative process was probably accelerated by the inflammation which existed previous to the application of the ligature. The patient recovered.
Of Contused Wounds of Arteries.
Gun shot wounds and severe bruises some- D»ng«r of. times destroy the vitality of a portion of artery. As it will afterwards slough, there is a remote danger in such a wound, which must be carefully guarded against. The slough ^will not separate until from eight to
Case.
Caie.
188
bleeding, fortunately put ^ wound, and called for ass was bound tightly row went to St. Thomas's Cline operated upon artery, in consequenr found to be the w( One of the appr the misfortune t< bleeding, he in of the mischi
a
bleeding, tl lost. He I^ and whc days af* at the ^ ratio*
the
t until the
ijluted; and he
the tightening of a
aist be applied, and left
0 limb, until all the slough-
the
.ji received a shot through the
. <v ^^^ was proceeding so well as
^^Qitu w sit up, and to put his limb
a#* • ^^^ *^® seventeenth day, he was
,^ »*ui a severe bleeding, from the
a ^aich he sunk.
.W.«5
Tl
ui rRKATMENT OF WOUNDS OF V'VUriCULAR ARTERIES.
Arteries of the Scalp.
v| vHiiiUs of these arteries require in their v^%iMViil. first, a complete division of the
191
^ond, the application of
t, retraction is per-
* is prievented ; by
nrhage is sup-
.>ee the son of Ctae,
.;eding freely from
. ich had been opened
i like to make an incision,
j)|)lication of a small tourni-
Hiipletely succeeded, and this
1 should advise in all wounds of
of the scalp, as the means of pros-
in aneurism, from wounds of the arteries of of the scalp, I have, in each case that I have "*™ operated upon, been obliged to open the aneurismal sac, and to tie each communi- WtiBgErtery.
, The aneurisms which I have seen on the 8calpfrominjury,havebeenin the temporal and posterior aural arteries, and have arisen from wounds and contusions.
Carotid Artery.
The wounds of this artery are usually so speediiy speedily fatal, that surgery is rarely able to preserve life.
190
ten days^ or more, al'tei : ars vaga must be inflicted ; and then tlic ^ . . and although the caution, may lose uii •-: ne artery cannot be blood, and someliiu.. securing the ligature, haemorrhage. *:.i^ is stopped, a fresh
The slough oji- .^ru upon the artery alone, and, no retra' ..ii^ upon that which has is unrestraiUv .mployed at first, blood.
Treatment In til'
patient m^uman Artery.
slough
^"^ ^ -a*»' ^«*tt this artery wounded, but
tou ^ _.^.. »m through.
( ,^ vitf' brought into Guy's Hospital
1 * . ^Lttc« cf the clavicle, in which acci-
^"*- ^ ^^ Hfc/oider was very forcibly drawn
^^ ^. ^j*i jfrtne. The dresser had to bleed
^ .s** a 21^ injured arm, but little blood
^^ ^ imwn ; and, thinking that he had
die lancet suflSciently deep, he
X so for as to wound the brachial
r!ic blood which issued from the
w;fe$ of a venous character, but it
^liittu A ver>' tight bandage to stop the
i,tfad(^'. Great tumefaction succeeded
i 'Jxc sJioulder, gangrene began in the
^t^t constitutional irritation followed,
jK* man died. Upon examination of the
vv> Atkr death, it was found that after the
193
■uire of the clavicle, the scapula was cibly drawn back, so that the subclavian nrtery was torn through, but a cord of cellular membrane united its ends, so that the extra- vasation of blood had been very slight.
Axillary.
Mr. Key operated, and tied the subclavian Mn Key's artery, on account of an aneurism of the ax- illary artery which had been produced by a forcible extension of a dislocated os humeri.
case.
Brachial Artery. This artery I have often known wounded Wounded
. -, ,. in bleeding.
fii bleedmg«
A slight bandage, and a thick dossil of Treatment, lint as a compress, have succeeded in healing flie artery. ■ If aneurism forms, the tourniquet should ^^^S »"
' A aneurism
lie employed, as I have described ; and if this ^<>"^™»- ^ifoes not succeed, apply a ligature upon the %rachial artery. Make an incision in the ittdddle of the arm, on the inner side of the Inceps, dud take care to exclude the vein and median nerve from the ligature.
VOL. III. o
192
sccaring In tying the artery the pn
the artery, ^^^j^^j^^ f^^^ ^^^ ^j^^j^j^
dissection of parts from tli made at the moment of so yet when the hsemorrhap ligature may be placed instead of dependinp been of necessity eir
Tonu
Cut.
Su/
I have nevei I have seen i
A man v with a frac dent the :^* back to this m: could not ) plui art
'.V
ubital
iie artery,
excluded from
of the free anas*
atery and the radial;
vo ligatures, one abovei
the opening into the
necessary to effectually
Artery,
V
ts much more frequently
^ ulna, being in every res-
The application of two
^ Mindly necessary, as in the
Mf thtf same reason. This vessel is
i^^ni oo the outer side of the flexor
i^iirf*^! •"^^ ^' ^ ^^' accompanied by magnitude.
]9S
rssels are very ^>«qneiitiy
"^ wounded.
bleeding may be (continued pressure, CSS and bandage, and the brachial artery; the t, and attention to position, assist. Should these means the bleeding, and if the openings lied vessel cannot be easily found, ::»e necessary to secure the ulna, or L arteries, or both ; as from the very free mmunication of these vessels, the securing of one only, will not, in many instances, pre- vent further bleeding. It will be best, liow- ever, in wounds of the superficial palmar arch, under such circumstances, first to put a ligature upon the ulna artery, and then try pressure again, before the radial is taken up ; iriiich should not be done unless a trouble- soine haemorrhage continues. On the con- trary, should the deep palmar arch be the .leat of injury, and It become necessary to • secure an artery, the radial should be first • fed, and afterwards, provided the bleeding does not stop, the ulna should be likewise secured.
o 2
196
Of the Femoral Ay^tery.
™^J*P If this artery be wounded high up in the K^n- groin, the finger must be thrust into the wound to stop the bleeding, until a com- press can be applied upon the pubes, and the vessel be secured.
d"e^f Ae " ^^ ^* ^ wounded in the middle of the thigh, ^^^' in the mode which I have described in the case of a relation of Mr. Saumarez, a large swelling will immediately form, and the artery will be deeply situated, under a large Treatment coagulum. A free iucisiou must be made to give the surgeon ample room to proceed in securing the wounded vessel, a tourniquet being first applied. The direction of the in- cision will be that required in the i;>.peration for popliteal aneurism, only it must be more extensive. The coagulum, which is then exposed, must be scooped out from the wound by the fingers, and the parts be cleanly sponged. The tourniquet is then to be loosen- ed, and the aperture in the vessel will be directly seen, when the tourniquet is to be again tightened, and two ligatures are to be placed in the artery, one above, and the other below the wound, an end of each thread being cut ofiF; the edges of the wound are to be approximated, so as to favour the union by adhesion.
197
It is always right in these cases to divide the artery, between the ligatures •
Of the Popliteal Artery.
This vessel is so protected by the condyles ««"•«'? ^ of the OS femoris, and so concealed behind the bone, that it is rarely lacerated, and when it is so, the wound must be highly dangerous, as it will be probably complicated with a division (^ the sciatic nerve.
It was a case of this accident which first attracted my attention to surgery, and which taught me its value:
A foster brother of mine, named John Love,. Cue. aged about thirteen years, was playing and fell, as a waggon was passing, and one of the wheels of tlie waggon went over the back of his knee, as he laid with his face to the ground. The waggon was stopped, and when' he was drawn from under it, a stream of Mood directly burst from his ham ; a handkerchief was tied tightly over the wound, and he was put upon the waggon, and was carried hcmie in a fainting state. Different surgeons in the neighbourhood were sent for ; but when they heard the nature of the case they all made excuses ; one had a most dangerous case of fever, another was at a labour; a third with a
t) 3
196
Of the Femoral
Hi^jip If this artery be wounc groin. groin, the finger must wound to stop the b' press can be applied the vessel be secured Kt'" If it be wounded ^'«^- in the mode whicl case of a relation swelling will \\ artery will be d
Treatment COagulum. A
give the sur^ securing thi being first l cision will for poplit.: . extensive .
iio was .,l; was ap- iiLc messenger, . would be stopped iv.d; and so it was« for rod.* ..:c a strong^impression upon : was the first death I had 1 was directly convinced how exposed, , jfeember of society a well informed jKu^n be» wsd how great a cuxsie an was. If the artery coidd not the limb might have beea
by th( spong ed, V diro'^
^1-
lie artery in the ham, there is of including the sciatic nerv^
^ f^i^ %«» forty-three years ago, when a man who -.^ag^^MU from the operation, for popliteal aneurism, ^ a sufBcient cnrionty to be annually shown at our Hospitak.
IM
^ artery in cutting into
-carefully avoided ;
^^om the vein
^ upon it.
included in
[)opliteal aneu-
ii a few hours.
/• Tibial Artery. at the upper part of the leg Rare at the
• opperpart*
i I lent, but they do sometimes
was brought into Guy's Hospital, Case.
I t alien from a considerable height,
a cart, and an iron peg in the cart had
.sed through the calf of his leg, between
ilie tibia and fibula ; a profuse haemorrhage
ensued, but by the application of a tourniquet
it was stopped. In six days the bleeding
recurred, when the tourniquet was tightened,
and the flow of blood was again suppressed ;
hat in two days haemorrhage again took
place. I tied the femoral artery at the usual
{dace, and for a week the man went on well,
but then the bleeding was renewed, and I
was obliged to amputate the limb. On ex-^
amining it after removal, it was found that
Ihe iron had passed through the posterior
tibial artery, at the origin of the anterior
o 4
198
Danger in tying the artery.
pressing case of inflammation of the they were all engaged, and could ^ or, like the hare and many friends
" The first, the stately bull imploi " And thus replied the mighty lo' *' Since erery beast alive can tel " That I sincerely wish you we' ** I may without oflfence pretei '< To take the freedom of a fr' ** Xooe trails me hence,^ &c.
Tired of waiting, an old deemed a sorceress in th< plied to, and she sent ba saying, that the bleedin by the time they retume John Love had expired.
This scene made a s^ my mind, as it was witnessed, and I was valuable a member c surgeon must be, 9 ignorant surgeon v have been tied, amputated.
In tying the some danger o
•{J
..)S1
• This was fo had recovered fr< was deemed a s; to the students
uundei^ Travipiti
pital^^xjyg
oy theteiij^fe9»|
ailed t0Mr^QHMWf:|
by Mi^WhgBMfij
uclMiftiit^viMstiMf . :axee WMb befcKre I iBv ^^ MIbqd very frequent,; ^^ Imt m time by pressure «f m tfNimiquet.
\ t
re^
.'t Treatment iCt,
lich I
le tibia,
ompapy-
oful to ex*
s upon the
should care-
e byadhesiop.
.mb the artery is At the
•^ lower
oehind the.malle^ part. j[)anied by the pos- lies on its fibular side
iterossial artery I have interoswai die case of such a wound the vessel from the outer and seek it between the close to the fibula.
the Anterior Tibial. 1 is rarely wounded at the upper Protected
ftDOve*
200
tibial, and had penetrated between t! and fibula. Immediate An immediate amputation woulr^
ampata-
Uoo. best course to pursue.
In com. I have several times known the
pound
fractnre. tibial artery wounded by the bor
pound fracture; once, in a pat^
Chandler, and a piece of lint wa
the wound, which stopped the 1
it was followed by gangreen,
patient died. Case. In a case of Mr. Lucas's, in (
Mr. Pollard, his dresser, seer
and the patient did well. Case. A patient of Mr. Key's, a
a tourniquet was applied, 1
restrained, and it did not re Case. In ^ patient of Mr.Travei
by a scythe, and was tie
in the theatre at St. Tho'
patient did well. It is sometimes wour Case. nient of the adzoi- I v
Hunton Bridge, Hert
surgeon, at Market S
small, and the artery r
injury had happened ^
the man, the bleedinp
and were restraine
on the wound, by n
Operatioii.
On the donnm of the foot.
e cd
inugt
rhage
anasto-
V.
ese arteries, I TreatmenU
iplioation of a ^)on the wound, jgh would effect, tibial artery, after ssful trial of these the artery placed, st tendinous parts IS should not be made
•r. o
poand tnctnr
part of the limb, but frequently at the lower.
Lyiug between the two bones above, it is much protected.
When wounded at the upper part of tlie limb, an incision must be made on the onto side of the tibialis anticus to find it: a tenaculum, or a pair of forceps, must be em- ployed to raise the wounded artery, to remove it from the interosseous ligament; and then two ligatures are to be applied upon it.
I have seen it wounded in compound frac- ture. First, in a brewer's servant, a patient of Mr. Birch's, in St. Thomas's Hospital ; the artery being tied, the compound fracture pro- ceeded quite favourably.
In a second case the result was singular. A man was brought into Guy's Hospital* with a compound fracture of the leg. A few days after his admission, he had a free haemorrhage from the wound, which was stopped by the application of the tourniquet ; but at different intervals the bleeding was frequently renewed, and I was at length compelled to amputate his limb. Upon ex- amining it afterwards, a spicula of bone was found penetrating the anterior tibial artery, and the opening into the vessel thus pro- duced, had been enlarged by a process of ulceration, so as to give rise to the hEemtMr- hage.
203
Wkcm Ae aoieriOT tibial aiteiy is woonded hm dofvm in the leg, it mart, wfaoi it is tied, be ci—|Ji5tdy raised from the tendons of the
wlndk it is placed ; bodi ends most
Wsartoy is sometimes woonded on the Om part of the foot, where it is placed Ae nafienlar bone;, and the middfe by a knife or drisd bcay dropped
Sash caUiemilj of the divided Tessd mnst be canfidty tied, otherwise the hoemofihage wit I'lmlinne^ on accuuut of the free anasto- of tins artery widi tiie ]daatar»
Qf the Fhatar Arterks.
fSor awmmd of eiAer of these arteries, I
try what the s^plication of a wilh a compress upon the wound, atonnnqnetiqNmthe tUgh would effect, sad ihonld tie the posterior tibial artery, after
and iDisiiccessfiil trial of these ; fer so deeply is the artery placed, so situated ammigst tendinous parts SHlncsfes, dbat incisions dioold not be made St Ae woonded part.
204
Styptics*
Wool.
Turpca- tine.
An old prescrip- tion.
In bleeding from small vessek on womided surfaces, very fine wool laid down and con- fined by bandage upon the part is (me of the best styptics. The wool may be dipped iin flour to add to its efficacy.
Turpentine is said to have power as t styptic, and I have seen bleedings stopped by it when it has been applied by lint, and with pressure ; but merely poured upon liie wounded surface it appears to me to be quit^ powerless.
There is an old prescription for a styptic^ in St. Thomas's Hospital which I have seen useful.
R. Pulv: Catechu
Pulv: Bol: Armen: aaSij.
Alum: ust: 5j.
Tinct : opii. q. s. iat fiat pasta.-
This will stop the troublesome bleeding: from leech bites.
205
LECTURE XXXIX.
Of Wounds of Veins.
Mr. Travers has published a very good Traverses paper tipon the mode in which they heal. p^p®"^-
In a healthy constitution they are little in healthy dangerous, as the cellular tissue adheres over Sall^erons! the apertures which have been made in them, and inflammation speedily closes them.
I €fnce saw the axillary vein wounded in case. rel&oving a scirrhous gland from the axilla, a dosil of lint was placed in the wound, and the arm was confined to the side, when no bleeding of consequence ensued.
In unhealthy constitutions they inflame in unheal- and suppurate ; they also ulcerate, and some- "^^^IZ: times life is destroyed, by bleeding or by the inflammation extending to the large vein, and to the heart.
Several cases of this kind I have witnessed; and in the greater number the wound of the vein had been made to abstract blood for inflammation of the lungs ; and I have thought that the inflammation of the vein was the result of the impediment to the pulmonary (^culation.
The patient in a few hours after the bleed- symptoms mg, complains of tenderness in the arm, and mation?™"
206
requests to have the bandage loosened ; he next finds great p^n in extending the limb ; the wound looks red, and its lips are sepa- rated. Then the plexus of veins on the fore arm become swollen, hard, and very painful; afterwards the basilic vein of the upper arm feels as a solid body, and is much enlarged. High constitutional fever ensues. If the patient has sufficient power of constituti<m, abscesses form in the veins of the fore ami; and by opening these early, great relief is afforded; but if the habit be particalarly feeble, the matter which is produced by Ae suppurative inflammation, does not point, but it remains in the veins, producing excessive constitutional irritation, which destroys life* Appear. Upou inspecting the vein after death, it is '^' found partly filled by adhesive matter, and in part by pus. There is in the collection at St. Thomas's Hospital, a beautiful specimen of abscess in the longitudinal sinus of the dura mater. I have seen the jugular vein inflamed and adherent throughout the greater part of its course. Specimen. We havc, in the collection atGuy's Hospital, the femoral and iliac veins obliterated, taken from a patient who had phlegmatia dolens ; which disease has been extremely well des- cribed by Dr. Davis, in the " Medico Chirur- gical Transactions."
207
But the worst cases of inflammation of veins Dwuion or which I have seen, have arisen from the appU- m^ "* "" cation of ligatures to the vena saphena.
First, I have seen a disease like phlegmatia Consefiueo- dolens follow the division of this vein.
Secondly, numerous abscesses form and break, sometimes destroying life, at others producing excessive irritative fever, from which the patient has been with difficulty recovered. One patient became insane during the irritation, and did not afterwards recover her mental faculties.
Thirdly, they have died from suppurative inflammation, without any abscess appearing, and this is the cause of death after the opera- tion of amputation, when it is performed during a very unhealthy state of the consti- tution. I have seen, under these circum- stances, both artery and vein, in a stump, in a state of partial adhesion and suppuration.
I saw, in Paris, in 1792, a case in which life was destroyed by suppuration of the femoral vein, after a gun-shot wound.
Of the Treatment of Wounds of Veins.
The first and greatest object is to empty PMidon. the veins as much as possible, by the position of the Umb, which should be such as to allow of the gravitation of the blood to the heart.
208
In the arm, an inclined plane ; in the leg, the position for a fractured tibia. This prevents accumulation of blood, and distention of the vessels. GenUe Sccondlv, a roller, from the extreme part
pressure. ^ ^
of the limb, to the wound, wetted with the liquor plumbi subacetatis, and spirit should be applied to approximate the sides of the vein, and to make gentle pressure.
Thirdly. — Leeches should be freely applied, and if suppuration be produced, fomentaticNos.
Wounds of the Abdomen.
Two kinds. Thesc injurfcs are of two kinds : 1. Those in which the cavity is opened, but the vis- cera are not wounded. 2. Those in which some of the viscera suffer. First kind, With rcspect to the first of these it is covered^ sfcarccly ucccssary to say, in the present state of surgical knowledge, that very exten- sive wounds of this description are often re- covered from, as is proved by the operations for umbilical or ventral herniae, by the Cesa- rian section ; and, recently, by the removal of enlarged ovaria.* But the most curious circumstance in these wounds, is the manner in which the intestines glide away from the
* See cases by Mr. Listoq.
from.
209
sharpest instruments, and escape injury. I shall relate two cases: —
In the year 1786, my second year of being ctse, at the Hospital, a gentleman came almost breathless to the Hospital; and finding me the only person there, requested that I would immediately accompany him. He took me to a house in the Borough ; and, leading me up stairs, showed me into a room, where I found a female in her shift only, lying upon the floor, weltering in her blood. I with diffi- culty raised her, and placed her upon the bed she had just quitted. On examining her, I found four wounds in her throat ; one of which was deep and extensive. These I closed by sutures ; after which she was able to speak; and I then asked her what had induced her to commit the act ; she made an incoherent reply; but repeated the word stomach two or three times, which induced me to raise her linen, when I was surprised to find her bowels exposed by a wound reach- kg nearly from the pubes to the ensiform cartilage of the sternum ; for, after cutting her throat with a razor, she had ripped up ker beUy with it, and let out her bowels, but the intestines were still distended with air; aad I had a difficulty in returning them into the abdomen. They had not received the smallest wound. Dr. Key now came intp
VOL. III. P
210
the room^ and I proceeded to sew up this extensive opening; but she died in niue hours.
Case. Mr. Tolman and myself were sent for to
see a gentleman who had stabbed himself in several parts of his abdomen^ with an old rusty dirk, and had for ^sorne time afterwards concealed himself from his family. When found, it was discovered, that a portion of omentum protruded through one of the open- ings ; this was carefully returned ; but, not- withstanding, the dirk still possessed its point, the intestines were not injured, and he recovered without a bad symptom.
The free motions of the intestines upon each other, independent of the. peristaltic motion, is a great preservative in wounds of, and blows upon the abdomen.
Peculiar There is another curious circumstance in wounds into the abdomen; which is, that they immediately produce universal cold- ness and paleness, with nausea and faintness, excepting in the operation for strangulated hernia ; in which case the intestine has been accustomed to violence.
Treatment In the treatment of these wounds, it is best to make interrupted sutures ; the needle should penetrate the skin and muscles, but not the peritoneum. If the muscle be not included in the ligature, a hernia is sure
211
afterwards to form ; and, if the thread is introduced through the peritoneum, it adds much to the danger of abdominal inflam- mation.
Between the sutures, strips of plaister, or of lint dipped in blood, should be applied, and the patient should be freely bled from the arm. If the local inflammation be great, leeches should be employed; purgatives must be avoided, and food must not be given finr several days.
Of the Second Kind of Wound of the Abdomen.
Wounds of the abdomen, extending to the Rare, stomach, or intestines, are extremely rare.
There, danger is much lessened, if the Dangerous, wounded portion of the viscus protrudes through the opening in the parietes ; for, if not, they are generally fatal.
Wounds of the Stomach.
The best case which I have heard of, is related by Mr. Scott, in^the medical commu- nications, from which the following account is taken : — "During the election for Weymouth, in Mr.scotfs
case.
p 2
•r
. •• ^
^^ \ii»w Thomas, a seaman,
^-ir. ii a strong and healthy
MM. !ie misfortune to receive
w-.alL sword on the left side
T^» sword passed in between
^ *«. :mv\ of the lower false ribs,
. •^cu :uto the cavity of the abdo-
, «/i!^ontaI direction, to the extent
jLi: dve inches, as appeared after-
Lt*: mark upon the blade.
tiiii about half an hour after the
His whole appearance was then
.*:ci ^\l ; his countenance being quite
A^^vw AUil covered with a cold sweat,
., !K' pulse at his wrist was scarcely
,.. ^'*ii>ic; he had also a constant hie-
.^tu .i frequent retching and vomiting of
v^>vv. ,iud u considerable discharge of blood,
X.V ^i>cr tluids, from the external wound.
b%\>m the i)lace and manner in which the v**vsv? hud entered, and the symptoms that <\K^^uhK I was led to conjecture that the x^oauu^h was wounded ; and that this was v;<sU\dv the case, I was soon convinced, on ^ \,iu\ming the fluid discharged by the exter- mI Nxound, and finding in it several small •MvVi*>^ t)f moat in a soft digested state, toge- »hvM with some particles of barley.
" llr had complained of thirst, and some {k\\U\ water had been given him to drink;
213
but this had been immediately thrown up after passing the oesophagus. Other mild fluids were now tried, as were likewise a common saline draught, in an effervescent state, and some thebaic tincture, but with no better effect ; and they were all instantly rejected, tinged with blood.
" The retching and action of the stomach continuing to be very violent, and the patient complaining, at the same time, of a lump, or dead weight, as he termed it, in his inside, he was desired to drink some warm water ; this was soon thrown up, accompanied with a good deal of barley in solid grains, with the surface slightly broken, and some pieces of meat in a half-digested state. More water being given him, it was quickly returned, tinged with blood, but, otherwise, nearly as pure as when swallowed.
"I now proposed that we should avoid giving any thing farther by the mouth ; but, as the spasms and hiccough were still very frequent, an emollient clyster was adminis- tered, by which a considerable quantity of fceces was discharged. Soon after this, another clyster, containing twelve ounces of barley-water, and sij of thebaic tincture, was thrown up, and the greater part of it retained. Warm fomentations were like- wise applied externally ; the surface of the
p 3
214
wound was loosely dressed; and he was desired to lie as mach as possible upon the injured side, with a view to &vour the duir charge.
'' On the first of April, the day after the accident, the symptoms were still rery im- favourable. His pulse continued low and languid, with a great prostration oi strength, and a coldness of the extremities. He had had several rigours towards morning, and the spasms were sometimes very violent. He complained of extreme coldness over his whole body, and of a constant gnawing pain about the pit of his stomach, to which part warm fomentations were frequently applied.
''A laxative clyster was again administered, which was followed by a copious discharge ; soon after this, another clyster, consistiiig of fourteen ounces of veal broth, and two drachms of thebaic tincture, was thrown up and retained. A similar clyster was repeated in about four hours, with the same effect Flannels, dipped in warm milk and water, were occasionally applied to his arms and legs, and hot bricks to the soles of his feet* He made a little water twice in the course of twenty-four hours; this was highly co* loured, and deposited no sediment, though kept for a considerable time.
'* April 2. He had passed a restless night,
215
plained of intense i hiccough and spasms were less frequent, but he sufiered much from a constant burning pain in the lower part of his stomach. His pnlse was small, and beat about 120 in a minute. The fomentations were applied as usual; and 3vj of the sal: cathart : amar : were dissolved iu some broth, and thrown up into the bowels as a laxative. This produced a considerable discharge of soft slimy foeces, in which were several small pieces of clotted blood enveloped in mucus. After this, in the course of the day, three clysters of broth and thebaic tincture were thrown up and retained. He was desired to use the pulp of an orange occasionally, to allay his thirst, and to wash his mouth frequently with barley water acidulated witii lemon juice.
" April 3. I was called to him early in the morning, and told he was at the point of A clergyman had been sent for at the same time to perform tlie last offices. The nurse informed me, that, whilst sup- ported in bed to wash his mouth, he had ien seized with a violent retching, accom- inied with convulsions of the chest, but lat nothing had been discharged from his stomach, except a small quantity of bloody fluid. When 1 saw him, the spasms still continued , his forehead and breast were p 4
216
covered with a cold sweat; his ptilse was low, and intermitted; so that it could only be felt at intervals ; and his strength seemed to be quite exhausted. Warm fomentations were immediately applied to the region of the stomach ; and^ as there was always some of the veal broth kept in readiness, I threw up about fourteen ounces of it, with sij of the thebaic tincture. The violence of the symptoms was soon moderated, and he ap- peared very languid, and showed a disposi- tion to sleep.
" When I saw him about four hours after- wards, I was told that he had enjoyed some rest. His pulse wras now regular, but small and quick; he was very weak, and just able to inform me, that, in washing his mouth, he had accidentally swallowed some of the liquor, and that this had thrown his stomach into violent action. About one pint of the broth was now injected without any addition. This was likewise retained, and repeated at intervals of five or six hours. He now made water frequently, which, upon standing, deposited a considerable quantity of sediment, of a light brick, or straw colour.
*'April 4. The hiccough, retching, and other unfavourable symptoms, were now entirely gone ; but he still complained of a fixed pain
217
in his stomach, accompanied with a sensation of heat, and of a soreness of the injured side, extending from the wound toward the middle of the ahdonien. He was likewise troubled with thirst; his pulse was small, and about 110. The external wound had now began to yield a discharge of good matter.
"The same mode of treatment was conti- nued, and the symptoms became daily more favourable. The broth was administered in clysters, to the amount of two quarts, or five pints a day. The fomentations were conti- nued externally, and his feet and hands were frequently bathed in warm milk and water. He voided his urine regularly, and in about the proportion of three pints in the twenty- four hours, though it sometimes considerably exceeded this quantity, and continued to i deposit a great deal of sediment. A little of I the sal : cathart : amar : was occasionally i added to the clysters in order to stimulate and cleanse the intestines ; after the fourth day, however, there was scarcely any foeculent matter discharged, but only a small quantity of viscid bile.
" On the 10th day from the time of his being wounded, he appeared to be very sensibly relieved ; his thirst and febrile symptoms Were much abated, and his pulse was regular, and about ninety. As he was in good spirits.
covered with ji c<»i . ^ lac he might be low, and intcrniiLiLu -icching, I procured be felt at iiitcr\ii.. . aade luke-warm, of to be quite c.\'. . uit. without feeling any were immediic.. -.Tie only remarkable
the stomnc h , « blended the first time of of the vopI ^ jB^ diat it occasioned fre- up abniit 1,-ni ^od a great discharge of
the thol ^ .^tijkfrauig to his own account, synip^ ^.^Bk X ^teful sensation than
!)(*•« •' , ijA lay he was allowed some til- ^ .^ ynnikiatst, and some chicken
rhe nutritious clysters were
#w«%er. till the 16th day, though
.fltttu before. From that period,
.'.itttti^ac, he lived wholly on bread
uM tigbt broth. He was then
tficifieu,. veal, and other meats easy
rhe external wound had been
« ^oitie time, and he recovered his
*«ir% jcradually. The only incon-
jij ^tUK^red was from costiveness,
s)t soreness and stricture which
i iivm the external wound towards
«i^o(c oi' the abdomen. This was par-
,\ cit Arter a violent expiration, or any
^^^u V \tctt^ton of the body, when, to use
*a c \tuv**ion, his side was drawn in-
^^^^ .uKi upwanls. The costiveness was
vH^^i^vM^ o> uuld Uixutives, and gently stimu-
.v' g'
219
■:\(l went off entirely as the v'crcd their true and natural ;i lier complaint which I appre- i originated from an adhesion of ■ icd stomach, to the peritoneum, to go off gradually as he recovered .reiigth; though it was still felt in a till degree in stooping, walking quick, or :reat exertion of the body. When I last iicard of him, two months ago, he enjoyed good health,"*
'' This case affords a striking instance of the resources and peculiar powers with which nature has endowed the animal machine, for its preservation, and for remedying any injury it may sustain. The treatment was sijch as was necessarily suggested by the symptoms. The wounded stomach was so extremely irri- table, that even the mildest fluids increased the violence of its action, and were rejected ; for had any substance, whether of medicine or aliment been admitted, it would probably have interrupted the union of the divided parts in the first instance, or afterwards, by the action necessary for its expulsion through the pylorus. '' The liquid contents of the stomach had
* This was in the September twelve months following, ^ the paper is dated November 15, 1786.
220
been chiefly discharged by the exteraal wound, though part of them must, no doubt, have passed into the cavity of the abdomen, and have been afterwards absorbed ; but the wound of the stomach collapsing, the barley and indigested meat were left, which increased the irritation, and occasioned the uneasiness and sense of weight he complained of, and which was, in a great measure, remored by the vomiting that took place upon his drink- ing the warm water.
" He felt some relief after the retention of the first clyster, but at that time his strength WBS so reduced, and the symptoms were altogether so unfavourable, that neither himself, nor those who saw him, entertained any hopes of his recovery. It is indeed sur- prising what an extreme debility took place immediately after the accident, which could , only arise from the nervous influence and general sympathy with a part so essential to life,
" The accident that happened on the fourth day, induced me to persevere in the mode of treatment we had adopted. Indeed there was great encouragement to continue it, as the broth clysters, were not only retained, but there was a proof of an absorption having taken place, by the secretion and evacuation of urine, which then began to be consi-
221
derable. It is a generally received opinion, that clysters seldom pass beyond the valve of the colon: the contrary has indeed been observed in the volvulus or iliac passion, but in that case the natural action of the in- testines is inverted, and a violent degree of auti-peristaltic motion prevails ; in this case, however, the broth was thrown up in a very gradual manner; and though, perhaps, it did not pass the valve of the colon, in the first instance, I am inclined to believe, from the sudden manner in which the absorption was afterwards carried on, that a gentle de- gree of anti-peristaltic motion took place, whereby it (the broth) was impelled to the smaller intestines ; this will appear less sur- prising, when we consider, that, in the natu- ral action, the first impulse is communicated by the stomach, in discharging the digested aliment at the pylorus, and continued through the intestines in determining the foeculent matter downwards: but here the natural action was suspended, the stomach was at rest, and there was no foreign matter to be discharged.
" The advantages to be derived firom throw- ing up a supply of fluid, and supporting nature in this manner, in particular cases of morbid affections of the digestive organs, will readily occur to the attentive practitioner."
222
Wounds of the Intestines.
In operat- In a Small wound of the intestine, whidi hcrnis. I witnessed in strangulated hernia, under the operation, I pinched up the opening with a pair of forceps, and tyed a thread around it; I then passed up the intestine to the mouth of the hernial sac, leaving the ligature to hang from the wound, and the patient recovered, but he had severe symptoms for several dajrs. Large In a morc considerable wound of tiie
intestine, I should make an uninterrupted suture, and return the intestine into the abdomen, letting the end of the ligature hang from the external wound, which I should otherwise close with great care. I well know, that in experiments on animals, the ligature has been cut off close to the in* testine, which has been returned into the cavity of the abdomen, and the external wound has been afterwards closed, so as to leave the ligature to separate into the in- testine. Now I do not clearly understand that this plan, in any way, adds to the patient's security; but, on the contrary, it increases his danger in my opinion, if the )>rocess of adhesion be deficient.
223
In the treatment of these wounds, it is Treatment, right, if the wound be in the small intestines, to keep the patient without food, and sup- port him by clysters of broth, &c. If it be in the large intestines, after a few days, a little jelly may be allowed. Perfect quiet is to be observed; and, if there be much tenderness of the abdomen, leeches should be applied.
Ruptures of the intestines from blows are Rapture of
/. ^ •J X • • /• 1*1 intestine.
more frequent accidents, arismg from kicks of horses, falling upon projecting bodies, &c. The symptoms are, great depression, cold- ness, and paleness; the pulse is scarcely to be felt if the laceration be large, and the patient dies in from twelve to twenty-four hours after the accident, quite sensible to the last moment of his existence.
But if the laceration be small, the symp- toms are less violent ; there is coldness, ten- sion of the abdomen, vomiting, costiveness, and not the least disposition for food ; there is subsequently great abdominal tenderness and great enervation.
A patient was brought into Guy's Hos- case. pital, under the care of Mr. Forster ; the man had been working in a gravel-pit, when the gravel fell in upon him. He vomited, Ui& abdomen became tense, and as he made scarcely any urine, the case had been thought
224
to be retention of urine. The man died six days after the accident, and, on examin- ation after death, a rupture was found in the intestines. Treatment. The treatment in these cases, is perfect rest, to prevent any disturbance of the adhesive process, to apply leeches and fomentations to the abdomen, to avoid giving any medicine, and to check the desire of friends in giving food for several days after the accident. Sometime! The intcstincs thus remaining for a length from^ of time at rest,* and inflammation being kept within the adhesive bounds, I have seen (what I believe to have been) cases of this injury recovered from.
Wounds of the Liver.
ca9c. I have seen deep stabs, with a pen-knife,
in the situation of this org^, recovered from, after great inflammation in the abdomen. The patient was bled generally, and by leeches, and fomentations were employed. Adhesive plaister had been applied to the stabs, and on its being removed, a bloody serum Mras discharged from the wounds.
* The perislaltic motiQii is •greater or less as flie iales- tiues are full or empty.
226
Wound of the Gall Bladder.
Mr. Edlin, of Uxbridge, informed me of Cate. the following case : — Two soldiers quarrelled, and one struck the other with his bayonet in the tight side, just below the margin of the ribs. The wounded man directly fainted and fell; when he recovered from his faint- ing state, he complained of agonizing pain in his abdomen, which became extremely tense and tender to the touch. In thirteen hours the man died; and, on examination of the body, the gall bladder was found to have been penetrated by the bayonet, and bile was extravasated into the abdomen. Mr« Edlin said, that wherever the bile rested, the peritoneum was highly iuflamedt
Wounds of the Spleen.
Although this organ may be removed from the body, without the destruction of life, as is known from the case of the soldier, mentioned by Dr. Gooch, and by numerous experiments on animals, yet a very small wound of it is sometimes destructive of life; the best example of which I shall give in the following case: —
VOL. III. Q
226
ca«e. A lieutenant of a press-gang was attempt-
ing to press a man, who resisted with much violence; a scuffle ensued, and the lieu- tenant struck the man with his dirk, which entered near the ensiform. cartilage, and its blade was nearly buried in the body. The man was brought to St. Thomas's Hospital^ pale and extremely depressed, his abdomen became tense, and he died. Upoa examine ing his body, it was discovered that the dirk had passed from the ensiform cartilage, under the margin of the chest into die abdomen, on the left side, and that its point had penetrated the concave surface of the spleen ; the cavity of the abdomen was filled with fluid blood, wonnded It is Said, that the spleen has been ( often in tapping, ^quj^^j^ j^j n^^ trochar, when tapping was
performed on the left side, which, under enlargement of this organ, might happen.
Ruptared. I havc Several times known the spleen ruptured by carriages going over the abdo- men, and once by the horn of an ox. Bach of these cases proved fatal.
Case. Twice have I known the spleen torn from
its natural attachment to the diaphragm. The first instance, was in a patient of Drs. Babington and Letsom, a Miss Harris, who, having vomited violently, discovered soon after a swelling at the groin, and at th^
' lover part of the abdomen. I waS asked if it was hernia, and ! declared it was not. She died after a week, vomiting; constantly the liquids which she swallowed. When the abdomen was opened after her death, the swelling was found to arise from the spleen, which had been detached from the dia- phragm, and was enlarged by the inter- ruption to the return of blood from the veins, although the artery still contained blood. The spleen was turned half round <Hi the axis of its vessels.
The other case was that of a gentleman Case.
who was hunting in Surrey; he fell from
his horse when going at full speed. He
died the following day, or the day after.
I Dr. Pitt, who attended him, examined the
I body after death, and found the spleen torn
1 from the diaphragm.
I In wounds or ruptures of the spleen, Trean 'I I believe nothing can be done. If the case ^L cOold be accurately ascertained, pressure by ^WMoller on the abdomen would be the best Vtreatmeot.
Wounds of the Kidney.
A wound of this organ is not fatal. A Boy called at ray house, and showed (:«•■. iiie some chalky concretions which he had Q 2
228
coughed up from his lungs or bronchial glands, I said, " How long have you been subject to this complaint?" He answered, " Ever since I have passed blood with my urine," I asked him to explain himself fur- ther, when he told me, that when quarrelling with another boy, he had been struck with a penknife in his back; that almost imme* diately he wished to make water, when he passed a large quantity of blood. This con- tinued for several days, but subsided by his remaining quiet in bed. The recumbent posture is in such a case the very best secjority.
Wounds of the Bladder. Danger Thcsc are dangerous, or not, as the
from state , ^
ofbiadder. bladder is full or empty, when the injury is inflicted. If full, urine is extravasated into the abdomen, or extensively into the cellular tissue, and death ensues. If empty, or nearly so, the danger is greatly lessened.
The bladder is sometimes ruptured when the above observations are applicable. The cause of its laceration is generally a fracture of the pubes.
Treatment. The treatment of these cases, consists in leaving a catheter in the bladder, and en- joining perfect rest.
229
Wounds of the Chest.
These are also of two kinds: — First, or two Wounds of the parietes. Second, Wounds of the viscera.
Wounds of the parietes are not * attended of parfetes. with much danger.
'A boy fell from a tree upon some pales, case. which entered his chest between the seventh and eighth ribs, tearing his intercostal mus- cles freely. The air rushed violently into his chest at each respiration, and was again expelled, when the anterior surface of the lungs appeared at the wound. The edges of the wound were brought together by ad- hesive plaister, a roller was applied tightly round the chest to confine the motion of the ribs, and he was bled very freely. He did extremely well.
A jnan was brought into St. Thomas's case. Hospital who had been stabbed between the . cartilages of his ribs, he bled very pro- fusely, and I thought the internal mammary artery was wounded, but the bleeding soon subsided, and he recovered.
Treatment in wounds of the parietes of the chest, is to promote as much as possible the adhesive inflammation to close the wound externally.
Q 3
230
Hsemorr- If there be bleeding from the intercostal ^^' artery, the finger should be pressed upon tiie orifice of the vessel, until the disposition to haemorrhage ceases. Case, A man died in Guy's Hospital, who had
been wounded through the intercostal mu^ cles with 'an iron spindle, the wound healed, but tetanus supervened, of which he died* Upon inspecting the chest after death, the lung was found to have assisted in closmg the wound, by adhering to the injured pleura.
\\
Of Wounds of the Lung.
symptomsi When this happens, the circumstance is known by the patient's coughing up florid and frothy blood ; by free bleeding from the wound, if sufficiently large to permit its escape ; by considerable irritation and tick- ling in the larynx, and by dyspnea.
Danger of. Danger in three ways results from wounds of the lung. First, From haemorrhage, if any large branch of the pulmonary artery is wounded. If the vessel be wounded by a . sword or knife, it bleeds very freely; but, if by a broken rib, very little, as it has the nature of a lacerated wound.
Tip.atnieiit. In either case, the patient must be freely
'^e of the 1 the
lion
ilimation Danger from in- Cavity of flaramation.
irded against
-;s, determined
CSS of the pulse ;
^ r bleeding too much
as it is an object not
iorce of the circulation,
jf the blood in the pul-
ioUows, it is the result of neg-
j ination, or of having closed the
ound.too early. In the one case,
^)urulent secretion; in the other, a
. serum, which produces the dyspnea
0 days after the accident.
For effusion into the chest, it is right to Operation
. .for effasion.
perform the operation for paracentesis of the thorax, to draw off the pus or bloody serum which has collected in the pleura. The mode of doing this has been already described.
In old persons, there is great danger in Effusion in fractured ribs with wounded lung, and I ^ p^"**"**
Q 4
230
Haemorr- hage.
Case.
If there be bleeding from the inten artery, the finger should be pressed up orifice of the vessel, until the dispos* haemorrhage ceases.
A man died in Guy's Hospital, been wounded through the interc cles with 'an iron spindle, the wor but tetanus supervened, of whi Upon inspecting the chest aftc lung was found to have assise the wound, by adhering t pleura.
Of Wounds of i
Symptoms. Whcu this happcus, '■ known by the patient's and frothy blood ; by i' wound, if sufficiently escape; byconsider? ling in the larynx, a^
Danger of. Danger in three ^ of the lung. Fir any large brand is wounded. If i . sword or knife if by a brokei nature of a la* : j
Tieatmeut. In either c
*Ci
;olkMAig«ttiit^ lira! with Mr^ called- had been
of
I in their
y fatal, as
>rding relief.
jh interest, I
IS a preparation
omas's Hospital.
19^
ited in the second 0 Chirurgical Trans- ient to me by Mr. ended the patient. o^e, a private in the North- Case, while on duty on the 29th
234
of March^ 1810, with an unfixed bayonet in hiS' hand, sUpped down, and his bayonet entered his left side, between the sixth and seventh ribs, upon the superior edge of the latter. He was some yards distant from the gate at which he was posted, and being challenged, he returned to open it^ with the bayonet still remaining in the wound; he was incapable of withdrawing it himself, but the person coming in extracted it iof him. I was called to him within five minutes of the accident ; he was then in a state of syncope, the extremities cold, and his pulse scarcely perceptible. In about the space of a quarter of an hour, he gradually revived, did not complain of any severe pain, and expressed, *that he believed he was more frightened than hurt.' I examined the^vound with much diligence, but could not trace its extent further than one inch and a quarter, though it was evident that the bayonet had penetrated two inches : the haemorrhage was very inconsiderable. His wound was dressed; he was conveyed to the military hospital, and put to bed ; he was incapable of lying on his right side, but slept tolerably well. On visiting him the following morning, he complained of lancinating pains extending from the wounded part across the chest, and of severe fugitive pains in different parts
235
of the abdomen; his pulse was quick and thready, and tongue white and dry. These symptoms led to a suspicion, that the pleura costaHs at least was wounded, though no opening could be ascertained extending into the cavity of the chest, ^xvj . of blood were taken trom his arm, a solution of sulphate of magnesia administered, and fomentations applied to the abdomen. He was obliged to be supported in bed nearly in a sitting posture, as respiration became much impeded when perfectly horizontal: in this position he appeared to breathe with freedom. In the evening, he expressed himself in every respect much relieved; his pulse was less quick, and had lost its thready sensation ; Lgue more moist; hU medicine h<ul ope- rated moderately. On the following morning, I found he had passed a good night, his pulse was calm and steady, scarcely quicker than natural, and the tongue quite moist; the lancinating pains had subsided, and he merely complained of a trifling pain in the wounded part ; this was increased by a slight cough, with which he became affected only this morning, and which was unattended by any expectoration. His aperient draught was repeated, an emulsion ordered for his cough, and the antiphlogistic regimen strictly adhered to. Throughout the day he wa3
236
walking about the ward, in very good spirits, quite jocular in his conversation with his fellow patients, and expressed himself to them, that ' low diet would not do for him any longer.' He retired to rest about nine o'clock, and fell asleep; at eleven, he got out of bed to the commode, had an eva* cuation, by no means costive ; said, ' he felt himself chilly, and a sensation that he should die;' returned to bed, and expired immediately; forty-nine hours from his re- ceiving the wound.
I examined the body on the following morning, in the presence of two other sur* geons. On opening the chesty the pleura was found slightly inflamed for some dis* tance round the puncture, and an effusion of adhesive matter, emitting a small portion of the lung to the wounded part ; the lung was not injured. At least two quarts of blood were effused into the cavity of the chest; the pericardium was nearly filled with blood, and had a puncture through it, extending three quarters of an inch into the muscular substance of the left ventricle, about two inches from its apex. A small coagulum was formed at the edge of the wound through the pericardium.
Upon opening the left ventricle of the heart, it was discovered that the bayonet had
237
penetrated the substance of the ventricle, and had cut one of the fleshy columns of the mitral valve.
On a review of the case, I conceive it very curious, that an organ like the heart, pos* sessing such excessive irritability, a point to which the most interesting of our sym^ pathies are referred, and which is in some degree influenced by the most trifling, should be so materially wounded, and yet the sys^ tern take so little cognizance of the injury. Death, in this case, it was perfectly evident, was not produced from any alarm excited in the system by the wound, but occurred as a secondary consequence, from the haemorr^ hage increasing to such an extent, as to interrupt the actions of the heart and lungs. That the haemorrhage proceeded chiefly from the heart, must be admitted : there was no symptom whatever that indicated a wound of the lung; none could be found on the most deliberate examination; and the in^ tercostal artery was entirely free from injury."
The second case has been published in the ^'Medical Records and Researches," from which the following particulars have been taken. It occurred during the time that Dr. Babington was employed as assistant surgeon at the Royal Hospital at Haslar,
238
and by him the particulars were communi* cated: — ca«e, «< Henry Thomas, a marine, was received
' into the hospital, from his Majesty's ship Foudroyant, having a wound in his side. He had slipped from the gangway, where h6 had been placed as sentinal, to the deck below ; and had fallen upon the point of his bayonet, which had penetrated his side a little below the false ribs, nearly in a perpen- dicular direction, as far as the hilt of the instrument. Immediately after the accident he drew out the bayonet without assistance, arose, took up his musket, walked cfight or ten steps, and then dropped down in a fainting state; from this state he soon recovered, and was taken to the hospital about two hours after the receipt of the injury; he then complained of but little
•
pain, was inclined to sleep, and when roused appeared in great distress. The wound wai^ on the left side, about two inches above the ilium, and communicated with the cavity of the abdomen ; but neither its direction nor depth could be ascertained. His body was cold, his pulse scarcely perceptible, but he had not apparently lost much blood. A por- tion of omentum, about sij in weight, pro- truded through the opening, this was cut off. A purgative enema was thrown up, which
239
procorecni motion, without any appearance of blood. He drank freely of coltsfoot tea, and took his medicines ; the fluids produced nausea, and attempts to vomit, but he did not eject any thing from the stomach. The breathing was at first slow, but free, by degrees it became more oppressed, and at length grew extremely quick and laborious, attended with a sense of weight on the right side of the thorax, which threatened suffoca- tion. The expectoration was not bloody. Soon after the injury he began to complain of a pain in the chest, and at the pit of the stomach, which gradually increased, and towards mid-night became almost insuffer- able. The upper part of the thorax had swelled a little, and the motion of the right arm much increased his sufferings. This tumefaction gradually augmented, and at eleven o'clock had reached the head and face ; it subsequently extended all over the body before his death, which took place a little after two o'clock in the morning, ap- parently from strangulation. He retained his Raises to the last minute.
" On examining the body twelve hours
after death, the following appearances were
discovered : — "The triangular wound from the bayonet, I was seated on the left side, midway between
240
the spine and the linea alba, having the last rib and the crista of the ilium at equal distances above and below it, it readily ai* mitted the point of the finger. A portion of omentum still protruded, and appeared gan- grenous. The direction of the wound was obliquely upwards and inwards, and had penetrated the following parts : — ^the intega* ment, abdominal muscles, peritoneum, Hie colon near its termination in the rectum, again at its arch ; the stomach inferiorly, two inches from the pylorus, and superiorly, under the left lobe of the liver, which was also wounded ; the diaphragm in the centre of the tendon ; after this the pericardium ; the right ventricle of the heart in two places, first the inferior part, and again near the tricurped valve; next the lungs were pierced; and last the anterior parietes of the right side of the thorax, between the cartilages of the second and third ribs, terminating in the substance of the pec* toral muscle. The abdomen contained a little bloody serum ; the pericardium a small quantity of blood ; but the right cavity of the pleura had about two quarts of blood within it.
*^ Although so many parts of importance were injured, but little was indicated of the extent of mischief from the symptoms which occurred during life. Thus the colon was
twice perforated, but the stools were not tinged with blood, nor was there any feculent matter in the cavity of the peritoneum. The stomach was also twice wounded, and yet vomiting did not take place, excepting once slightly, as he wjts brought to the hospital . The liver was opened to the extent of one inch, but yielded scarcely any hsemorrhage. The heart had been pierced in two places, but yet its action continued regular, and supported circulation for above nine hours. The middle and upper lobes of the right lung were both wounded ; yet he did not cough up any blood. The emphysema had originated under the pectoral muscle, and had gradually extended over the whole body."
Wou7tds of the Throat.
Attempts to commit the act of suicide are f?"* . the usual causes of these injuries, and usually one of the following parts suffer : — The pharynx, the larynx, the trachea, or the
If the chin be a little elevated, its dis- Vbkt tance from the sternum is about nine inches. First. Three inches below is the thyroid cartilage, and the space has the muscles of
VOL. III. R
242
the OS hyoides and tongue on t]»e fore (Mtrt. Second. In the middle division is the larynx, with the pharynx behind it. Thirds In the lower part is the trachea before^ and the oesophagus behind. On the sides of tb^e parts are situated the carotid arteries, wUdi are divided near the bs hyoides. The int^nal jugular veins are also placed laterally. The pars vaga accompany the carotid arteries, and the grand sympathetic nerves are found somewhat nearer the vertebrae.
Of the Wound above the Larynx.
This is the most frequent seat of injury, which is inflicted whilst the chin is ele- vated. Symptoms. Through the wound, air and blood issue with frightful impetuosity, more especially when the patient coughs. A lighted candle brought near the aperture is immediatdy blown out, and liquids, when attempted to be swallowed, are violently ejected from tie wound. Hence, those ignorant of the struc- ture of the parts, suppose that the air tube is injured, but the anatomist is aware that the wound has "passed through the muscles of the jaw and tongue into the pharynx, being
generally inflicted between the chin and os hyoides.
The arteries which bleed freely, are tlie ' sublingual, that pass just above the os hyoides on each side to the tongue ; but sometimes the external carotid arteries are divided, when, from the rapid haemorrhage, death is ^most immediate.
Treatment.
The wound is generally in itself but little dangerous; and when persons die shortly after its infliction, it is frequently from the fever which has led to the commission of the act, if it be not from haemorrhage.
Position in this wound is to be carefully PosUion. attended to. If the chin be elevated, the ■^ouod gapes widely ; but when the chin is depressed, the frightful aperture becomes closed ; the head should therefore be brought down towards the chest, and confined in that position, in order to prevent a separation of the edges of the wound.
I have generally put three sutures in the Suiore. integument only, the more effectually to guard against any disturbance of the aproxi- mated edges, which may otherwise, from
Lit motion of the patient during
244
Enema.
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irritability or delirium, be pro |
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sutures, through the integuir |
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ill this respeet very useful, n |
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The patient's mouth anc' |
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kept cool and moist, by ' |
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portion of lemon dippet |
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should be chiefly sup« |
.1 wa.^ |
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broth and gruel, to v |
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added if they quickb |
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fever has subsided. |
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:ifpital, the^ |
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should be made. |
remained |
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I knew a lady * |
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skin fron'^ |
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oesophagus, wh |
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days by clystc |
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she could n " ' |
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water. |
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245
the firoenum, on the dorsum of the epiglottis, and fixed it again to the thyroid cartilage. The man recovered; but whether it was a post hoc, or a prc^ter hoc, God knows! In general, these cases are fatal, in which the epiglottis is separated from the thyroid car- tilage, from a want of defence to the air tube.
Of the Wound into the Larynx.
This wound is either into the thyroid or symptoms, ^^icoid cartilages, or into the ligament which ^^ites them.
The air rushes out through the wound in ^^piration, and violently in coughing, and is ^Xso inspired through it. The person is not ^Vile to speak, unless the aperture be closed ^^ pressure ; but the food does not pass out ^t)m it.
A wound confined to the cartilages of the
l^irynx, or to the ligament uniting them, is
^ot dangerous, and by far the greater number
of these cases/which I have seen, have done
"Well. The treatment of them consists in
sipproximation of the parts by position, and
in the application. of adhesive plaister to
retain; the edges in contact.
a 3
246
When the wound is inflicted with excessive violence^ or by a stab, the pharynx may be wonnded, as it is situated behmd the larynx, and then the treatment of the wound is to be similar to that of the wound above the larynx.
Case. In a case of this nature, which was under
the care of Dr. Ludlow, of Galne, he informed me that the thyroid cartilage/ which wa& many weeks in healing, became ossified^ and that portions of it exfoliated «
Cafe. In a patient of mine in Guy's Hospital, the
wound upon the thyroid cartilage remained fistulous, and I raised a piece of skin from the surface of the neck, above the opening, and turned it over the opening, the edges of which I had previously pared : it united extremely welL
Of the Wound below the Larynx^
When the wound is inflicted within three inches of the sternum, it is more dangerous than in any other situation. The trachea is ^ here on the fore part, the oesophagus behind^ and the carotid arteries are situated close to the trachea, more especially the right. The thyroid gland crosses the upper part of the trachea, and its veins cov«r the fore part. Symptoms. If the trachea be cut, the air rushes
247
through the wousd both in expiration and ins^uration. The blood gets into the trachea, and excites a violent coughing^ by which a bloody froth is forcibly ejected, but the food or liquids do not pass out through the aperture^
The external opening, in these cases, is generally small, a9 the wqund often arises from a stab, and the consequence is, that the blood does not freely escape, but lodging in the bronchia, adds excessively to the dyspnea.
In the treatment, the first object is to stop Treatment, the bleeding ; and if the wound be not suf- ficiently large to lead to the easy discovery of the source of the hsBmorrhage, an incision should be made, in a longitudinal direction, to expose the mouths of the vessels. If the trachea be widely opened, pass a needle and ligature through the cellular tissue, upon its surface, which, from its firmness, will support the ligature, and thus bring the edges of the aperture into contact; but do not penetrate the trachea itself with the needle. Thus securing the trachea, bring the edges of the external wound together by bending the head forwards; but do not apply adhesive plaister, as it prevents the escape of air and blood in coughing, produces additional diffi- culty of breathing, and occasions emphysema.
R 4
248
The ligature upon the cellular covering «f the trachea, is to be separated by the ulcer- ative process, which will generally be effected in a week.
A transverse wound in the trachea, will be followed sometimes by a loss of voice, on ac- count of the division of the recurrent nerves.
If one of the carotid arteries be opened, death is usually so instantaneous, that the patient cannot be saved. If a surgeon were present, or the wound was very small, and he could reach the patient before he expired, he should thrust his hnger into the wound, to stop the flow of blood, and then cut down upon the vessel, to expose it sufficiently, to place a ligature upon it, which he can after- wards better adjust.*
When the trachea is deeply cut, the ceso- phagus is sometimes wounded ; and, if the injury be extensive, death will generally ensue ; but a stab into the cesophagus, or a small wound, may be recovered from.
After an injury of this kind, the wound into the trachea is to be treated as in the former instance, but whi-h that in the CESophagus will be best approximated ; all food, liquid or solid, must be avoided, and the patient is to be supported, as long as
indcd carotid.
249
nature can bear it^ by clysters. I object entirely to the introduction of tubes into the pharynx and cesophagus, as worse than un- necessary ; for they are highly injurious by the cough which they occasion^ by their irritating the wound ; and, if adhesion or granulation have taken place to close the wound, such tubes tear it open again and destroy the process of restoration.
260
LECTURE XL.
Of Wounds of Joinii.
■
These accidents are but trivial, or very dan*? gerous, as the surgeon is directed by proper principles, or is ignorant of the treatment which they require.
Jj^Pj^®' If the patient has a poultice applied, or if the utmost attention be not paid to the im- mediate closure of the wound, inflammation of the ' synovial membrane arises, and sup- puration ensues. The most violent consti- tutional irritation succeeds, — shivering, heat, flushing, and profuse perspiration ; generally, great swelling and excessive pain in the joint. Abscesses form in diflerent parts of the joint, one succeeding another, until the strength becomes exhausted.
In young In youug and healthy constitutions, these
sons. wounds in the largest joints are recovered . from ; but, in aged and weak persons, they^ destroy life.
Dissection Upou disscctiou in the first stage, suppu — rative inflammation of the synovial membrane is found ; in the second stage, the ligaments of
251
joint are thickened, and the synovial membrane in part ulcerated, in part granu- lating. The cartilages are absorbed ; granu- lations arising from some parts of the bones, and exfoliation taken place from other portions.
Recovery from these injuries, when infiam- Anchjiotu. mation has followed, is by adhesion, so as to destroy the synovial surface; or else by gra- nulation, when a partial or general ossific aachylosis is the result.
AU these effects may be prevented by an Treaimeni. intelligent surgeon. "When called to treat a Wound of from one to two inches extent into the knee joint, he will, with a fine needle and thread, passed through the skin only, (avoid- ing the ligaments,) bring the edges of the external wounds together ; for a wound in the joint is different to most others, as the synovia has a constant tendency to force a passage outwards, and it is more abundantly secreted than usual, so that adhesive plaister is apt to be separated, and union prevented ; he will apply, therefore, lint dipped in blood over the surface of the wound, and place the plaister over it; then cover the surface of ilie knee with soft linen, dipped into a lotion of the liquor ; plumbi subacet : and spirit. Afterwards he will place a splint I behind the limb to prevent all motion
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252
of the injured joint, and enjoin positire rest.
Purgatives should be as much as possible avoided, and a rigid abstinence enforced* In eight days, the threads may be cut and drawn away, but the adhesive plaister and lotion should be continued. Three weeks should elapse before the patient be allowed to quit the bed.
If inflammation follow a wound into a joint, leeches and an evaporating lotion must be employed ; and if it run high, the patient should be bled freely from the arm.
If suppuration be produced, fomentations and poultices are required locally; liquor: amoniee acet : and opium internally.
A fungus granulation forms at the wound, which must not be disturbed, as it is formed by nature to close the aperture; fresh irri^ tation is produced by disturbing it.
When a limb is stiff firom inflammation and adhosion» early motion of the joint is re- quin^t and its use may generally be restored. A joint thus circumstanced is not injured, but liH^AC^Atod by motioii» whilst in a chronic w ntHU'tViUHia mflimmatioii of a joint, rest is »uwtt «^»»«^utial to its cure. In this case, there- II^HV% ^ )Mjitiout si^tLmM not only use the limb «^ \H^uuu>l^ t^^t^wW* but he $iioiild set upon A U^h tt^M^". Am) c^m|4oy the muscles, for
'8ome length of time at once, in fiesing and
extending the limb.
Partial anchylosis, when the joint is not altered in form, may, in young persons, be considerably relieved.
Where ossific granulations have arisen from every part of the surface, permanent and complete anchylosis must be the result.
In removing loose cartilages from joints, it Removal of is proper first to draw down the skin to render lages. the aperture afterwards valvular. The carti- lage is fixed by an assistant, an incision is made over it, after the skin has been drawn an inch to one side, then as soon as the sur- face of the cartilage is well exposed it jumps from its situation, the skin is let go, and then no direct opening remains communicat- ing with the joint.
The after treatment is the same as in simple incised wounds, only a suture is not required.
Wounds of Tendons.
The division of the teudo achillis is most ■ frequently occasioned by a wound from an adze, and sometimes the injury arises from accident with a scythe.
In whatever way it is produced, the im- hediate effect of the division of the tendon is
■iediate efi
254
a great d^aration of its divided portions, tk upper one being drawn up by the action of tke gastrocnemei, and a fiiUing of the heel, the foot being influenced foy oppon^t muscles. Sometimes the posterior. iikkA artery and nwve are also divided with the tendon; where the surgeon shouid secure the former by a ligature as soon as possiblei or else apply a tourniquet.
Mischtefor. The mischief arising from this accident de- pends in a great measure upon the treatmeit which may be adopted. If the edges of tlie wound be not approximated, and if l&e e»di of the divided t^idon are allowed to remiM at a distance from each cfQier, inflammaliM arises, granulations are produced, and a unim of the ends of the tendon takes place t& iSkt surrounding parts, destroying permanently the action of the muscles, and the motions of the tendon. But if the wound be united by adhesion, and the ends of the divided tendon brought into contact, or nearly so, the mo- tions of the foot are generdly restored.
Treatment. The principle in the treatment is to ap- proximate the ends of the tendon by raising the heel, extending the foot, and bendtffig the loaee ; the external wound is then to be care- fully closed, in order that it may be healed by the adhesive inflammation. To effect this, a shoe with a heel one inch and a half in
255
height is to be placed on the foot of the injured limb, and a strap is to be carried from the heel of the shoe, to the calf of the leg, then d roller is to be Ughtly applied upon the upper part of the leg, to confine the strap and to keep the foot extended. The edges of the external wound are to be brought together by a small suture, and all pressure at the part should be avoided, only an evaporating lotion being placed upon it. The patient is to be confined to his bed until the wound be healed, and then he may be allowed to walk a little with a high heeled shoe. This shoe is to have the heel gradually lowered until it becomes of the same thickness as the heel of the shoe irorn on the sound side. By this means, the muscle which had contracted, and the tendon which had been injured are gently brought to their proper action.
If the divided extremities of the tendon are allowed to remain separate during the union, an addition is made to the tendon in its length, and the power of the muscle acting upon it is thus reduced.
Should much inflammation arise during the cure, the limb must be elevated to prevent all gravitation of blood, and leeches should be applied near the wound.
If the extensor tendons of the fingers be i
256
during the cure, by a splint placed under the hand and fingers. Indeed it is only necessary to consider whether the divided tendon, in any case, belongs to a flexor or extensor muscle, to know what is to be done to assist its union.
Punctured Wounds of Tendons.
Dangerous. Thesc are dangerous accidents, being often productive of tetanus. Several times within my knowledge, this has occurred from persons treading upon a nail, which has penetrated the shoe, and wounded the tendinous apon- eurosis of the sole of the foot; also an accident of a somewhat similar nature to the palm of the hand, I have seen productive of a similar eflect.
Teunus. Tetauus seems to be the result of a wound of a structure difiicult to heal, and requiring great constitutional eflbrts to produce the effect ; and these efforts in a very irritable constitution produce the highest nervous ex- citement.
Treatment. I^ thcsc injuries, I havc observed that it is best to foment and poultice the parts, so as to sooth and tranquillize them ; also to care- fully avoid depletion, even from the first to any great extent, either locally or constitutionally.
257
The patient should be allowed his common diet, and if he be restless or complain of much pain in the wound, opium should be given. Lowermg the patient only adds to his irritability.
Of Laceration of Tendons. The tendo achillis, and sometimes, but not of tcfcdo
achillit.
80 frequently, other tendons are torn through. This accident to the tendo achillis is pro- duced either by a violent effort of the muscles as in jumping or dancing, or by an unexpected extension of the tendon ; — as for instance, by treading unawares with the toe only upon an elevated substance. Dr. Curry, late physician to 6uy*s Hospital, informed me that he tore Ms tendo achillis by catching his toes upon a. scraper, when walking in a dark street; being at the time unprepared for such an occurrence.
In whatever way the accident may be pro- Treatment, duced, the treatment required will be to ex- tend the* foot, and bend the knee to allow the ends of the lacerated tendon to approximate. In this way the tendon soon unites by the adhesive process, and the use of the limb is afterwards gradually restored. Some degree of thickening of the tendon for a long time VOL. jii. ^ s
^5B
remains^ and th^ patient halts a little in rapi^ motioa.
The position of the foot and leg is to bi^ maintained in the same way as when the tendon is divided by incision, and an evapo- rating lotion should be employed. After the union, the same precautions are to be ob- served with respect to the employment of the high heeled shoe.
Of Partial Laceration of the Tendo AchilUs and Gastrocmmeus Muscle.
Cause of. A porson in running or walking fast, or if his foot slips backwards when it has beea advanced, sometimes feels as if he had re- ceived a severe blow upon the back of his leg, and is immediately unable to walk, but with the greatest difficulty, and with the foot
extended-
The cause of this feeling is a laceration, of some fibres of the tendo achillis, or of the gastrocnemeus muscle, where it joins the tendon. There is great tenderness upon pres- sure on the following day, with some ecehy- mosis, which daily increases, until the limh becomes considerably discoloured. The least sitttempt to bend the foot is accompanied with great pain, and followed by swelling of the leg and ancle.
259
From a belief that the injury is slight, and from negligence in treating it, the lameness which results from this accident is often of rery long continuance; but, if properly attended to from the first, it is in general soon recovered from.
A similar treatment to that recommended for division or lacei^tion of the tendon, is requisite for the cure of this injury, and when the patient can bend the foot without pro- ducing pain, then the high heeled shoe must be worn, and the heel be gradually lowered, ^in the previous cases.
Prom three to six weeks are required to ^fect a cure in.
Of Wounds of the Nerves.
The immediate effect of the division of Effect of.
^ nerve of a limb, is the loss of volition in
*l^se muscles to which the nerve is dis-
Mbuted, and the antagonist muscles being
^KQopposed, gradually contract. If the nerve
supplying the flexors is divided, the limb
Incomes extended; if that distributed to
fte extensors is separated, the opponent
muscles keep the extremity flexed. This
arises from the tendency a muscle possesses
to occupy the smallest space possible, and
s 2
260
which 'diflfers from voluntary or involuntary contraction, as the latter can only continu* for a time; but the former is permanent, or as long as the antagonist muscles are para- lysed.
The second effect of the division of a nerve is the diminution of sensibility; I <^all it diminished, because I do not find that the. division of the branch of a nerve, although it benumbs the parts, entirely depriv6s them of sensation.
In the division of the infra orbitar nerve, or of one of the nerves of the fingers, some sensation remains, but numbness is pro- duced ; when, however, all the nerves pass- ing to an extremity are divided, sensation is entirely destroyed. Case. I once saw a case, in which one of the
branches of the median nerve was divided in the palm of the hand ; and if pressure was made on the radio spiral nerve at the elbow, . it produced a tingling sensation in the be- numbed finger.*
The temperature of the part to which the nerve is distributed, if it be covered so as to prevent the access of a colder medium, is greater than that of parts similarly covered ;
* It appears, therefore, as if nervous influence is supported in a degree by anastomosis.
261
but if it be left altogether bare, it then has less power of resisting diminished tempe- rature than the surrounding parts. I have seen severe chilblains, and during the winter, incurable ulceration follow the division of the median nerve.
.When a nerve has been divided, if its ^^Jj,^,** extremities are brought together, it unites, ""**«• and the function of the nerve becomes gra- dually restored.
Dr. Haighton divided the pars vaga on one !>"'• Haigh- siae of the neck of a dog, and, after some nments. time, he cut through the nerve on the other side : . the dog lived, which he would not haye done,. had both the nerves been divided at the sapae time. When he had allowed time for the union of the second, he divided both ^t once, and the animal died under the same circumstances as would have occurred, had J^o previous experiment been made.
The time required for the union and re- storation of function, appears to depend upon the size of the nerve.
A young gentleman who had injured the ^"«- external condyle of the os humeri, had numb- ness in the direction of the radial nerve, and he recovered the sensibility of the parts in four months.
The numbness sometimes produced by Weeding is recovered from in three months.
s 3
262
In a fracture of the thigh bone, by which the sciatic nerve was injured, so as to pro-" duce numbness in the limb below, the person recovered in nine months. <^as«* Koschiusko, the Polish General, had his sciatic nerve inj ured by a pike, and when in this country, many months after receiving the wound, he had not got rid of the effects ; and I have heard since, that he remained lame.
At the place of union, after the division of a nerve, there is the appearance of a gan- glion, as may be seen in a preparation I made from the finger of a person brought into the dissecting room at St. Thomas's Hospital, a cicatrix covered the ganglion.
Independent of the size of a nerve, the time in which union will be complete, must also depend much on the positicm and ap- proximation of the ends. Tr«auiieiit In the treatment of a wounded nerve^ the only objects are the approximation of its ends and union by adhesion.
Many bad symptoms have been attributed to the partial division of a nerve ; but I have, in part, cut through the sciatic nerve of a dog, without producing any other symptom than partial paralysis. Cwe. I removed from the median nerve, a tu-
mor for a gentleman, and took away two
263
thirds of the nerve witb it, and numbness with tingling were the only unpleasant symp- toms following. J^ A Mr. H. called at my house, who had a Caie. P^wuliat division of the median nerve, ati'ecting the fore, middle, and ring fingers, but not the thumb ; he had tingling with the numb- ness, but no other bad symptom.
A nerve divided in part, therefore, occa- sions tingling and numbness ; one completely separated, only numbness ; the treatment of the former is as that of the latter.
If a ligature be applied upon a nerve of i-igat'"' magnitude, the consequences are sometimes fatal, and sometimes productive of lingering
Mr. Cline informed me, that in a case of (;»»'■ popUteal aneurism, operated upon in the old way, by opening the tumor in the ham, lie popliteal nerve was included in the
iture with the artery, and that the man lied in a few hours.
In a case of amputation at Guy's Hospital, casc i saw the whole sciatic nerve included in a ligature, which was applied to sup- press hsemorrhage from the artery which iccompanies the nerve. In four days, man was seized with violent spasm in
stump. On the fifth day, spasms afl'ected le limb, and from thence extended to the
264
other muscles of th6 body. On the seventh day, he died.
If a nerve be included in a ligature, when tying an artery, the process of ulceration is extremely slow, and the slightest drawing of the ligature produces agonizing pain. Case. Lord Nelson suffered excessively from
this cause after his limb had been am- putated ; and with all his heroism, he could ' not bear the least touch of the ligature,
without uttering the most violent expres*. sions. , "
After amputation, then it is right to avoid, with the greatest circumspection, any nerve, or portion of a nerve, in placing the ligatures on the vessels.
The division of a nerve, or even pressure upon the spinal marrow, so as to destroy volition and sensation, does not prevent the involuntary action of the limb or limbs from proceeding. The circulation still proceeds, and the irritability of the part remains as is shown in the application of a blister, which produces the usual vesication ; also, a wound heals by the adhesive process.
Friction and electricity seem to have some influence in restoring action in a divided nerve, or of one which has partially lost its power from any other cause.
Pressure upon b. nerve, occasions the
•266
sensation of a part being asleep; striking the cubital nerve at the elbow, occasions violent tingling in the little finger, and half the rmg finger.
Of Sprains.
A sprain is an injury occurring to the Definition, ligaments or tendons surrounding a joint, which are either forcibly stretched or lace- rated.
It usually happens from the sudden exten- How pro- sion of the joint in a direction which the muscles are unprepared for; in the iSame manner as when a dislocation is produced, only that the violence is not sufficient to occasion a displacement of the bones.
The most common situations of these acci- Common dents are either at the wrist or ancle, arising from sudden falls, by which joints are unex- pectedly and forcibly bent.
These injuries are attended with consider- symptoms, ^ble pain at the time of the accident, and the part soon becomes swollen and tender ; the fonner symptom arises from the effusion of Uood in the first instance, out of the lacerated Wood vessels, and becomes subsequently much increased from inflammation; the
tenderness and pain are generally in propor-' tion to the tumefaction.
At first the surface of the skin pnesents it» natural appearance, but after a short time, aa the effused blood coagluates it becomes much discoloured.
Sensation When inflammation has been set up, and given rise to effusion of fibrin, a sensation of crepitus is experienced on examining the injured part, which might, by an ignorant surgeon, be mistaken for the crepitus of fractured bone ; but it never ' give& that dis- tinct grating feel which occurs from the rubbing of one portion of broken bone upon another.
^n*t dV^ Immediately after the receipt of the injury,
Btroyed. the Ordinary motions of the joints can be readily performed ; but as the swelling takes place, these motions become much impeded^ and ultimately cannot be performed \/ithout producing acute pain, and increasing the mischief.
Treatment. In the treatment of these cases, the fiwt object is to arrest the haemorrhage firom tbe lacerated vessels, and then to prevent the occurrence of severe inflammation; after- wards to promote the absorption of the effused matter, and subsequently to restore the motions of the injured parts.
poiitiS!' ^^ *^^ ^^^^ instance, the application of cold
267
by means of evaporating lotions, and attention to the position of the limb, will efiect much HI arresting the effusion, and preventing acute inflammation. The position should be such as to relax those muscles which act on the injured tendons, and at the same time such as. will favour the return of blood to the heart.
Should the pain and tumefaction increase Bleeding, in spite of these means, leeches should be freely employed over the seat of mischief, and the bleeding encouraged by tepid appli-* cations ; purgatives should also be adminis- tered ; and in very robust persons, when the injury is extensive, general blood letting, and other constitutional remedies must be had bourse to.
When the inflammation is subdued, and Aftereffecu. the patient is free from pain, still the surgeon hie much to do in effecting the absorption of the effused matter, and this he should be careful to remove, as it is from neglecting this stage of the injury that other and more im- portant disease originates, thi§ more particu- larly in persons suffering from any constitu- tional disease, as in those affected with serofula.
In persons free from constitutional disease, in healthy these injuries, if not very extensive, are ^"**"'* fafndly recovered from ; the effusion quickly
subsides^ and the motions of the joint ai^ restored; but in no : case should the patienl: be allowed to exercise the part as usdal^ until all pain has ceased^ and the part has nearly regained its original form. Too early By a two early use of the part, the effects of the injury are kept up, so that weeksi months, or even years may elapse ; and the patient still suffer from them ; whereas a little more attention to the disease in the first instance, would have completely removed jdl the suffering and danger. In an- In persous suffering from constitutional
persons, disease, a chronic form of inflammation is often set up, which terminates in suppuratioBr and often affects the bones, which become carious, and make it necessary for the surgeon to remove the diseased part by amputatioD^ in order to save the patient's life.
Therefore, after the acute symptoms hare been removed, be careful to get rid of all the effects of the injury before the patient be allowed to employ the limb, as previous to the accident. Treatment Rest, position, and the use of mild stimu- stage. lants, with friction and moderate pressure, are the best means of producing the desired effect. The liniment : ammonise ; liniment : hydrargyri ; liniment : saponis, may either of them be rubbed over the affected part, night
assure by
. part may
i the following
Empl: ammon:
iii, over which the
J have also known
A from, the pouring a
i cold water on the part
j'ge pitcher.
:sease prove obstinate, and be
.11 occasional pain, the aid of
itation may with great advantage
ced, either in the form of blister, or
ig: Antimon: Tartarizat: I have known
y casj3S quickly cured by these means.
^Vhen the marks of disease have been re- Exercise.
moved, the motions of the parts should be
pFomoted by moderate, but regular exercise.
Too early motion.
(■■
In nn-
healthy
persons.
Tres.
ofci
StU!
subsides, and th restored; but in be allowed to < ^ all pain has c( regained its oi By a two
of the inju)
months, or
patient sti
little mor.
instance, -
the sutr»^'" In ^
':1£ XLI.
_ 4.ujr^n^.
disea>
oftei
am!
caij
to
.« « :2ie displacement of the -Y X Jooe. from the surface .aczrxibr received.
some general obser-
Kcssoents, and afterwards
dislocations.
Kiadents to which the
,w^r » iiiiiie. diat are more likely
as :if?<iacon of the surgeon,
^aytfK,^.tTvinN IS die restoration of the
55 ii:ytac> very much upon his
:C5x:c assistance ; for, if
2nt ,^-:ii?t: b^rbre the parts are
r aex mrjraLl positions, the re-
> t: rc-sit-^'c rr^rortionably diflScult,
•a* XV- mc vtrrrictly impracticable;
:r^ xtct^^c ?«:v.vc:e6 a Hiring memorial
b T c:v^vi st^i^rai instances in which •i>'it^5^ccji: knowledge or inat- ^^i.vu. : :tv yart ,:' ihe surgeon, to these
%»u
•A^ occasion of irre- iiis patient, and of the )nal character. viedjfe of the anatomy Anatomical
^ *^ knowledge
rcssary, to enable the requuite.
:o detect the nature of
s, as also to adopt the best
ig them. Let me, therefore,
examine and study well the
rhe different joints, the forms
;on, the bones and cartilages com-
jm, the ligaments connecting them,
action of the muscles moving them ;
ithout this knowledge, you cannot
ice your profession with credit to your-
es, or to the advantage of those who may
ome under your care.
I have known a case of fracture of the neck of the thigh bone treated as a dislo- cationi, and the puUies applied to the limb, hy a hospital surgeon, who was deficient in soatomical knowledge. In some cases, however, so much tume- sometin)e»
A . . . « ^ ^. /» 1 -I 1 difficult to
mtion arises from extravasation of blood, detect, or the parts become so tense from the effu- sion, in consequence of inflammation, that the best surgeon will not be able exactly to ascertain the precise nature of the injury daring the first few days after its receipt; it would be, therefore, extremely illiberal
272
and unjust to attribute ignorance to a sur- geon who might have given an incorrect opinion under such circumstances.
Immediate The immediate effects of a dislocation are, to produce an alteration in the form of the joint, in the length and ordinary position of the limb ; also, after a short time, when the muscles have contracted, to destroy the motions of the joint.
At first, In the first few minutes, however, after
mnch mo- tion, the injury, the degree of motion is consider-
able, which I had an excellent opportuniiy
of seeing in a patient brought to Guy's
Hospital, with a dislocation of the tiiigh bone
into the foramen ovale, which had occurred
only a few minutes before his admissicHi.
The nature of the injury was extremely well
marked, only there was great mobility of
the limb at first, but in less than three hours
it became firmly fixed by the contraction of
the muscles.
Lim^ In dislocation of the extremities, the limb
lengthened
or short- is usuallv shortened ; but when the femur is displaced into the foramen ovale, or the humerus into the axilla, the limbs are lengthened.
Pain. A dull pain is felt from the pressure of
the dislocated bone upon the muscles, but the pain is sometimes severe when the' bone rests upon a large nerve or nerves, as vrheli
273
.slocated into the ischiatic iuimerus into the axilla; and, / cause, numbness and a partial I he limb are also produced. 40 blood vessels also, occasionally, y?"«**
, iDjared.
... auch injury from these accidents. ^ known the subclavian artery so much essed by a dislocation of the sternal Linity of the clavicle backwards, as to p completely the pulsation at the wrist. Ill another case, the axillary artery was so much injured by a dislocation of the hu- merus into the axilla, as to give rise to aneurism, for the cure of which the subcla- vian artery was tied.
If there be not much extravasation or Head of effusion, the head of the displaced bone may be easily discovered in its new situation, and may be distinctly felt to roll, if the limb be stated. In some instances, the usual pro- minence of the joint is lost, as when the humerus is dislocated into the axilla, or an unnatural projection occurs, as in the dis- locations of the elbow.
■ The remote eflFects of these injuries are, — Remate First. The sensation of crepitus, which oc- curs a day or two after the accident, from the effusion of fibrin into the joint or burso&, although it does not give that grating feel which arises from the motion of the frac-
VOL. HI. T
274
tured ends of a bone upon each other ; yetj I have known medical men, not aware of this circumstance, suspect a fracture when none existed. JjJ^- In general, the degree of inflammation
arising from these injuries is very 3light< Sometimes, however, it is considerahlei causing, together with the extr^yasatioo, great tumefaction of the surrounding parted and rendering it difficult to ascertain the nature of the injury. I have known, in a few instances, so high a degree of inflajoi- mation to follow tl^e receipt of these injurieai as to destroy the patient. Case. A master of a ship who had dislocated his
thigh upwards, a few days after its reduc- tion, had extensive suppurative inflammation take place in the thigh, under which he sunk. Mr. Howden, a surgeon in the army, hjas given the history of a somewhat similar case to the Physical Society of Guy's Hospital. Dissection ^^ disscctiug the injured parts in those ot parts. ^j^Q ^j^ shortly after a dislocation from vio- lence, the capsular ligament is found torn transversely to a great extent, and the per culiar ligaments of the joint are also rupr tured, the head of the bone being rempved from its socket.
In dislocations of the hip, I believe th^
275
ligamenttim teres is always torn through, or separated from its attachment, sometimes ^ with a piece of cartilage, or even of bone.
When the humerus is dislocated, however, the tendon of the biceps, which answers the purpose of a ligament, is, as far as I have had as opportunity of witnessing, uninjured, — although I do not mean to deny the possi- bility of its being ruptured.
The muscles and tendons surrounding the Tendons
^ and muscles
jmnt are frequently much injured, as for »nj"f«d. instance, the tendon of the subscapularis muscle, when the head of the humerus is displaced into the axilla, or the pectineus aad adductor brevis muscles, in dislocation of the femur into the foramen ovale.
When a dislocation has remained unre- when un- duced for a length of time, some degree of "'""' motion is gradually restored, but the power and mobility of the limb are never com^ pletely regained ; and, in the dislocations of the thigh, the patient is ever after lame.
In dissecting cases of this kind, the head i>i«section of the bone is- found much altered in figure; this alteration, however, does not depend very much upon the length of time that the bone has been displaced, but more upon the structure which the head of the bone presses on, whether bone or muscle.
T 2
276 If the bone If it rest .upou muscle. the bone under-
resti on ' *"
mascie.<> gocs but little change, its articular carti- lage remains, and a new capsular ligamrat forms around it, from the thickening and condensation of the surrounding cellular tissue.
If on bone. If, ou the contrary, it presses upon bone, an extraordinary change is produced^ both in the head of the disloclBLted bone, and in the ossious surface on which it rests. Th& articular cartilage becomes absorbed from, the dislocated extremity, and the peiiosteum. of the bone on which it presses is removed in the same manner, so that a smooth .hollow surface is formed, to which the head of the displaced bone becomes adapted. At the same time that the hollow is formed at tibiat part on which the head of the didocated bone immediately presses, a deposit takes place from the surrounding periosteum, be- tween it and the surface it naturally co- vers, by which a ridge or lip is produced, forming with the depression a deep cup to^ receive the head of the bone ; also, the ten- dons or muscles which were lacerated, are united, and the latter accommodate them- selves to their altered positions, so that, by a beautiful and gradual change in the injured parts, a new articulation is estal)^ lished.
1277
A- great change which thus > location has remained un- it ngth of time, it becomes rt^store the bone to its original after the expiration of many : an attempt would not only be I attended with much risk to the
I
attempt to reduce a dislocation of case, iinerus, which had existed only six s, so much injury was done to the mus- - by the violence employed, that the i'^tient died in consequence.
But although dislocations are generally Dislocation occasioned by violence, and are accompanied sioni ^Y laceration of the ligaments, yet they oc- casionally arise from relaxation of the liga- nients only, the result usually of a morbid accumulation of synovia in the joint.
I have seen the patella frequently dis- ofpateiu.
placed from this cause; and, in the year
1810, 1 admitted a girl into Guy's Hospital,
who was the subject of such dislocation. The
patella- was suddenly and frequently thrown
outwards in walking, which occasioned her
to fall, and it required considerable force to
reduce it. By the application of some strips
of plaister, and a bandage, the bone was
readily kept in its proper situation.
I once saw a girl who had the power of case.
'r 3
278
throwing the patellee outwards at wiU,-^she had been brought up as a dancer or tumbkr.
From pa- The loss of power in muscles surrouniiiig ^*"* a joint, either from paralysis, or from l^iiig kept a long time upon the stretch, allow of the joint being easily dislocated ; but, und^ such circumstances, the reduction is effected without difficulty.
Case. A young gentleman who had becdme
paralytic on one side during dentition, would readily dislocate the head of the humems, throwing it over the posterior edge of the glenoid cavity, from whence it could be replaced with facility.
The loss of muscular power, Arising from continued extension, is well illustrated by the following case : —
Case. A junior officer, on board of one of the
Company's ships in India, was punished by one of the mates, during the absence bf the captain, in the following manner :— His foot was placed upon a small projection on the deck, and his arm was' tied and forcibly drawn toward the yard of the ship ; in this position he was kept for one hour. After this, the muscles of the arm gradually wasted, and the bon|^could be dislocated merely by his raisitfg the extremity to his head, but was easily replaced by slight extension.
at the muscles Muscles
prevent
Ave considerable dislocation, lisplacement from >ting the reduction curred.
Ilient cause of dislo- Fromulcer- ^ ation.
M, by which the attach* ionts are destroyed, when I he joint takes place, either -11 of the muscles, or from Jig sufficient support to coun- v.iglit of the bone. Thus, in long ulcerative disease of the hip joint, the head of the femur drawn up on i sum of the ilium ; and, in the same .ion of the knee, I have seen the tibia ^ off the condyles of the femur. There is in the Museum at St. Thomas's case, ilospital, a preparation, showing an anchy- losis of the tibia, at right angles with the femur, after a dislocation from ulceration. It frequently happens that a fracture occurs Dislocation
, , , with frac-
at the same time with a dislocation ; this is tnre. more especially the case in the displacements of the ankle joint, which seldom take place without fracture. The acetabulum is some- times broken in dislocations of the hip, and the coronoid proceli^ of the ulna is occa- sionally separated when that bone is dis- located, which renders it scarcely possible
T 4
280
for the surgeon to preserve the partd in their natural position during the treatment.
Case. A preparation in St. Thome's Museitei
shows a fracture of the head of the husienis^ occurring with displacement.
TreatiiMBt. When dislocation and fracture of a bone occur at the same time, the dislocatbn should, if possible, be reduced immediatdly, taking care to prevent further injury to the fractured part, by the application of ban* dages and splints. For, if the fractured bone- be allowed to unite before attempting to replace the dislocation, such union would most probably be destroyed by the addi- tional violence necessary to reduce the bone, after having remained so long out of its niBi- tural situation.
So also, if a bone in one limb is dislocated,
and in another fractured^ the dislocation should
be reduced as soon as the fractured bone has
been supported and secured from injury.
Dislocations Dislocations are not always complete ; but
not com- . . ^ • 1 T 1 ^ t>
piete. in some mstances a partial displacement of
an articulating surface occurs. A preparation in St. Thomas's Museum, dissected by Mr. Tyrrell, shows an imperfect dislocation of the ankle ; the end of the tibia rests still in part upon the astragalus, but the greatest portion is seated on the os naviculare.
kifee^^ The knee joint, on account of the extensive
281
articular surfaces^ is seldom completely dis* placed*
The humerus is sometimes thrown upon oftheha- the anterior edge of the glenoid cavity, but is easily replaced.
The elbow joint is liable to partial displace- or the ment^ both of the ulna and radius.
The injuries to the spine, which are some- Soppoied
_, , , diuocfttioii
times called dislocations, and are producing of vertebrae.
paralysis of the part of the body below the
seat of mischief, are really fractures with dis^
placement of the broken bone. Simple dislo-
csition of the vertebrae, I believe to be an
exceedingly rare accident, if we except that
^v^hich is said to occur sometimes between the
^irst and second cervical vertebrae.
Violence is usually the cause of dislocations, Caasc*, '^^d is generally applied unexpectedly, when
le muscles are not prepared for resistance, ^nd when the bone is in an oblique posi- "*^ion with respect to its socket. Under these ^circumstances, very slight force will produce ^^e displacement which could not otherwise ^^ occasioned, but by great violence.
The power of the muscles in resisting ex- Execntion ^essrve lorce, when prepared for its applica- tion, is well illustrated by what occurred in the execution of Damien, for an attempt to murder Louis the XVth. Four young horses ^ere fixed, one to each limb, and were then
for the giugeoii to preserve the par' '
natural position during the treatmt : . .r. Csi Cm*. a preparation in St. Thomas hii. aia^
shows a fracture of the head of I ,tc',iiioaerr.^<
occurring with displacement. Trcatmwt. Wheti dislocation and frac
occur at the same time.
should, if possible, be redin
taking care to prevent fur
fractured part, by the
dages and splints. F-i
be allowed to unili'
replace the dislocatioi _^
most probably be d'
tiouat violence nece*»
after having remami
tural situation. So also, if a ii
andinanothc-rr
be reduced ii
been suppoi: I Dislocaii:
in some ini
an articuliii
in St. Th-
Tyrrell, / '
ankle ;
upon '
is sc;i' Th.
^iW
integument, il. the synovia
i ended with con- Danger of.
>unt of the inflam-
the synovial mem-
■aments ; the former
X indy quickly takes on
(inmation, and thus a
iipidly ensues. The arti-
.vering the extremities of
t adually destroyed by an
•as, and the bone inflames,
re thrown out from the extre-
<.'d of cartilage, so as to fill up
Generally these granulations
i )ecome ossified, producing anchy-
occasionally some degree of motion
lly regained.
effect all this, great constitutional often re- quire ampa-
s are necessary, and persons naturally taUon. ; are often, under these circumstances, :i:ed to submit to the removal of the limb
preserve life.
Compound dislocation occurs but very Rare in
_, ••* xi_i' vij 8omc joints.
rarely m some joints, as the hip, shoulder, and knee ; but is often met with in the ankle, elbow, and wrist.
Much may be done in these cases by Judicious
treatment*
judicious treatment in the first instance, when
-.1
284
the object should be to promote adhesions of the external wound, and thus render the dis* location simple. . Instead of applpng emol'- lients, therefore, to encourage suppuration, which is productive of so much mischief, tiie edges of the wound should be carefully fipproximated by strips of plaister, and evaporating lotions should be applied over the limb, which should be ^ left undisturbed for several days. ?
I shall, however, enter more fully into the treatment of these injuries, when describing the particular dislocations. '■
Treatment of Simple Dislocations. •
RedncHon. The first and principal object is the reduc*
tion of the dislocated bone, which I have
mentioned, becomes difficult in proportion to
the time allowed to escape after the receipt
of the injury.
Difficoity If the muscular power be great, great foroe
Mtimr* will be required to overcome the contractioa
elapses. ^£ ^^ musclcs, and this difficulty will increase
in proportion to the length of time allowed
to pass by between the injury and the attempt
to reduce the dislocation. In very muscular
persons, therefore, no endeavour should be
made to reduce a dislocation of the arm, after
285
a lapse of three montlis from the receipt of the injury; but in persons with little mus- cular power, reduction may be effected before the expiration of four months after the acci- dent. In displacement of the thigh, two QiODths in stout persons, and a few days more in those of relaxed fibre may be allowed as the period after which it would be wrong to employ violent means to endeavour to re- duce the dislocation.
The difficulty in reducing dislocations is From con- chiefly owing to the contraction of the muscles, muKicj. which is involuntary, and which becomes greater in proportion to the length of time which has elapsed after the injury. The muscles have a power of contraction inde- pendent of the voluntary or involuntary 3etion, which are common to them, and the former of which cannot be maintained but for ^ very limited period.
When the power of a muscle is destroyed, Effeci on
the antagonist muscle immediately contracts,
^d this contraction is permanent, or as long
^ the power of the other muscle is wanting.
T'iiis may be seen in those persons who have
Suffered from paralysis of the muscles on one
aide of the face, the opposite side being drawn
up and disfigured by the contraction of the
apposing muscles. In the same way when a
dislocation has taken place, the muscles soon
286
contract and fix the bone in its new position, and this contraction becomes firmer Bxd more difficult to overcome, the longer the time allowed to elapse before any attempt be made to replace the bone. The reductioii should therefore be made as soon as possible after the receipt of the injury. Other But independent of the muscular contrac-
creating tiou. Other circumstanccs give rise to difficulty in attempting to reduce a dislocation of long standing, and often render the reduction nn- practicable. The head of the bone becomes adherent to the surrounding parts, so that when the muscles have been divided in dis* secting the injured joint, the bone ca^nnot be replaced ; this I have observed in the dislo- cation of the humerus, and also of the raditii^. After a time the original cavity becomes filled with new matter, and sometimes a new articular socket is formed for th^ head of the dislocated bone ; under these circumstances the possibility of the reduction is destroyed. Form of In rcccnt dislocations, the form of the joint
joiots. "^
may in some instances afford an obstaicle to the reduction ; as, when the articular cavity is surrounded by a projecting edge as in the hip, in which case the head of the bone re- quires to be lifted over the edge when re- ducing the displacement. If the head of the bone be much larger than its cervix, as in the
287
radius, it affords an impedioient to the Feductiou.
Some persons have supposed that the Capmur return of a dislocated bone to its natural position, might be impeded by the smallness oC the aperture in the capsular ligament ; but this cannot happen, a9 the ligament is in- elastic, and an aperture admitting the dislo- ciatitQ^ would as readily admit of the reduction. The capsular ligaments possess, in fact, but little power of preventing dislocations, and the protection is principally afforded by the peculiar ligaments and tendons covering each Joint. Constitutional, as well as mechanical constitu^
A ... tional
rneani^, are often necessary to assist m the means, reduction of dislocations ; and in many cases, the eniployment' of force only, is very im- proper; as, unassisted by constitutional nieang, roinch greater violence must be exer- cised, and consequently the immediate suffer- ing, jxj^d subsequent inflammation, will be IH:c|)ortioned to this violence.
bleeding, the warm bath, and such medi- Bleeding, cia^s as create nausea, are the best means of assisting constitutionally in the reduction of dislocation, as. they most readily produce a state of faintness, during which the muscular, power is greatly diminished. Bleeding is the most powerful, and at the same time the
288
Warm bath.
Creating nans^a.
Opium.
Mode of ^reduction.
most speedy method of the three, if the blood be drawn from a large orifice, and the pi^i^t be kept in the erect positicm ; it caimo^ how- ever, be resorted to in all <^ases, and might be highly injurious in very old or debiUtated persons ; but in the young and robost it may be employed with safety and adyimtage in the mode I have proposed.
In using the warm bath, the temperature should be from 100^ to 110''; and the heat should be kept up until the patient feels ftint, when he should be taken out, and die mechanical means should be immedii^Iy resorted to. The desired effect is much sooner produced by abstraction of blood, during the time that the patient is in the bath, than by bleeding, or the bath singly.
The third mode, viz. that of exciting nausea by the exhibition of tartarised anti- mony in small doses, h not so certain as the former modes, but it is exceedingly useful in keeping up the state of faintness produced by bleeding or the warm bath, when the disk)' cation has been of long standing and likely to require a continued application of me- chanical means for its reduction.
Opium might, perhaps, be serviceable in large doses, as it greatly diminishes muscular power. I have not yet tried it.
When the power of the muscles has been
289
lessened^ the reduction of the dislobation should be attempted^ by fixing one bone^ whilst the extremity of the other is drawn towards the socket by extending the limb. Inattention to this point is one of the great causes of failure in attempting to reduce dis- locations ; for if the bone in which the socket is situated be not fixed, the reduction cannot be accomplished* If, for instance, in attempt- mg to reduce a dislocation of the humerus llie scapula be not fixed, it is necessarily drawn down with the os humeri, and the ex- tension is unavailing. If one person holds the scapula, whilst two extend the humerus, the . extension will still be very imperfect: the one bone must be firmly fixed, at the time that the other is extended, to render the force effectual. Tlie extension should be gradu- ally and carefully made, and continued rather to fatigue than extend the muscles by violence. Violence is as likely to lacerate sound parts as to reduce the dislocation, and this I have known to occur.
The force required may be applied by the u»e of pui- aid of assistants, or by compound puUies, and in cases of difficulty the latter is much the more preferable mode, as the extension can be thus made gradually and continued ; whereas that made by assistants, is usually irr^ular, and often ill timed, being more
VOL. III. u
288
Warm bath.
Creating naatea.
Opi
Mode of •"^■otioii
most speedy method of the three* be drawn from a large orificet an be kept in the erect positkm ; i' ever, be resorted to in all cr be highly injurious in very o^ persons ; but in the young be employed with safety the mode I have propose
In using the warm 1 should be from lOO"* should be kept up ui when he should mechanical mean resorted to. The
iucation,
L such as to
.arger muscles,
be greatly iacili-
produced by ab' time that the p bleeding, or th
The third ^ nausea by mony in former
.ILuil
whether the
ttedidocated
M. Boyer,
in surgery,
<^Hnionitia
bone wUch is
dislocations of
Badenoion from
m liBe with the
placing
at the
Ae reduction
from the
adbidingmuch
will, as long
; but this
^rcumstance T have
nt.
cted
■ ug the
iiiey had
diminished
s, a wetted roller Mode of lib, and the leather tiS^pt^ifes. lixed to receive the should be buckled on iiis will prevent it from the extension. The cord be drawn very gently, until je of the muscles is felt, when )ii should rest for two or three , and then gradually and carefully i again, and so on until he perceives the Aes quiver; after which a very little >re extension will accomplish the desired purpose.
The surgeon may know when dislocation when re- is reduced, by the restoration of the natural figure of the articulation. Fot some time after the reduction of the ^eatmont.
u 2
292
dislocation of the shoulder of long standing, bandages are required to retain the bone in its proper situation ; and the same treatment must be adopted after similar accidents to those joints in which the articular cavity is shallow.
In all cases after reduction, rest is neces- sary, to allow of the union of the ruptured ligaments; evaporating lotions should be employed to prevent excess of inflammatory action, and leeches should be applied if the inflammation run high. Subsequently firiction will be found of great service in restoring the natural functions of the joint.
The injuries to the spine, commonly des- cribed as dislocations, have been already treated of in a former lecture. I shall now, therefore, proceed with the description of these injuries to the other articulations'/ a^ commence with those taking place at the junction of the ribs.
Of Dislocation of the Bibs.
Three Three forms of dislocation are mentioned
as occurring to the ribs and their cartilages ; viz. — First, a displacement of the posterior or vertebral extremity forwards on to the body of the vertebrae. Second, a separation
293
of the anterior extremity of the riD fronTTta cartilage. Third, a similar injury between the cartilage and the sternum.
PThe dislocation of the vertebral extremity J might occur from a person falling backward on some pointed substance, so as to drive the head of the rib from its natural situation ; such accidents are, however, very rare.
This injury would produce symptoms nearly ; similar to those from fracture of the rib, as pain on motion, and difficulty of respiration.
The same mode of treatment would be also Treaiiucnt. proper in either case ; as bleeding to prevent inflammation, and the application of a roller to confine the motions of the ribs.
When a cartilage has been separated and Bii|>iace. displaced either from the rib or from the ster- cartii&ge. Cum it may usually be replaced with ease, if the patient will take a deep inspiration, so as to enlarge as much as possible, the diameter ef the chest ; for under these circumstances very slight pressure will return the parts to Aieir original position.
After the reduction, a small compress con- Tr« "" fined over the seat of injury by a bandage, as applied for fractured rib, will be requisite to prevent any future displacement.
In sickly and weak children, an alteration Deformity sometimes takes place in the form and direc-
E cartilages of the ribs, which might
■ven
294
be mistaken for a dislocatton. It most fre- quently occurs at the cartilages of the sixth, seventh, or eighth ribs, and is accompanied with some alteration in the course of the ribs themselves.
Dislocation of the Clavicle.
Articular The articulatious of the clavicle with the
strong. sternum, and with the scapula, are so firm as
to render displacement of either extremely
rare, when compared with the dislocation of
some other joints.
Dislocations of the Sternal Extremity:
Two kinds. The stcmal end of the clavicle may be dis- placed in two ways; — ^first, when thrown anterior to the sternum, or forwards ; — second, backwards, or behind the sternum.
Anteriorly. In the autcrior dislocation, a swelling is readily perceived on the anterior and upper part of the sternum ; and if the finger be carried on the surface of the sternum upwards, this projection stops it. On placing the knee between the scapulae and drawing the shoulders backwards, the swelling disap- pears; but it reappears when the shoulders^
p
are again allowed to advance. If the shoulder be elevated, the swelling descends, and if the shoulder be depressed, the projection ascends towards the neck.
The patient experiences much difficulty Painfi in moving the shoulder, and the attempt creates pain ; but when at rest, he suffers but little pain or inconvenience. In very thin persons, the nature of the accident is at first view easily detected, but some difficulty may occur in ascertaining its nature in very fat people.
This injury is generally occasioned by a CaiiBc. fell, either on the pointof the shoulder, which drives the clavicle inwards and forwards, or Upon the elbow, at the time that it is separated from the side, which produces the same effect.
Sometimes this dislocation is only partial, the anterior part of the capsular hgament ais^i alone being lacerated ; in this case the pro- jection is but slight, but most frequently all the ligaments are torn through, and the bone with the interarticular cartilage is completely displaced.
This dislocation is easily reduced by draw- Tipa ing the shoulders backwards, by which the clavicle is drawn off the sternum, when it falls into its natural situation ; but the shoulders must be kept in this position to
pffcvcBt a recsrrcBce cf the
and the arm flmst be snpportoi, or ks wci^
wiD afect the poshioB of the faoBC
The a^iplkatioB of die dwride favidage wd pads IB the aziDK wiD effect the fini iibfect, and the second win be gpiaed hj plaoBg the arm in a short sliiig.
I hare nerer seen, or kaowiiof aniBBlaBee, in which the didoratinn badmaids has been produced by rioknce ; jti I coMcife that it might happen from a blow ob the finte part of the bone.
The ooly ease oi this fiMrm of didocatioii that I hare known, was occanoned by great d^nrmity of the qpine, from which the aayofai was thrown so mnch fiawaids^ as not to leare sufficient space for tile davide between it and the sternum : in consequence i)i this the chnricle was gradually forced bdiind tiie sternum, whaeit jMresseduponthecesc^diagus, and gave rise to so much inconTUuence, as to occasion a necessity for the remoral of the extremi^; the trachea from its elasticity escaped pressure, being pushed to one side.
This case was under the care of Mr. Darie, surgeon, at Bungay, in Suffolk, from whom I had many of the particulars. He deserved great praise for suggesting the mode of relief; and the skill with which he performed the
297
operation was a proof of the soundness oims professional knowledge.
Miss Loffty, of Met6eld, in SutFolk, had c««- very great distortion of her spine, by which the scapula was gradually thrown so much forwards, as to displace the sternal extremity of the clavicle, forcing it inwards behind the sternum, so as to press upon the cesophagus, and occasion great difficulty in swallowing.
She had become very much emaciated.
Mr. Davie thinking that he could relieve the sufferings of the patient, and prevent the threatened destruction of life, by removing the sternal extremity of the clavicle, per- formed the following operation : —
He first made an incision of between two and three inches in extent, over the seat of the dislocation, in a line with the direc- tion of the clavicle. After dividing the soft parts surrounding the bone, he placed a portion of stiff sole leather behind it, whilst he carefully sawed through it, about one inch from its end, with Hey's saw ; he then elevated it, and separated it from the inter- clavicular ligament.
The wound afterwards healed quickly, and the patient was again able to swallow without difficulty. She lived six years after the per- formance of the operation.
VCIV
1
Extremity.
s HIT other dislocation incauEv of the clavicle, \ end of the clavicle ,^ .- wMc 2t: Bsomion process ; and disit.r ^^ t^ci'^e c reiy unlikely for any
^^^ u^Dziic lut I do not mean to deny L L i:2$placement beneath the i£ se scapula. ^lEP- :s more frequently dis- jm: :» iTcmal end, and may be % at x'lj: wing signs : — tiofs^isr K. the injured side appears . aM iriwn nearer to the sternum, 4^ ifc ^uizc :ce. This arises from the «* IK .'-"St the support of the cla- 2rt ixiiitiaation, the nature of the ^^Y > >t^aiily Ascertained, by passing the ^^ ^wtK ^<^ :^f^^ of the scapula, so as 9 •mn ^a«r ^vauacaiion of the acromion with -j: ^^ik ^^ ibe finger is stopped by 4^ ^oit.-'iKOf :i'the clavicle, which projects ^>j^c :^te iccciion. and pain is experi- — ^^«: w'ltfa ti:5 elevation is pressed. The •'iiv- jLsarc^TA:^ when the shoulders are ^.;^v,i rocrv'^xr.is, but rises again if they • ui^^xv, :'^ *-'v^ni« forward. Pressure
299
upon the end of the dislocated bone causes pain ; but when at rest, the patient suffers but little.
This injury is most frequently occasioned causes. by a fall upon the shoulder, by which the scapula is forced inwards towards the chest.*
The reduction of the displaced bone in TreatmcDt. these cases, may be, in most instances, rea- dily accomplished, by placing the knee be- tween the scapula of the patient, and then drawing his shoulders backwards and up* wards. After the reduction, a pad or cushion should be placed in each axilla, for the purpose of elevating the scapulae, keeping them from the side of the thorax, and to defend the soft parts from the bandage, which should next be applied, as in the for- mer case, only it should be broad, and made to press over the seat of injury. The em- ployment of a short sling is likewise of essential importance.
It rarely happens that these accidents to Not per-
fectly re-
the clavicle are perfectly recovered from; csovered some degree of deformity usually remains, and of this the patient should be informed at the commencement of the treatment,
* I have known this dislocation arise from a blow, ^ die falling of a heavy piece of timber upon the extre-^ "Mty of the shoulder. — ^T.
-rrrr^^t .: lo iho neg-
-is^ . ac j^rgeon; but
ip„, - — ^^i^tre with the
r tic ih Humeri.
^ - =te X'lzienis may be dis- m r: o=:=2uiii w-iniy of the scapula, •--^tffi^ — dreie of the dislocations itoi 3« perfectly so.
and inwards into
't --«*Nii£ ^ vr»ari>, under the pectoral
cr*;"* lie •lanc^. ^ itrr. ^ :)A:kv:mi$, on the dorsum of .^,^:9itti» j«:iu'v ±e spine. ^ iecta > :aly partial, when the head tss j^nisst the external side II Tr:ces5 of the scapula.
^f I9L rtsiuxuxxm in the Axilla.
'T^ zisicctccc niay be known by the
j;*c ^ .^: s:ris — The rotundity of the
s;^.«.-v > ::os:r:yt\:. and a hollow may be
. ; X c * -ic ic-viiuon process of the sca-
.: ,\c;Si\:uci:cc of the head of the
«. «••
301
Iiumerus being displaced from the glenoid cavity, by which the deltoid muscles looses its support, and is dragged down with the depressed bone. The arm is lengthened, as the superior extremity of the humerus is placed beneath its natural articular surface. The elbow is separated from the side, and cannot be made to touch it, but with diffi- culty, as the effort presses the head of the bone upon the axillary nerves, occasioning severe pain, and the patient generally sup- ports the arm with the hand of the sound limb, to prevent the weight from pressing on these nerves. If the elbow be fer re- moved from the side, the head of the os humeri can be easily felt in the axilla, but not so if the arm be allowed to remain nearly close to the side ; raising of the limb throws the heaid of the bone downwards, and to the lower part of the axilla, so that it can be more readily felt.
The motions of the joint are in a great degree destroyed, especially upwards and outwards, and the patient cannot raise his arm by muscular effort ; for this reason, it is. usual, when wishing to detect a dislo- cation, to ask the patient if he can raise his hand to his head. The answer invariably % that he cannot, if a dislocation exists . The arm cannot be rotated, but a slight
302
degree of motion backwards and forwards still remains.
Motion In very old persons, and in those having
coniTider!^ a relaxed state of muscles, the degree of motion is occasionally but little inferior to that which exists when the bone is in iti natural state.
Crepitus. Somo time after the accident, a crepitus may be often felt, occasioned by inflammatory effusion, and from the escape of synovia ; but it is never so distinct as that produced fit)m fracture.
There is frequently a numbness of the fingers, from the pressure of the head of tiie bone upon the axillary nerves.
Thus it will be found, that the prindpal marks of the accident are, the loss of tbe rotundity of the shoulder, the presence of the head of the bone in the axilla, and the destruction of the natural motions of the
Signs in- joiut. But oftcu thesc marks are but little apparent in a few hours after the receipt of the injury, from the extent of swelling which occurs, on account of extravasation; they, however, became again distinct when the tumefaction and inflammation have sub* sided. Under these latter circumstances it is, that the London Surgeons are generally consulted, when the nature of the injury can^be mistaken; whereas, the general
303
practitioner is called upon during the state of tumefaction and inflammation, to form his opinion, and should he then overlook a dis- location, it is our duty, in justice to the jeneral practitioner, to inform the patient
«
that the difficulty of ascertaining the true oature of the accident is very greatly di- minished by the cessation of swelling and inflammation.
The readiness with which the injury may be detected, will also differ much in very dun and emaciated persons, or in those kaded with fat, and possessing large and powerful muscles.
The most common causes of this accident, causes. Ae falls upon the hand, when the arm is time the horizontal line, or upon the elbow, when the arm is raised from the side; but aifire especially by a fall upon the shoulder iMf^ when the muscles are unprepared to mist the violence.
When the arm has been once displaced, liabmtyto it'fe much more liable, after the reduction, to be again dislocated, unless great attention bn^pidd to the injured joint; and very slight caises will often produce a recurrence of the 'Wjfi^y which I have known take place OHrely from the action of lifting up the sash ijpft window. •When an apprentice at St, Thomas's Hos- case.
304
>uau i» I was one morning going through ne wds^ I was called to visit a man who md indocated his shoulder in the ordinary iAft of stretching himself, and rubbing his jTesy when he first awoke.
To prevent as much as possible this dis- poRCain to fotore dislocation, the limb should be kepc perfectly at rest for three weeb jAst t&e reduction, during which time, a pai£ s&oafai be fixed on the axilla, and the SSL bound to the side, thus the lacerated parts w2I have time and opportunity to unitei wiuc& diey cannot well do if the usual mo- tioos are permitted.
I hsve had opportunities of dissecting two recent cases of the dislocation downward^^ in which I found the following appear-
In the first case, the axillary vessels anci nerves were forced backwards upon the sub- ^capularis muscle, by the head of the dis- located humerus. The deltoid muscle was drawn down, and the supra and infra spinati muscles were stretched over the glenoid cavity, and inferior edge of the scapula. The head of the bone was seated be- tw\^M\ the coraco brachialis and axillary I^Wxus. The capsular ligament was exten- mvclv lacerated on the inner side of the ^Iciuud cavity, as was also the tendon of the
Inbscapularis muscle, where it covers the
kament.
I In the second case, violent attempts had case.
made to reduce the dislocation five peeks after its occurrence, but without suc- jsSf and the patient died from the effects &the violenceused in ihe extension. The pec- major was slightly lacerated, the tapra spinatus very much so ; the infra spi- ns and teres minor were also torn, but to any jp-eat extent; the deltoid and [oraco bracUialis had also suffered a little. The capsular ligament had given way be- tween the teres minor and subscapularis ten- i 4ons, the latter being separated from the |,fcBser tubercle of the humerus, r In these dissections, I found that the supra spinatus and deltoid muscles were those which afforded the chief resistance to the reduction of this dislocation ; therefore, io order to effect the reduction, the best di- rection in which the arm can be extended, is at a right angle with the body. The biceps should be at the same time relaxed by bend'
J the elbow. \ In examining a dislocation which has pstedfor several years unreduced, the head i the bone is found much altered in form, jping flattened on that side next the sca- but it is perfectly covered by a
I VOL. III. X.
Propr 1- mode <- previ'ijf
*^^
r!ie glenoid cavity is
.^ \ L substance of a liga-
^^ ma some small portions of
..^. -.ttfefMaded in it, and a new
^..M« :^ tunned for the head of the
^^ jam, m the inferior costa of the
turn of the Dislocation in the Axilla.
s employed for the reduction of
^^^ 01 the humerus when dislocated
^.mmus^ into the axilla, must differ ac-
.«^ u the circumstances attending the
^isMi. but in all recent cases, I gene-
^ i»cciupt the reduction by the heel in
^ o^ila» which may be done in the foUow-
tH; patient should be placed on a so&,
. .«a>4c. near the edge, in a recumbent pos-
^si^ luid a wetted roller should be bound
^^aU the arm, just above the elbow, over
^^lish a handkerchief or towel should be
^i^vueil; the elbow being then separated
4Viik the side, the surgeon places the heel
■i v»uo foot in the axilla, and rests the other
'i(H»n tlio ground, as he sits by the patient's
k\kW riu* hoel should be placed far enough
307
back to receive the inferior edge of the sca- pula, and prevent its descent at the time that the arm is extended. The extension is to be made from the handkerchief or towel, and continued steadily for four or five mi- nirtes, in which time usually the head of the bone slips into its proper cavity. The force of two or more persons may be employed in extending;, by means of the towel, if required.
If, however, the accident is of several ifof«"'n« days standing, and if the muscles have been fixed and rigid, more force than can be ap- plied as above will be required to effect the reduction, and the following means must be resorted to : —
The patient must be placed in a chair, and ^^?"^ the scapula fixed by a bandage with a slit in it, which admits the arm through it; this niust be tied over the acromion, so as to keep it well in the axilla. Next, place a wetted wUer round the arm immediately above the dbow, to protect the skin, and upon it fix a Pery strong worsted tape, by what is termed the clove-hitch. Then raise the arm at right angles with the body, or a little above the ^_ I horizontal line, to relax the deltoid and supra ^H I Epibatus muscles. Two persons then holding ^| 1 the scapula bandage, should keep it fixed, i whilst two others draw from the bandage ^■ifixed to the arm with a steady, equal, and
L M
*'•• .. 2.Z extension ha
* " z--::c5, the surgeo
— :: ~f axilla, restin -^^ - iiHT ; he shoul ending his fool
cliH.
— r :=!:. v-± his right hand
- : - '^'^irds and inwards.
- —iv-iic will be generally
^ii^^rii -5 kept up, a gentle
. - ■• .; -r- '.:>h the counteract-
.^i . :l^ ULscles, and materially
^**"'' _. .: >-:v::i:ii: rut should the force
-^ ^." i«:c r^e sufficiently steady
... .^-^ Hull vr niust apply the pul-
^ . . -. . c»v :i: exerting greater force,
z^ :c at ?;ir-xre:'2 to employ it more
^: :i^u:-j^i^ A.'.. "ritJic applied, as in the
w ,>^ .-. :2c iiizfizz is to be seated be-
^ -. -iUi'iii^ ▼iich are to be fixed in
^ ^, - :^^ Lra:T::::ent. so that the force
•^ XL "/- *:':c .* :ie same direction as
, ^.-r-^-.r.Micc Tie surgeon should first
• . ^- ^.:' i^J«" jCidiily until the patient
> . :u. • -vii" he should stop, but
•\ . .:i:::vZ. Much advantage
X : *»: -• *ry conversing with the
-.•^ V ..c iis attention to indif-
V. '. • r**.- or three minutes he
309
may carefully extend a little more> and then cease again, and so on, until he has made as much extension as he thinks correct, but he should at intervals slightly rotate the Umb. Then giving the string of the pulley io an assistant, desiring him not to relax, he skould place the knee in the axilla, and press the acromion as before described, when the bone glides into its proper situation, not however with a snap> as when the other means are employed.
In the hospital practice, I usually order Hospital the patient to be bled, and put into a warm bath at the "temperature of 100° to 110**, giving him a solution of tartar emetic until he becomes nauseated and faint, when he is. immediately taken from the bath, and ex- tension applied before he regains muscular power. This plan obviates the necessity of losing any great force.
In very old relaxed persons, or in very Py^^^?«« dehcate females, another mode of reducing thb dislocation may be resorted to, by plac- ing the knee in the axilla in the following manner: — The patient should be seated npon a low chair, when the surgeon should separate the injured arm from the side, and then resting his foot upon the chair, should ptaiee his kneie in the axilla, and holding the arm with one hand over the condyles of the
316
humerus, and pressing the acromibn ^ the scapula with the other^ he should then de- press the elbow, by which the dd6lpcfttiq& will be reduced. Znmt ^ft^^ frequent displacements of the shwil-
tv^re^^' ^^^* ^^* ^^^y ®^^8r^* (oTce is necessvy to duced. reduce any future dislocations. A gentlefiaan
in the country, of my acquaintance^ who has frequently dislocated his shoulder^ has often reduced it himself in the following way,— by leaning over one of the common field gates, and laying hold of one of the lower bars, then allowing his body to weigh down on the other side ; — this is on the same prin- ciple as placing the heel in the axilla, which will effect the reduction of three-fourths of the recent dislocations «
Of Dislocation forwards under the Pectoral
• Muscle.
Easily de- This dislocatiou is much more readily de-*
tcclcd
tected than the former. The depression be- neath the acromion process of the scapula is greater, and the process itself appears more prominent. The head of the os humeri can be distinctly felt, and, in thin persons, may be seen forming a swelling beneath the cla- vicle, which moves when the elbow is rotated.
The head of the bone is situated internal signs of to the coracoid process, between it and the sternum, and is covered by the large pec- toral muscle. The arm is shortened, and the elbow is separated from the side, being forced outwards and backwards ; the mo- tions of the arm are more affected than in ' the former dislocation, the head of the bone being fixed, by the coracoid process and neck of the scapula on the outer side, by the olavicle above, and by the muscle on the fore part, as well as by the action of the ^eres minor with tlie supra and infra spinati amuscles, which are rendered very tense.
The pain occasioned by this injury is uot :so severe as in the dislocation into tlie ^axilla, because the axillary vessels and nerves 3 less compressed.
aition of the limb, the elbow being carried from the side and backwards ; the head of bone being readily felt below the cla- (cle, and its moving when the arm is petated. There is in the Museum at St. Thomas's Dissection ] [ospital, a beautiful preparation, showing a liBlocation of this kind of long standing, ■hich presents the followiag appearances : — [The head of the humerus rests upon the ■peck and part of the venter of the scapula, X 4
312
just below the supra-scapular notcii; ^e subscapularifr muscle has id part been raised . so that the head of the bone reirts on the scapula ; the subscapukfis and serratu^ mag^ nus muscles being between the extremity of the humerus and the surface iof the ribs. The 'tendons of all the muscles attached to the tubercles^ as also that of the long head vi the biceps muscle remain perfect* The gle*' noid cavity is filled with a ligsmientous sub^i stance, but its general figure is not much altered; and to this ligamentous stmctare the tendons of the supra and infra spinati, and of the teres minor muscles are adherent,^ having however a sesamoid bone formed in them : a new socket has been formed, M^iich extends from the glenoid cavity, to the resL^ ter of the scapula, occupying about one*third of its width, it has a complete lip, and is irregularly covered with cartilage ; the head: of the humerus is a good deal altered in form, and its cartilage has been in maay places removed by absorption: a perfect capsular ligament has bejen formed. Caases. Violent blows upon the shoulder, or falls upon the elbow, when it is thrown behind the line of the body, are the usual causes of this dislocation.
313
^ €^the Reduction of the Dislocation fortoards.
1^ In recent dislocations of the kind, the re- when b duction may be accompUshed by placing the ^""^^ ^ bed in the axilla, and making extension \ &om the arm as before described ; the foot should, however, be placed rather more for- wards, to press on the head of the bone, and the arm should be drawn a little backwards as well as downwards. When the dislocation has existed for some J^h«nof
long stand- days, it will be best to use the puUies, as *"«•
continued and steady extension will be re- paired to reduce it.
The scapula must be fixed by the 'same Mode of bandage as formerly described, and the Netted roller, with a strap for the puUies, ^^d on in the same manner above the elbow. '^he fore-arm should be bent to relax the biceps muscle.
The most important circumstance, is the Du-ecUonof
!• . . \ extension.
^^ection m which the extension is to be ^^ixade, which must be outwards, a little downwards and backwards ; for if it be made l^wizontally, as in the former case, the cora- ^id process of the scapula prevents the head ^f the humerus from' passing outwards in its pioper situation.
When the head of the bone has been
314
brought below the coracoid process, by the extenskm, the surgeoa should, with Ids kiiee^ press it backwards and upwards to the gle- noid cavity, at the same time puUiogthe am forwards from the elbow, fa^ which m^eaos he will expedite the reduction. As the i^esist* ance is greater, the extenskm must gene* rally be continued longer than that required to reduce the dislocation into the axilla.
Of the Dislocation backwards an the Dorsum
of the Scapula.
sitofttion In this dislocation, the head of the. ha* °^' merus is thrown upon the dorsum . of the scapula, below the spine, where it forms a projection at once perceptible to the eyes of the surgeon, and this enlargement, may be seen and felt to move when the elbow is rotated. The motions of the arm are less confined than in either of the former dis- locations.
Very rare. Only two cascs of this kind has occurred in Guy's Hospital during thirty-eight years. One was during my apprenticeship, and was under the care of Mr. Forster. The nature of the injury was scarcely to be mistaken, on account of the projection formed by the head of the bone upon the posterior part of the
315
bandages were applied, and
made in the same way as for
uii into the axilla, and the re-
s quickly accomplished.
)nd case was reduced in the same
hy the dresser, it occurred some
Ver the former.
. >
occurrence.
Partial Dislocation of the Os Humeri.
This is an accident of frequent occurrence, of common ^ he head of the humerus is displaced for- ^^ards, and rests against the coracoid process of the scapula ; there is a depression under ^e back part of the acromion, the axis of the arm is directed inwards and forwards, ^d the under motions of the arm can still 1^^ made, but it cannot be elevated as the *^^ad of the bone strikes against the coracoid Pi^ocess, over which it forms an evident pro- jection, moving when the arm is rotated.
Mr. Brown, aged fifty, was thrown from case* ^is chaise and injured his shoulder, which ^pon examination was found to have lost its Soundness, and a depression was perceptible ^nder the acromion process; the arm could ^e moved readily, except directly upwards.
The only opportunity which I have had of Seeing the dissection of this accident, was
through the kindness of Mr. Paty, surgeotf, Bouverie Street, he had the subject brought to him for dissection at St. Thomas's Hos^ pital. The following is Mr. Paty's account:-^ Mr. Paty's Partial dislocation of the head of the os hu-
dUsection
•T meri, found in a subject brought for dis-
section to St. Thomas's Hospital, during the latter part of the year 1819.
The appearances were as follows: — ^The head of the os humeri, on the left side, was placed more forwards than is natural, and the arm could be drawn no further from the side, than the half-way to the horizontd position.
Dissection. The tendons of those mus- cles which are connected with the joint were not torn, and ' the capsular ligament was found attached to the coracoid process of the scapula. When this ligament was opened, it was found that the head of the os humeri was ' situated under the coracoid process, which
formed the upper part of the new glenoid cavity; the head of the bone appeared to be thrown upon the anterior part of the neck of the scapula, which was hollowed, and formed the lower portion of the new glenoid cavity. The natural rounded form of the head of the bone was much altered, it hav? ing become irregularly oviform, with its long
V*
sin
axis from above downwards ; a small por- tion of the original glenoid cavity remained, but this was rendered irregular on its sur- face, by the deposition of cartilage ; there were also many particles of cartilaginous matter upon the head of the os humeri, and upon the hollow of the new cavity in the cervix scapulse, which received the head of the bone. At the upper and back part of the joint, there was a large piece of the car- tilage, which hung loosely into the cavity, being connected with the synovial membrane at the upper part only by two or three small membranous bands. The long head of the biceps muscle seemed to have been rup- tured near to its origin, at the upper part of the glenoid cavity ; for at this part the tendon was very small, and had the appearance of being a new formation.
The same causes which produce the dis- Cau>e»or. location under the clavicle, only with less violence, will occasion this displacement.
The reduction in these cases may be ac- Reduction complished by the same means as those di- rected to be employed for the dislocation forwards; but in addition, it is necessary to ' the shoulders backwards, and after the
duction, a bandage must be applied to keep
5 head of the bone in its proper situation, to prevent the motions of the scapuke a-
318
forwards, or otherwise the bone will ftgf^n slip out of the glenoid caTity.
Of Cmipimnd Disiocation of the Os Humeri.
Forwards. In the dislocation of the os humeri f(Hr'' wards, the head of th6 bone may, by exces- sive violence, be forced through the extemr soft parts.
Treatment In such a casc, the reduction of the dis-
of • ■
placed bone should be immediately efieeieft by the means I bare already recommended for the simple dislocation ; and when re-^ placed, the edges of the externieil wcMCttd should be approximated by a suture, ^Bind then Hnt dipped in. blood should be applied ' over 1^ wound, which is to be further sup- ported by strips of adhesive plaister. The limb must be fixed to the side, by a roller passed round it and the body, this will pre- vent any motion of the limb, and thus tbei^ will be less risk of the suppurative inflam- mation occurring, which would gready efi^ danger the patient's life. Mn Dixon's Mr, Dixou, of Ncwingtou, kindly fur- nished me with the following particulars erf a case which was under his care : —
Robert Price, aged fifty-five, fell, wfeen in* state of intoxication, upon his shoulder,
case.
319
which produced a dislocation of the humerus, and forced the head of the bone forwards, through the integuments of the axilla ; and I found it situated on the anterior part of the thorax, over the large pectoral muscle. The reduction was accomplished with great ease, after which he was placed in bed, and an evaporating lotion was applied. The following morning he complained of great pain, and considerable swelling had taken place, for this he was bled and purged freely, the injured part was poulticed, and anodynes were given to relieve pain and procure rest. For several days afterwards, leeches were repeatedly and freely applied over the joint, until after about two weeks from the receipt of the injury, when the wound began to dis- charge very freely a healthy pus. This con- ^nued for ten or twelve weeks, during which time his constitution suffered much, he was restless, irritable, and became emaciated. Afterwards, a number of small abscesses formed in the surrounding cellular tissue, Occasioning sinuses, some of which were exceedingly troublesome, requiring dilitation. This was kept up for twelve months, when all discharge ceased, but the joint was com- pletely anchylosed. He retained, however, terfect use of the fore arm and hand.
320
Ofltfjurks near the ShouUer Joint. Habk to k mistaken for Dislocations.
Fracture of the Acromion.
Signs of. When this process of' bone is broken . off^ it is drawn down by the weight of the arm, the deltoid muscle having in part lost its support, allows the head of the os humeri to sink as far as the capsular ligament will admit of its doing so, and the roundness 4£ the shoulder is consequently destroyed* On tracing the finger along the spine of the scapula, towards the acromion, a depcessioa is felt at the point of natural junction between these two parts. If the arm be raised fyom the elbow, so as to carry the head of the humerus upwards, the shape of the should^ is immediately restored, as the acromion pror cess is returned to its original position, but as soon as the arm is allowed again to hang down, the deformity recurs ; when the arm has been elevated, a crepitus may be dis-r tinctly felt, by pressing one hand over the seat of injury, and at the same time rotating the elbow.
Treatment . In the treatment of this accident, the os humeri is to be made the splint, to keep the fractured bone in its proper position ; and to
321
effect this^ the elbow is to be raised^ and the
itrm fixed, but a thick pad or cushion must
be placed between the elbow and side, to
Tfieparate the former from the latter, and thus
{elax the deltoid muscle, otherwise the
%loken extremities of the bone will not be
contact. The pad having been placed be^
IQ the side and elbow, the arm should be
4 firmly to the chest by a roller, and a
bandage, or a $hort sling should be
ijied to support the elbow, and this
should be maintained for thre^
li^euy little inflammation usually follows ^^J^l
i; ittjury, and the disposition to ossific
16 very feeble ; thus, Unless the firac-
ends of the bone be placed in close
rt; and if they be not kept perfectly
idlest during the time required for such
Mi9lii the junction will be by a ligamentous
lllrbeture, instead of by bone,
■ , ft y - ^
.*' fracture of the Neck of the Scapula.
r\
\ '''This accident is much more likely to be lakeduio- ^(mfounded with dislocation than any other ^* W the injuries to the shoulder joint. The ticture takes place through the narrow part of the neck of the scapula, opposite the notch
VOL. III. Y
:jl^
^f Injuries near ihv S mistakai /*
Fractuf'
Signs of. When this >
It is drawn iUr the deltoid support, ih ' sink as admit the s trac
■ IS
.:oid cavitv
.:.*.:s into the
..ier is there-
:>:> below the
- - lead of the os
—.1, as when the
•- -">.
-1 i^~
'^-
"^^'' j\ the shoulder .<-,: the arm ; but : L.-i':vn. the appear- Trfsent themselves; ::oier so that the .rizi'.i process, a r.: -B^iien the arm is :- which the form
m
"i::-? re-appearance .rcr: is withdrawn; .r.s in the situation the principal •icrure of the neck
— ^-i i -1=
n-: ^ra-cfl I have given for
-:•; * ucii I thought fully to
r ^'.ujcjms attending this
• :t:t:a coatirmed by any
••a.-cs
:\ >• : ::2*:ni^lves, in which I
' t*x.vr.\iminingthe shoulder -I ir»:<, which, at the time, »%'iipconis, and which had -^ if -a»? cervix scapulse.
^-rU
^
323
i eatment of this injury, two principal Treatment, ust be attended to. First, to elevate
first case was that of a Mr. B. a West India Mer- . who, at my request, bequeathed to me the joint in I this accident was supposed to have occurred ; his ;iitors resisted my claim, but after some little difficulty otained my legacy. On exposing the cavity of the villa, I there found the head of the os humeri separated irom the shaft of the bone ; it was seated just below the ceryix of the scapula, and was united by a ligamentous matter to the venter of the scapula, close to the anterior costa. The fracture had taken place between the articular surface of the humerus,and its tubercles ; the capsular %ament had been lacerated, so as to permit the sepa^ t Tited portion to escape into the axilla ; and the upper jnrt of the shaft of the bone with the tubercles, had &IIml in upon the glenoid cavity, by which the round* ^89 of ihe shoulder had been destroyed ; the glenoid c&yity was but little altered, and the patient had before ^ death, acquired a free motion of the joint in every ^bection, excepting as a sword arm, for he could not liae his elbow above the horizontal line. The parts are K^served in the museum at St. Thomas's Hospital. • In the second, that of a gentleman in Gainsford S^tbet, a patient of Mr. Greenwood's, in whom a frac- tipe-of the cervix scapulas was supposed to have occurred, «it Wbo ^tied in consequence of retention of urine, I ' 4ipi»v€red| en inspecting the injured joint, nearly the MiM appearances as in the former dissection^ * i^Haraig> thus ascertained the true nature of this injury, hff Ike <mly aecurate mode, viz. that of dissection, I ^ha^m since been able readily to trace it in the living
Mr. Bi the medical attendant of Lord Y. whilst
Y 2
324
•
the head of the humerus ; and, Secondlyi to carry it outwards ; the latter object will be effected by putting a thick compress on the axilla ; and the former, by elevating the arm and confining it in a short sling.
Of Fracture below the Tubercles of the
Humerus.
Sddic" '^^^^ injury sometimes occurs in the young wnt^ ^^' and old, but rarely in the middle aged. In the young the separation takes place between the epiphysis and shalf of the bone, and iu the old, near the same spot, from the weak- ness of the bone at that part. In these cases
travelling with his lordship in the Isle of Wight, had his shoulder injured in consequence of the carriage being overturned. Sometime after I saw him in London, in consultation with several medical gentlemen, and on examining the shoulder I found a depression beneath the acromion process ; and could distinctly feel the head of the humerus in the axilla. The rotundity of Hie shoulder could be easily restored by elevating the arm so as to carry the upper portion of the bone upwards and outwards ; but whilst the humerus was supported in this position, I could still plainly feel the head of the humerus in the axilla, separated from the shaft of the bone.
I must confess, that I now doubt the very frequent occurrence of the fracture of the cervix scapulte.
.„'J
14.*.^
aierus remains in the
liic body of the bone sinks
ilrawing down the deltoid
'"» lessen the roundness of the
.<: following notes respecting the Case
*iild about ten years of age, brought
; s Hospital with this injury. The
>uld not be moved without creating
pain : if the upper part of the bone was
a, the lower portion could be tilted out so
to be felt, and to form a visible projection,
Hud in doing this a crepitV^ was distinctly
perceived, which could not be felt whilst the
lH)ne remained depressed into the axilla. The
bead of the humerus did not obey the ro-^
tatory motions of the elbow.
In treating this accident, a roller should Treatment, be applied from the elbow to the shoulder ; and then a splint must be placed on the inner, and another on the outer side of the ann, with proper pads, and these must be fixed on with tapes, or a roller. A cushion should be put in the axilla, to throw out the ^per part of the bone, and the limb should be gently stipported in a sUng, but not at all forced up, or the bones will overlap.
326
LECTURE XLII.
' Dislocations of the Elbow Joint.
«
^HE elbow may be dislocated in five differeirt ways.
1st. The ulna and radius backwards.
2nd. The ulna and radius laterally.
3rd. The ulna separately from the radius.
4th. The radius alone forwards.
5th. The radius alone backwards.
Of Dislocation of the Ulna and Radius bach
wards.
Signs of. This injury is strongly marked by the great change in the figure of the joint, and by the destruction of its principal motions. The ulna and radius form a considerable pro- jection above the natural position of the olecranon posteriorly, with a depression on each side ; on the fore part, the extremity of the humerus occasions a swelling, behind the tendon of the biceps muscle- The flexion
327
of the joint is almost destroyed, and the for& hand are fixed in a supine positian. the museum at St. Thomas's Hospital preparation showing the effects of a com- dislocatiou of this kind, which I had aa opportunity of dissecting.
The olceranon projected one inch and a DiasecUon ialf above its usual position, posteriorly, and the coronoid process of the ulna rested in the posterior fossa of the humerus ; the radius Was thrown upon the back part of the exter-- nal condyle of the humerus ; the condyles themselves formed a large swelling anteriorly. The capsular ligament was lacerated exten- sively on its forepart, but the coronary liga- nient remained entire. The brachialis anticus ^Tiscle was greatly stretched, and the biceps Qloderately so, by the altered position of the ''^ius and ulna.
The mode in which this accident is pro- Canw. Sliced is by a severe fall, when the person puts out the hand to save himself; but the ^hole weight of the body being received Upon the limb before it is perfectly extended, . the radius and ulna are forced backwards and upwards behind the humerus. ^■^The reduction of this dislocation maybe Modeof readily accomplished by the following means. The patient being seated on a chair, the surgeon should lay hold of his wrist and place Y 4
328
his knee on the inner side of the elbow joints then pressing down the ulna and radius with his knee, so as to separate them from the humerus ; he should at the same time bend the arm gradually and firmly ; the coronoid process is thus removed from the posterior fossa of the humerus, and the action of the muscles draws the bones into their proper situations. Bending the arm aroimd a bed post, or over the back of a chair, will also effect the reduction. After After the reduction the arm should be
treatment.
bandaged in the bentrposition, at rather less than a right angle with the upper arm ; the bandage should be kept wet with an evapo- rating lotion, and the limb supported by a sling.
Of Dislocation of the Ulna and Radius laterally.
iJixtertiai This dislocation may take place either or mter* externally or internally ; in one case the ulna is thrown upon the external condyle of the humerus, and in the other instance, upon the internal condyle* Signs of In the external displacement, the olecranon forms a greater projection than in the dislo- cation backwards, as its coronoid process is seated upon the external condyle of the
329
humerus, instead of being placed in its pos- terior fossa ; the head of the radius is thrown to the outer side, and behind, where it forms a swelling, which moves when the hand is ro- tated.
When dislocated internally, the olecranon of internal, projects equally as in the former case, but the head of the radius falls into the posterior fossa of the humerus ; the external condyle fonns a large protuberance on the outer side.
This accident is produced in the same way Cawc. as the former, only that the direction of the limb' at the time varies.
The reduction in these cases may be Redaction, effected by the method described as proper for the dislocation backwards ; it is not ne* cessary to move the fore- arm outwards or in- wards, as the actions of the biceps and brachialis anticus muscles draw the bones into their natural positions, immediately that they are separated from the extremity of the humerus.
, . In a recent case of this dislocation in a Case, lady, I speedily reduced it by forcibly ex- tending the arm ; when the tendons of the biceps and the brachialis anticus muscles 4tQted as strings from a pulley, and forced the condyles of the humerus, backwards.
33a
Of Dislocation of the Ulna backwards^
Bigm ofr When the ulna is thrown backwards upon the OS humeri, and the radius remains in its natural situation, the olecranon forms a pro- jection behind, and the fore-arm and hand are twisted inwards. The fore-arm cannot be brought to more than a right angle with the upper-arm, without considerable force.
It is not so readily detected as the former injuries ; but its chief diagnostic marks are the projection of the ulna, and the turning of the fore-arm inwards.
Dissection A preparation in the museum at St, Thomas's hospital affords an excellent oppor^ tunity of viewing the nature of this dislocation^ The displacement had existed for a long time unreduced. The coronoid process of the ulna rests in the posterior fossa of the humerus ; the olecranon projects behind ; the head of the radius has made a considerable depres- sion in the external condyle. The coronary, oblique, and a small portion of the inter- osseous ligaments have been torn through.
Cause. '^^^^ dislocation is produced by the appli-
cation of violence in the direction of the lower extremity of the ulna, which forces it sud- denly upwards and backwards.
33 r
The reduction is in this case much more Reductioa
1 readily made than when both bones are dis- placed, and by the same means. The radius assists the return of the ulna to its proper position, by pushing the condyles back, when the fore-arm is bent, and the brachialis anti- cus acts at the same time in drawing the ulna forwards.
Of Dislocation of the Radius forwards. The radius is sometimes separated from situation
4 of b<m€.
its attachment to the coronoid process of the ulna, and is displaced into the depression above the anterior part of the external condyle of the humerus, and also above the coronoid process.
I have seen several cases of this injfury, signs of. ^hich exhibits the following marks. The fore-arm is a little bent, but cannot be either completely flexed or extended. When an attempt is made to bend the fore-arm, the inotion is suddenly stopped by the striking of the radius against the humerus, and the surgeon is immediately convinced that this check to the flexion is by the striking of one hone upon another. The hand is nearly in a state of complete pronation, but cannot be I'endered entirely so, nor can it be placed
332
in a supine position. The head of the radias may be felt on the fore and upper part of tlie elbow joint, and its moyements are percepttUe when the hand is rotated.
The sudden stop to the flexion of the fore- arm, and the situation of the head of the radius are the most distinguishing marks of this injury.*
DisftectiGB On dissecting this injury, the head of the radius is found resting in the depression above the external condyle of the humerus. The coronary, the oblique, with part of the interosseous, and the anterior portion of the capsular ligaments are lacerated. The biceps^ muscle is shortened.
CwMt^ The dislocation is occasioned by a fall upon
* A sailor about thirty years of age, applied at St. Thomas's Hospital with a dislocation of the radius for- wards, which had existed above six months. I could readily feel the head of the radius- above the external ■^- condyle, particularly when I bent the arm .as much as
possible, and flexed the hand towards the fore- arm. The hand was half supine, and could not be placed entirely in the supine or prone positions, if the .humerus was fixed, A sudden stop was experienced when balding the arm, by the head of the radius striking upon the humerus. The man had regained a great degree of mo- tion, yet was extremely anxious for me to attempt the reduction, which I declined, and urged him not to allow any one to make the trial, as I was confident it woald have been useless. — T.
333
i when the limb is fully extended, i weight of the body being received upon the inferior extremity of the radius.
The first case I had an opportunity of see- ca»e. ing of this accident, occurred under the care of Mr. Cline, during my apprenticeship to him, at St. Thomas's Hospital. The most varied attempts, which his strong judgment could suggest, were made to reduce the dis- placement, but without success ; and the woman was discharged with the bone still displaced.
The second case which I witnessed was in Cwe. a lad, whom I was asked to visit by Mr. Balmanno, in Bishopsgate Street ; hut I could not succeed in reducing the dislocation
B although I persevered, with varied modes of
^uxtension, for more than an hour and a
^buarter.
j^ In the third case, I succeeded in replacing Cue. the bone during the time that the patient wels in a state of syncope ; by resting his olecranon upon my foot, (as he lay upon the fleor,) to prevent the ulna from receding, and then ex- tending the fore-arm.
Another case which I attended with Mr. case. Gordon, was reduced by placing the arm over the back of a sofa, thus fixing the hu- merus, whilst we made extension from the hand so as to act alone on the radius.
Hjliand
L
I hjMl lectured upon this espfauned the difficulties of ]Hh WiDiamSy one of my pupils, he had known this dislocation i br estaaufing the hand only. This I myself was correct, by experi- r the detd body. The connection of with the radius, allows of the appli- of force to extend this bone without 3ttudxiK the ohia. In making the extension iM iKmenis should be fixed, and the hand ^efuefed js much as possible supine, to re-
of the radius from the upper it thtt cwoid process of the ulna.
^* Jt&fitinffiwi iff ike Radius backwards.
f!^ sittiy tfistance in which I have seen this
««» in a subject brought to St.
ifissecting room, in the year 1821 ;
^|^$|ilK«aeiit had existed some time.
ni^ Itead of the radius was thrown behind, 1^ Qi^ th^ outside of the external condyle of '»K? lwitteru?Ss where it formed a projection v^ilK^h wuW be readily seen as well as felt, wiKit tht." *^^ ^'^'^^ extended. The oblique,
i c\>rvHi*r\- ligaments were torn through, ^Hi tiK^ vni{X3talar ligament was partially
335
Of the cause of this accident I am ignorant, as I have never seen the accident in the living subject.
The reduction, I should imagine, would be Red"cUon. easily effected by bending the arm, after which it would be proper to support the bone in its proper position, by means of bandages, and keep the arm bent at right angles, for three or four weeks, until the ligaments have I had time to unite.
ccidents at the Elbow Joint likely to be con- founded with Dislocations.
fracture above the Condyles of the Humerus.
When the condyles of the os humeri are iJi^e the
, dislocation
Obliquely fractured a little above the elbow backwardi. I joint, the appearances presented are so like lo those occurring from the dislocation of the llna and radius backwards, that the two injuries might be readily confounded ; in the fracture, however, all marks of dislocation are easily removed by extension, but return again as soon as the extension is withheld, and by rotating the fore-arm upon the humerus, a distinct crepitus can be usually felt.
In July, 1822, a boy about nine years of ^"^ age was admitted into Guy's Hospital, having
336
fallen from a cart upon his elbow. The arm was a little bent, and the ulna and radius appeared to form a large projecting behind the elbow joint : when the fore-arm was ex- tended, the appearances of dislocation sub- sided, but they returned immediately that the extension was discontinued. The arm was secured in splints, which were removed in ten days, when passive motion was carefully employed ; the lad recovered.
Fmuent This injury is much more frequently met * with in children than adults ; but I have known it to occur at nearly all aj^es.
Tr«itnMiit In treating this accident, the arm should be bent, and the fore-arm drawn forwards to replace the fractured portions, and should be then secured by a bandage.
A splint having two portions joined at right angles, is best adapted to this case; the upper portion is to be placed behind the upper arm, and the lower part under the fore-arm ; a splint will be also required on the fore part of the upper arm ; these should be weU secured by straps, the arm should be sup- )>orted by a sling, and evaporating lotions ke)>t applied.
i««H(v^ AlVer the lapse of a fortnight in the young
IH^licuU and of three weeks with the adult, |MMMU\f moiiou should be carefully employed \%\ \\kv\t\\\ anchykisis, which may otherwise
m«til^
337
I 'take place. In some of these cases, the ^ loss
t>f motion in the joint is considerable^ even
after the greatest care and attention on the
part of the surgeon.
Of Fracture of the Internal Condyle of ihe
Humerus.
When this accident occurs the ulna pro- signs of. jects backwards, from having lost its support. The injury may be distinguished from others by the crepitus, which can be felt upon bend- ing and straightening ^the arm, and from the hand being turned towards the side during tbe extension.
The same mode of treatment as that di- Treatment. reeled for the fracture above the condyles, will be proper in this case; passive motion wi»t be employed early, when the recovery will be complete.
Of Fracture of the External Condyle of the
Humerus.
This injury produces swelling over the ex- signs of: iemal condyle, and pain is experienced at the part on pressure, or during the flexion and extension of the arm ; but it is best
VOL. III. z
338
distinguished by the crepitus, which, can be readily felt during the rotatory motimis of the hand. If the portion of bone detadied be large, it is displaced backwards, and the head of the radius accompanies it.
Dissection Two preparations in the museum at St. Thomas's Hospital, exhibit specimens of this fracture ; one is oblique, and the other trans- verse at the extremity of the condyle. There is not any ossific union in either, but the fractured portions are joined by a ligamentous substance, and this appears to be the case in all instances of fracture with a capsular liga- ment.
i^'hTd*"* Children are generally the subjects of this accident; it is seldom met with in adults, and very rarely in advanced age; and it is occasioned usually by a fall upon the elbow.
Treatment. The bcst modc of treatment in this injury, is to place a roller around the joints which should pass also above and below it, then to support the limb in the splint, having two portions at right angles, as in fracture above the condyles ; and to this, the upper and lower arm are to be well secured. In young children, a portion of stiff paste board, applied wet, and bent to the shape of the elbow, will answer best, as when dry it adapts itself to the form of the limb, and affords an excellent support.
339
-I After three weeks, the surgeon should rery Pwii'e ^utiously commence the passive motion.
If the fracture in these cases extends with- Bony out the capsular ligament, a bony union may with care be effected ; but when entirely within the capsule, the union, as far as I have seen, is always ligamentous.
Of Fracture nf the Cnronoid process of the Ulna.
The following case which I have for many
years related in my lecture, was considered
as a fracture of the coronoid process, and will
show the symptoms produced by such an
I injury.
A gentleman in the act of rimning, fell case. upon his hand, which he extended to break his fall, and immediately afterwards he dis- covered that the motions of his elbow joint Were greatly diminished, as he could bend the arm but little, nor could he entirely ■ straighten it. His medical attendant in the country, to whom he applied, found the ulna projecting backwards, but that on forcibly bending the arm, the figure of the joint be- L ^ime immediately restored. A splint and
ndages were applied, and the arm sup- wrted by a sling. Several months afterwards fee gentleman came to town, when I saw z 2
340
him; his ukia still projected behind the condyles of the humerus; but could with little violence be restored to its situation by bending the arm.
mentowT' Somc time after I had seen this gentleman,
^^*^* I had an opportunity of dissecting a case this injury, in a subject brought to St. Thomas's anatomical theatre. The coronoicL process of the ulna had been broken off with- in the joint, and had only united by ligament^ so as to move freely on the ulna, and to allow^ the ulna to be carried back between the con- dyles, when the arm was extended. .
Reasoo of. J ^^jj^ doubtful if the most careful treatment: would effect a perfect cure, as the coronoidi process loses its ossific nourishment, and has only a ligamentous support. The vitality of the fractured process oi bone 1$ only sup- ported by the vessels of the reflected pwtions of the capsular ligament, which do not appear sufficient to create a bony union.
TreatMM. In the treatment oi this accident, the arm should be kqpt steadily in the bent position for three weeks, to allow time for the liga- mentous union, and to make it as short as possible.
Of Fract9it>e of the Olecranon.
niitiu M. Tho iu;!irk$ of the injury are generally so
341
evident, that it can scarcely be mistaken. jA swelling takes place at the back of the elbow, which, when pressed, feels soft, and allows the finger to sink in towards the joint; ■this is between the two extremities of the fractured bone ; the detached portion is drawn upwards from the head of the ulna, to the extent of from half an inch, to two inches; it can be readily moved from side to side teneath the integument, and becomes further Hftfeparated from its former connection when Wfce arm. is bent. The patient can bend the T7 ann with ease, but he cannot extend it with- out great difficulty, and the attempt gives him much pain ; without exertion it remains semiflexed. No crepitus can be felt; and the rotatory motion of the radius upon the ulna are perfect. Considerable tumefaction from effusion of blood usually follows this accident, atid in a few days the surrounding parts are fQuch discoloured from ecchymosis. The fracture generally occurs about the centre of the process, transversely ; but I have seen the bone obliquely fractured, ^L In dissecting the injured parts, sometime DinMtion. ^pfter the occurrence of the accident, the por- "tion of the olecranon, still connected to the ulna, exhibits some evidence of ossific de- posit, and sometimes the detached part has Lit marks of a similar character; z 3
342
the cancellated stracture is filled with new ottific matter. The capsular ligament is lace^ rated posteriorly on each side of the olecra- non. It appears, therefore, that as soon as the fracture takes place, the action of the triceps muscle draws up the extremity of the process, from half an inch to two inches, ac- cording to the extent of laceration ci the capsular ligament, and the ligamentous band naturally connecting the olecranon to the coronoid process.
Kxpf rt* To satisfy myself whether this process when broken would again unite by bone, I tried several experiments upon dogs and rabits, when I found that if the fracture was trans- yerse, and such as to allow of separation be- tween the fractured ends, by the action c^tiie muaclee, the union was atwmys ligamentous ; but if the fimcture was oblique, and not ad-* mittinir <^ sepantikm, the parts woe readily^ unittil by ossific deposit The want of bon]^ unnm^ appMTSi^ tber^ure, to depend upcm a wtnut t4' ada|>tiQii of die brokea sufrces, and m4 u|>^M\ ;9^uy ddkwKy of support, as in tilie <HM^ witK iW feKfiire$ of processes within iW \M^>$ular t^wmnis of toinis.
^>Miii^ l^l^i^ tjimci^f^^ VMT be Mrasnaed by fiilling ^|VM\ I W <^K>>w^wWft tbe ana b bent, or it may M^y4iii\*i^l^>w^ lli^ ^ncwai <if tlie trieqps muscle
The principle of treatment in these cases t is to render the separation of the fractured extremities of the bone as slight as possible, as the limb is weakened in proportion to the length of the ligamentous union, from the (Uminished power of the triceps muscle. The arm, if possible, should be placed and fixed in a straight position, and if much swelling and pain exist, leeches and evaporating lotions must be employed for two or three days ; and immediately the tumefaction has subsided, a bandage must be applied above the elbow, and another below, having a por- tion of linen or broad tape placed beneath them longitudinally on each side of the joint ; the ends of these pieces of linen or tapes are then to be tightly tied over the rollers, so as to approximate them, and thus bring the hroken surfaces together. A splint well padded must be placed on the fore part of the arm and joint, and confined by rollers, so as completely to prevent any flexion of the limb. The bandages about the seat of injury should be kept wetted with the evaporating lotion.
This is the only injury to the elbow joint, in which the straight position is proper.
Passive motion should be very carefully i employed about a month after the accident, hut not sooner.
z 4
344 When When this fracture is compound, uniofi by
compoond*
adhesion should be effected if possible, by approximating the edges of the external wound with adhesive plaister, and placing over this, lint dipped in blood ; the treatment in other respects, will be the same as in the simple injury.
Fracture of the Neck of the Radius.
Very rire. This injury, which is said by some surgeons to be of frequent occurrence, I have never seen; but I do not mean to deny that it sometimes happens.
When it exists, I should imagine that it would be readily detected by the crepitus, which the rotating of the radius would oc- casion.
Treatment. The samc mode of treatment as that already recommended for fracture of the external condyle, would in such cases be most proper
Of Compound Fractures, and Dislocations of
the Elbow Joint.
Not dan- I havc kuowu scvcral cases of this nature
gerous.
recover, with a partial anchylosis of the joint;
\
345
if properly treated, the constitutional derange- ment in consequence of the injury, is not productive of any serious mischief,
A brewer's servant was admitted into Case. Guy's Hospital, on account of a compound fracture of his elbow joint, attended with considerable comminution of bone. The ex- tent of injury was so great as to induce me to recommend immediate amputation, but I could not by any means persuade the patient to submit to the operation. The limb was therefore placed upon a splint, in a bent T*osition, the bones being easily reduced ; the ^^Iges of the exterior wound were carefully < Approximated. He recovered without any : Vintoward symptoms, and retained sufficient j **iotioa of the joint, to enable him to resume | liis former employment.
I have known several other cases in whichf ^he patient have recovered, without any ^^^* ■Bevere constitutional sufferings. P In the treatment of this injury, the limb Treatment, should be kept in a flexed position, as anchy- losis to some extent is sure to be the conse- quence of it, when the position will lessen the inconvenience attending it. If attended with much comminution of bone, the loose portions should be removed before the ex- ternal wound is closed. In elderly persons, or in those not possessing sufficient power of
I
L.
^mpor — -^- — "^ -^ iuppurative pro
:e amputated in th< . che edges of the cogether by adhe- Ljwred with lint dipped in aopported by a band- «iiii ia evaporating lotion.
:uw *f tkt Wrist Joint.
ji "iuA articulation may occur
»aw- Jxuc3tiiia Of the ulna and radius
jTSiuoicoa of the radius alone. Jbax:i£:oa of the ulna alone.
••.?*-
"t^MOListsm tr VIA Ulna atid Radius.
H^M 3%nie$ nay be displaced from the
ja v^ci ^ carpal bones^ either for-
^^,^ I .ntvs.'^'ird^- If a person in falling
^^1^ %t'C^c ,'£ tie body received upon the
It t :tv i^i^. ^'* 2^s to occasion a dis-
^^•1 I '••i. c^^ forwards; the radius
. *^ ^^<:ft;r uron the anterior annu-
c^uv'tv .i •iv'' carpus ; should the fall.
347
however, be upon the back of the hand, the contrary displacement may be {nroduced.
In each of these cases, two projections are sigm of. perceptible, anteriorly and posteriorly, one from the extremities of the radius and ulna, the other from the bones of the carpus, which render the detection of either injury easy.
The effusion which so frequently follows injanrre-
sembliDg
sprains of the tendons, frequently produces disioci&ik an appearance somewhat similar to that re* suiting from dislocation ; it may, however, be distinguished from that occasioned by the dislocations, as it takes place gradually, and is rarely found on both sides, — ^whereas, in the displacement, the projections immediately follow the accident, and appears both ante- riorly and posteriorly.
These dislocations may be easily reduced, RedmstiMi. by fixing the fore and ijipper ?trm, whilst ex- tension is made from the hand ; immediately that the ends of the bones are separated from each other, the actions of the muscles restore them to their proper situations. When re- placed^ they must be supported by ban- di^es, and two splints, one placed before and another behind the articulation, reaching frt>m the elbow to the ends of the metacarpal bcmes, to prevent motion, as weU as to pro- tect the injured parts. The fore arm and hand should be placed in a sling.
348
Dislocation of the Radius alone.
Forwards. The radius is sometimes thrown from its articular surface anteriorly, so as to rest upon the scaphoid and trapezium, where it forms a projection ; the hand is twisted, the inner side of the palm being placed forwards.
canie of. . A fall upou the hand, when it is bent back, is the common cause of this injury.
Reduction. It may be reduced by the same me^s as the former dislocation, and will require the same after treatment.
Dislocation of the Ulna alone.
Backmrds. The displacement of the ulna alone, occurs much more frequently than that of the radius . alone ; the mode in which the former bone is articulated by means of an inter-articular car^ tilage, and its not forming a part of the wrist joint, allows of its being more readily thrown from its natural position. It usually projects backwards, and is attended with laceration of the sacciform ligament. It may be easily pressed into its proper situation, but imme- diately the pressure is discontinued, it again protrudes, as the support of the ligament is destroyed. *
349
In the treatment of the injury, it is, there- Treatiicnt. (ore, necessary to employ a compress over the extremity of the ulna, aind then to sup- port the bone in its natural position, , by bandages and splints, as in the former dis- location.
Of Dislocations of the Uina, with Fracture of
the Radius.
The ulna is often dislocated forwards, the Jadius being at the same time fractured obliquely about an inch above the ar- ticulation.
The hand is, in these cases, thrown back- signs of. wards, as in the dislocation of both bones forwards j the extremity of the ulna can be felt just above the pisiform bone, beneath the teiuion of the flexor carpi ulnaris, and the fir?tct]ired extremity of the superior portion of ^ie radius is situated under the flexor ten- ddiisof the hand,
.The reduction in these cases is usually ReducUoo. very difficult, requiring powerful extension ; Wtd there exists a further difficulty in pre- serving the proper position, when the reduc- tion has been effected, as the bones are again displaced from the slightest cause, unless confined by bandages, &c. The extension
xV nV "^
Vbx*\»»*^
350
-,^ r .:aue as in the former cases, an<
_^ _c .ones have been drawn into thei
_^ ..uiauons, two cushions must h
_^ a» Jeibre and the other behind th<
^--u'^i and there firmly bound down b]
.^, . ver these, splints, lined with pads
^^ je Jiaced, to reach from the elbow tc
. ...uiu, and secured by a long roller- The
^ :iu$c be placed in a sling for three
.v^* i' "he patient be young ; or from four
• V. veeks if aged, before passive motion
V tsorted to for the purpose of restoring
i«: ULOcions of the joint, which will not be
viitfcdv effected under four or five months.
Jr Cofnpound Dislocation of the Ulna, with Fracture of the Radius.
The consequences of this injury are serious sH tK^t, according to the degree of surround- ing mischief, and the extent of the firacture ; ii ^vmminuted, the subsequent inflammation iM sovere, but otherwise of trifling extent, when judicious treatment is adopted.
Iho reduction is to be accomplished as \vhi*u the simple dislocation and fracture \HH*ur ; the edges of the wound must be care- hill v approximated, and every means taken lo iironiote adhesive inflammation, and to
351
Tteep it within bounds by evaporating lotions, and tbe employment of leecbes if necessary. The arm must be laid on a spHnt, and sup- ported by a sling. The dressings should not be disturbed so long as the patient remains free from suffering, or until the wound has united ; should symptoms of suppuration t'OCcur, the removal of part of the dressings I «iay be sufficient to allow the escape of the JUS, without taking off the whole.
Dislocation of the Carpal Bones.
This injury is of very rare occurrence. ^"y ■■'
An elderly woman was admitted into Guy's Case. Hospital, in consequence of an accident to ''er wrist, produced by a fall upon the back of her hand ; the radius was found to be frac- tured obliquely through its inferior extremity, 3Qd the part thus separated from the shaft of tile bone, was thrown backwards upon the ''^rpus with the scaphoid bone. The fingers •^Ould be extended, but not entirely flexed, ■''he reduction was readily accomplished by ^^ctension and steady pressure, and the part ^^ipported by splints. Leeches and evaporat- '**g lotions were employed at first, to subdue '■he inflammation and tumefaction which followed the injury, and afterwards, further l^pport was given by strips of soap plaistcr.
352
GangUa. I have knowH ganglia, which so frequently form about this part, several times mistaken for displaced bones, but a little attention to the history of the case will readily explain the difference.
Partial Relaxation of the carpal ligaments will
18 oca on gQjjjgjijj^^g admit of a partial ^location of
some of the bones, when the joint is forcibly flexed; and this state is generally accom- panied with great debility of the part, pre- venting the patient from any continued exer- cise of it. Treatment. Moderate pressure and support are the best means of relieving such complaints, the use of friction and of cold water poured from a height upon the part, I have known of service.
Of Compound Dislocation of the Carpal Bones.
Causes. ' This frequently happens from the bursting of guns, or from the hand and wrist being caught in machinery, and in such cases, one or two of the carpal bones may be removed, and a considerable degree of motion be afterwards preserved in the articulation; but, if attended with extensive surround- ing mischief, amputation should be per- formed.
353
The following case occurred under tlie care '^*- of Mr. Forster, in Guy's Hospital. Richard Mitchell, aged 22, was admitted iuto the Hospital in consequence of an extensive Wound into the wrist joint, inflicted by a wool combing machine. Two-thirds of the joint Were opened, and the surrounding soft parts 'lad suffered considerably. The scaphoid t>one was dislocated backwards, and nearly
Separated from its usual connexions ; the
extensor tendons of the thumb, of the fore
^nd middle fingers were torn through, as was
^'so the radial artery, which, however, did
**ot bleed much. The scaphoid bone was re-
i^oved, and the edges of the wound were
approximated by sutures, and adhesive plais-
*^^r applied in strips; the whole was covered
"J lint dipped in blood, and supported upon
^ splint to prevent any motion of the joint; .
^ small quantity of blood was taken from the
^TiQ, and the seat of injury kept moistened
^Vith an evaporating lotion. In two or three
*lays it became necessary to remove these
•Itessings ill consequence of suppuration,
^heii a poultice was applied. A small slough
■^liich had formed, separated kindly, and the
Process of granulation went on without a
^^teck, so as to fill up the wound in the course
'^f three weeks. His recovery was somewhat
•"etarded by the occurrence of a pulmonary
VOL. III. 2 A
354
affection, requirmg the use of leeches^ dia- phoreticsy kc. to which it yielded. He Idt tiie Hospital^ with but little motion of the fingers, but this appeared to be gradually increasing.
Dislocation of the Metacarpal Bones,
Aiticaution The articulation of these bones with (he carpal is so strong, that great violeace is re- quisite to separate them. I have seen them displaced from the bursting of guns, or the passage of a heavy laden carrit^e over the hand.
Removal of In thesc cascs, one or more of the m^-
'^' carpal bones may be removed without am- putating the whole hand.
caso. I amputated the middle and ring fingers,
with their metacarpal bones, from the hand of a Mr. Waddle, of Cheapside, in con- sequence of their being extensively injured by the bursting of a gun. I brought the edges of the wound together by sutures, and approximated the fore and little fingers by .a roller ; the wound united readUy, aiid he had afterwards a very useful extremity^
Case. A boy was admitted into Guy's Hoi^[ntaI
with a very severe injury to the hand, fiom the bursting of a gun, by which all the
365
iftetacarpat bones, excepting that of the fere fing^er, were so sliattered, as to render it im- possible to save them. The thumb had been entirely separated, with its metacarpal bone, and the trapezium was so much injured, that 1 thought it proper to remove it ; I therefore toolt it away, as well as the metacarpal bones of the middle, ring, and little fingers, with the fingers themselves ; thus only leaving the fore finger with its metacarpal bone. He iovered quickly, and could use this finger a hook with the greatest facility and ailvantage.*
fracture of the Head of the Metacarpal Bone.
The digital extremity of a metacarpal Sf«iof. ^ne, which is called the head, ia sometimes '"'oken off, and gives rise to an appearance of I dislocation, but the crepitus, on exami-
^^^ A case somewhat similar to the above, occurred I *nder my care in Si. Thomas's Hospital, in whicli I was obliged to amputata tlie little and ring fingers from the 'Bjured hand, with their metacarpal bones. I also re- ■Xored the unciform bone, and the middle finger, with Iwo-thirds of its metacarpal bone. The recovery was D^dual, but complete, and ttie patient can ni)w use bis tbumb and fore finger very expertly.~T. - '"- ■■' — i
L
360
iiation, makes the nature, of the accideiit mrj evident. j ;. : ' . Treatment. I^ the tfeabptent Df Hm^. accident, the pa- tient should be made to grasp a large .ball of firm materials, and over this his hand should be confined by a roller ; this is the best me- thod of restoring the firactured bone to its natural position.
Dislocations of the Fingers.
commwi The most frequent seat of this displace- ment is between the first and second pha- langes ; but it is not an accident of common occurrence.
Nature of. The dislocation may occur either back- wards or forwards, when the projections formed by the ends of die bones plainly in- dicate the nature of tie injury.
Reduction. If reccut, the reduction may be easily ac- complished, by making extension with a slight inclination forwards, to relax the flexor muscles ; if of some days standing, a long continued, and steady extension^ is necessary to replace the bones. It has been recom- mended, in cases of difficulty, to divide the ligaments or tendons, btit I have seejoi too much mischief result from injuries to these parts, ever to advise such a practice.
367
The same observations are applicable to Remarks the dislocations of the toes, but rather more ^a^es diflSculty is experienced in t^ reduction, on ^ account of the shortness of the phalanges.
of ^^n\ d
Of Dislocation from Contraction of the Tendon. ^IVJ^^^
The phalanges are sometimes drawn out Cause. of their proper positions, by the cbnitraction of a flexor tendon and its theca; in consequence of a chronic inflammation, induced by exces- sive employment of the hand in rowing, ploughing, hammering, &c. ; nothing can be 'done to relieve these cases, but when merely a single band of fascia is thickened, and pro- duces this deformity, it may be divided with much advantage by a narrow bistory, intro- duced by a small opening through the skin. A splint must afterwards be applied, to keep ilie finger straight during the healing of the wdund.
A similar contraction also occurs in the inthetoea. tendons of the toes from the wearing of tight 'sitoes ; the projection of the first and second ; phalanges, in these cases, often gives rise to so much suffering and inconvenience, as to ^akeit necessary to amputate the toe, other- wise the patient cannot take necessary e^lcer- cise, and is deprived of many enjoytnents.
2 A 3
368
riH^ omm in which I have performed the •>|MttttiiNi» have generally done extremely w%^U, and restored the patients to comfort:
Dislocations of the Thumb.
viiucuiHi jjig number of strong muscles connected
^uiHig. ^itd Uie bones of the thumb, render the
reductions of their dislocations very difficulty
especially when much time has been allowed
to elapse from the receipt of the injury.
^tke Mttacarpal from the Carpal
JSotK*
VoTM oc In the majority of cases in which I have MTitnessed a displacement of the metacarpal bone of the thumb firom Ae trapeamn, (he former has been throwii inwards towards the metacarpal bone of the fore finger. The thumb has heca, beat backwards, and the extr»nity oi the bcme has formed a pm- jection in the palm oi the hand ; it has been attended with ccmsideraMe pain and tome- - faction*
H«iiihiNm. In midcing the extension for reduction, it:== is )>articularly necessary to attend to the re — Uxatit^n^ as for as possiUe, of the most^
powerful muscles^ which are the flexors, thu$ the thumb iQ,ust^ during the process^ be ixk- dmed towards the palm of the hand. The force applied must be continued and steady^ as violence will not eifect the desired object.
If simple e2(tension does not succeed in reducing the dislocation^ the part must be left to the degree of recoyery which nature will effect, as it would be improper to attempt relief by any division c^ muscles or tendons.
A compound dislocation may be pr^i^duced ^J*^^^ at this articulation by the bursting of a gun> and in such a case, if the tendons are not lacerated, the dislocation should be reduced, which it can be easily, and the edges of the external wound should be brought together by suture, when, with careful treatment^ a good emre may be effected.
A $ai3e of this kind occurred at Brentford, ciue. under the care of Mr. George Cooper, in a young ge^tlen^an, aged thirteen; the injury W|LS CK^casioned by the bursting of a powder v^asli; ifi his hand. The mass of muscle con- iKtcting the thumb to the hand was torn ^through, but the tendons of the long flexor, and of the extensors were pot injured. The dfelocation was redaeed^ and the wound doMd^ by sutures a^d adhesive plaister, over which an waporating lotion was applied. The wound unU;ed in part rapidly, and the
2 A 4
360
remaining portion healed kindly by grann- lation. Two weeks after the receipt of the injury, Mr. Cooper began the use of passive motion, and the patient ultimately gained perfect motion in the joint. AmputatioB Should, howevcr, the tendons be Jace-
required.
rated, or much surrounding mischief didst, amputation will be required ; and I have found it necessary, in such a case, to remove the articular surface of the trapezium, which I think may be done with advantage, espe- cially when there is a scarcity of superficial soft parts.
Dislocation of the First Phalanjr.
Simple. Ii^ the simple dislocation at this articu-
lation, the first phalanx is thrown back upon the metacarpal bone, • forming a projection there, whilst the end of the metacarpal Ixme protrudes towards the palm of the hand ; the motions of the joint are destroyed, although the thumb can be made to approximate the fingers by the movements of the carpo- metacarpal articulation. .
Rednction. The modc of applying the extension finr the reduction of this dislocation, should be as follows, and the direction should be to- wards the palm of the hand, to relax the
361
r muscles. The hand should be id warm water for a considerable time, to relax the soft parts as much as possible, then a piece of soft leather wetted, should be placed closely around the first phalanx, and
I over this a portion of tape, two or three yards m length should be fixed by the clove hitch, (a knot, so called by sailors.) An assistant should next firmly hold the metacarpal por- tion of the thumb, by passing his fore and middle finger between the patient's fore-fin- ger and thumb, whilst the surgeon draws the first phalanx from the metacarpal bone, in a direction somewhat inwards to the palm of tLe hand.
if the above plan does not succeed, the Another ! fi)liowing should be adopted ; — The leather and tape being applied as before, a strong Worsted tape should be passed between the patient's fore-finger and thumb, and this should be tyed to a bed post, around which the arm should be bent ; a pulley being then fised to the tape connected to the first phalanx, a gradual and steady extension should be "nade.whichwill generally effect the reduction.
When the above described means have Sometimes i^eeu fairly tried, without success, it will be ''est to leave the case to nature, when the patient will, after some time, acquire a great
362
When In cases of compound dislocation^ should
*^^**®"" the redaction be difficulty a part of the extre- mity of the bone may be removed by ampu- tation ; and the patient may afterwards ob- tain a useful joints by the early employment <tf pasttve motion.
Of Disiocatian of the Second PhtUanj^.
Easily de- In a simplc dislocation of this kind, the nature of the injuiry can scarcely be mistaken, and the reduction may be accomplished in the following way:---The surgeoa ahooM grasp the back of the first phalanx with im fingers, and apply his thumb upon the ftre- part of the dislocated phalanx, and then Sei it upon the first as much as possible.
Treatment The treatment of tiie compound dislocation
of com- ^ *
pound, of this articulation, is the same as that reerai- mended for a similar accident in the fint phalanx ; but the ends of the tendon should be made smooth by the knife, wh^i,. by care- ful approxijnation they will unites Passive motion may be used in two or three weeks.
363
I I
LECTURE Xtlll.
11 : J^locatioiu of the Hip
.J ;i 1 1. • « .' ■ »■
•at
"'Hit head df the femur may be throwH Mm tbe acetabulum in four directioiis.
' Flr8t«-^-^Upwards» upon the dorsum of the mini*'
Second.r-Downwardft, into the fbramen Wte;- • '.. .
11iifd;--^Backwarda and upwards, m the iiehialic notch.
«'ti Ainrth« — FcNrwards and upiwards/upon the body ef the pnbea.
A digplacement downwards and backwards AfifthfonB. W been described by some surgeons, but t haire neveir had an opportunity of witness- ^ it, and I am inclined to beliere that some ^stake exists about this injury, although 1 do not mean to deny the possibility of its ^Hicurrence.
364
Dislocation Upwards and Backwards an the
Dorsum Jliii.
The Mott This is the most common of the displace* ments of the hip joint, and is marked by tiie foUowmg signs :—
Signs of. The limb on the injured side is firom one inch and a half, to two inches and a half shorter than the sound limb. The knee and foot are turned inwards ; the knee being a little advanced upon the other, and the great toe rests upon the tarsus of the other foot. The motion outwards is destroyed, so that the leg cannot be separated finom the other, but the thigh may be a little bent across the sound limb. The head of the boiie may be felt, and seen to move, upon the dorsum of the ilium, if the knee is rotated inwards ; excepting when the injury gives rise to extensive extravasation' of Mood ; the trochanter major is thrown much nearer fhan usual to the anterior supierior spinous pro- cess of the ilium, so as to render the rotun- dity of the injured hip much less than that of the sound side. The chief marks will there^ fore be, difference in length, change of posi- tion, diminuticai of motion, and loss of pro- jeckion or rotundity Irom the altered position of th^ trochanter major.
366
The accident with which this dislocation Fracture of is most liable to be confounded, is the frac- ture of the neck of the thigh bone within the capsular ligament. The distinguishing marks are, however, sufficient to prevent any mis- take, if common attention be paid to the e^e. In the fracture of the neck of the thigh bone, the knee and foot are usually turned outwards, and the trochanter is drawn upwards and backwards upon the dorsum of the ilium ; the limb which is shortened cue or two inches by the contraction of the mus- cles, can be restored to the same length as Ihe other by slight extension ; but the shortening immediately recurs when the extension is abandoned ; and the limb j may be readily flexed, although it creates much pain. On rotating the limb, when extended, a crepitus can be felt, which
^is not perceptible whilst the limb is drawn ^ This fracture rarely happens, but ifiold persons, and is generally the effect of a very trifling injury ; it occurs, hovrever, much more frequently than the dislocation.
Thus the greater mobility of the joint, the
ease with which the length of the limb is
i^atored ; and the perception of crepitus
I Airing rotation, when the limb is extended,
^nish ample marks of distinction between
i the two injuries. ,.:aj:|ui ■.!:_;
u^
366
The alterations in the figure of the jdnt
produced from inflammation and nlceratioBj
can hardly be mistaken finr dislocations from
▼ioleiice, excepting by persons ignorant at
anatomy, and but little attentife to thiifa'
{Mofessional duties. The gradnid progress >tf
the symptoms, the pain in the knee, ^
increased length of the limb at first, and AH
marked shortening afterwards; the extent oT
moticm, but the sufferings created by- any
extreme movement, are differences ^whkh
wookl Inrdly escape the notice <rf tfie most
careleas observer. The coasequeiieea of Hm
disease, when of long standii^, are uksr^
ation of tiie heiNl of tiie bone, l^aments^ and
acetabohim, accompanied with aiidi> a
diange of situaticm of the parts, as acMBetimei
to present the appearances of ^Hriocatioa,
but the history of the ease wiH readily infimi
the surgeon of its tme natore.
SI1I9 tr In the dislocatiQa upoii die dofsom of Ikt
ilram, tiie pyiiiMnais and gintei mnadea^ thi
trieqis, tiie pectineiK, the psoas magnoB, and
iUacus intemus, die rectos, die semitendi-
mosus, and membranosos, the obturator ez-
leraus, and one head d die bicqia are aH
sAKMTtened. The obturator intemus, the ge-
rnini^ and quadratus lemoris are all stretched.
The triceps and glutei chiefly oppose the
r^uction.
This dislocation is occasioned by a fall or Camc. blow when the limb is turned inwards.
following manner ; bleed the patient to the extent of from twelve to twenty ounces, or even more if he be very robust, then place him in a warm bath, at the temperature of 100°, and gradually increase the heat to 110°, until he faints : eind to accelerate the fiantness, give him in solution a grain of tartarized antimony every ten minutes, until nausea is excited. When faint, remove him from the bath, envelope him in blankets, and place him between two strong posts, about ten feet asunder, and in which two staples Me fixed ; or rings may be fixed in the floor, and the patient laid between them. He tuld be placed upon his back, and covered Ji with blankets. A strong girt should then passed between the tliighs, close to the upper and inner part of the injured limb, and the ends of this should be fastened to one of tte staples. A wetted roller should next be placed tightly on the lower part of the thigh, just above the knee of the injured limb, and upon this a leatlier belt, with straps and rings affixed for the attachment of the pul- lies, should be closely buckled. The knee should be slightly bent, and the thigh di- rected across the sound one just above the
• and
I
L
368
knee 4 The pulUes must be attached to the straps of the belt, and ta the other staple. The.surgeon now should gradually and care- fully commence the extension^ and continue it until the patient begins ito complain of pain, when he should rest a little, without relaxing, so as to fatigue the muscles ; haying waited a short time, he should again draw the ccurd, and when the patient again: complains, he should again suspend the extension, and so on, until the muscles yield, and he finds tiie head of the bone is brought near to the ace- tabulum, when he should give the string of the puUies in charge to an assistant, with directions to keep up the extension, whilst he himself rotates the knee and foot gently, under which motion the reduction will be usually accomplished. When the pullies are used, the head of the bone. does not generally return into the acetabulum with a snap, as the muscles, from continued extension^ have not sufficient power remaining to allow of any powerful contraction ; thus the surgeon can only be assured of the accomplishment of the reduction, by the restoration of the figure of the part, and by loosening the pul- lies and examining the joint.
It sometimes happens, that the bandages get loose before the extension is sufficient, when they should be carefully re-applied, but
369
io as short time as possible, to prevent the muscles from recovering tbeir original tone.
When the head of the femnr has been Head of l^ught by the extension to the edge of the acetabulum, the rotatory motion above-men- tioned, is not always sufficient to promote the reduction, but the head requires to be l^ted over the lip of this cavity ; this may be performed by passing a towel or napkin as near to the joint as possible^ at the upper part of the thigh, and by it an assistant may raise the upper part of the bone from the surface of the ilium.
When the reduction has been accom- pliriied, the patient must be very carefully removed to bed, in consequence of the risk of fmrther displacement, frpm the very re- laxed state of the muscles.
. ' The reduction of this dislocation may be in recent completed, in a very recent case, before the muscles have had time to contract, by exten- sion made in a direction, not under other circumstances, well adapted for this purpose ; and I have seen it thus effected : — ^The mode described by Mr. Hey, if I understand it correctly, appears to me but little calculated to succeed, unless in a very recent case ; but I state this with great deference, as no one can have a higher opinion of the talents and professional acquirements of Mr. Hey,
VOL. III. 2 B
i30
i«
ittT tNi aa cJiceptSMn to a rul occQT but verr sekiom.
-viuii I haare advaBcecL
ot' txfsaBBBt deiaiied i^
dir
beoents to be oin lii li bv^tfae Qi* dK piiUia, and the aHHOBce of tHBad tnestmcnl*
I ami iodefalefL 10 Jfic* 1^ ^^j ■■■iigwn^ M
Chester, isrtlieiiulDry^af liiefiiDaipm|rewe. Jofan Fonter, aged tw^Hr-two jrem^ had iuft dufi^ dislocatied in conaeqiiemre irf* acafft paaan^ owtt his pelm^ and was aiAnitted into the ClK^er Infinnary Jiiiy 10, lgl8, scMMi after the receipt of die injmj. Hie nature of die injury was well marked. The patient being ptaced upon a table, extension was made by poHies for fifty minutes without
»
He was then placed in the warm loath for twenty minutes, after which the ex- tension was repeated for a quarter of an hour, but stiil without the desired efteet. He was then bled to the amount of twenty-four tmnces, and he took forty drops of tincture of Opium, but as this did not create faintness, the solution of tartar emetic was exhibited in small and frequent doses ; this soon produced nausea and faintness, during which a steady extension for ten minutes accomplished the reduction.
Mr. Nott, of CoUumpton, Devon, sent me the following particulars ; —
John Lee, aged thirty-three, a very stout caie. ^laan, dislocated his left hip by a fall, Octo- .(ber9, 1819, but was not seen by Mr. Nott iintil the 4th of December following, just «ght weeks after the accident, the effects of which still remained, exhibiting distinctly the usual appearances. The bandages and pullies being applied, extension was gra- dually made, and at the time of its com- mencement, the solution of tartar emetic was fcpven him, and repeated every ten minutes, ^teut without creating much nausea. The ex- tension still being continued, he was bled to the extent of sixty ounces, but without producing syncope. The extension was kept pup for two hours, when an evident alteration 2 a 2
372
•js •^.'T.vL'Cible in the injured limb; the ...a; •! :iie bone was elevated by means of a >. iwr* titiier the upper part of the thighs and •IV iinb was rotated ; soon after this period . ^Ttiau^ ^"us heard from the situation of the x^HiK ot' the bone, and the man immediately , \c* aimed that the limb was reduced ; and tiiss on relaxing the pullies, we found to be ^»rtvcC : before removing him to bed his legs >»tMX' bound firmly together to prevent any tviirrence of the displacement, and a large >iisterwas applied over the trochanter. When io wus first allowed to rise from his bed, a Xiitduiro was applied upon the thigh and |K*lvis ; passive motion was previously em- ployed. In five weeks after the reduction he walked noarlv twenty miles without incon- ^euionoo.
Tho above case shews that the reduction nuw Ih^ ofiected bv skilful mana^fement a 0\M\siderable time after the receipt of the uyiury. And this is fiirther confirmed by OAsos rolaicni by >Ir. Mayo, and Mr. Tripe, of Plymouth, in each of which the disloca- tions hftii oxisiod seven weeks before the \xsluotiov.s were accomplished,
Tho t>"\^M i-.ic eases prove that this dislo- %';Uior, r..;\> ■>;' ;v:^'.Avv\i w.thout the use o \\\x' ]K,\.w<, >\\\ a: :he s:"u:\e ume shew how il% vua^;^^ ;lv:: r.ss,sr<v.:oe would have been.
Holt of Tottenham requested me to c visit, with him, Mr. Piper, aged twenty-five years, who was the subject of dislocation of the thigh upon the dorsum of the ilium, but which had existed a month previous to his coming under the care of Mr. Holt. Mr. Holt and myself, assisted by five powerful men, used our utmost exertions to replace the bone, and we were several times obliged, from fatigue, to relax, and renew our at- Htempts. After repeated trials, for fifty-two Hiiinutes, we succeeded in effecting the re- duction, when we had determined to make but one more effort.
Another case, which I attended with Mr. case. Dyson of Fore-street, was reduced without be use of pullies, but with so much violence, nd such unequal extension, that I am sure i surgeon, who had seen the puUies em- ibloyed in reducing this form of dislocation, ould have recourse to any other method. Mr. Oldnow, of Nottingham, sent me the Cnsc. irticulars of a case in which the reduction iras effected without the assistance of pullies, "but in which an extension was made from the ankle, the pelvis being secured by tow- els. The dislocation was recent, and the t reduction easy. L. '
374
Dislocation doumwards, or into the Foramen
Ovale.
Signs of The displacement of the head of thermos femoris into the obturator foramen, ooca^ sions an immediate lengthening of the lioib, to the extent generally of two inches. The projection of the trochanter major is lessened, and the body is bent forwards from the stretching of the iliacus internus and psoas muscles. When the patient is erect the knee of the injured limb projeete fiN^ wards, and the thigh is widely separated from the sound one from the action of the glutei and pyriformis muscles, and it cannot be made to touch the knee of the perfect extremity without great violence. The foot is also widely separated from the other, but the toes are not either everted or inverted, but are usually directed forwards. In very thin subjects, the head of the bone may be felt, by firmly pressing the fingers upon the inner and upper part of the thigh, towards the perineum.
The chief diagnostic marks are, therefore, the increased length of the limb, the separa- tion of the legs, and the bent position of the bodv.
375
The head of the bone is thrown below, and situation of Hither anterior to the axis of the acetabulum ; 9mA a depression exists below Poupart's liga- ment.
,erThe dislocation is produced by a fall or Cause. Jbiw when the legs are much parted from other, mischief occasioned by this injury is Dissection ely well shewn by a preparation in ^'
Museum of St. Thomas's Hospital which cted many years ago* The head of the is rested in the foramen ovale,^ which tirely filled by bone, the external obtu- muscle and the ligament, naturally oc- lying this space, being absorbed ; bony er had been also extensively deposited iftbund the edge of the foramen, so as to form iMleep socket, which enclosed the head of At bone, so that it could not be removed mithout breaking the cup, but still allowing inconsiderable motion ; the interior of this locket was perfectly smooth. The acetabu- lum waB half filled with ossific matter* and Sefinuch altered as not to be capable of con-^ kttming the head of the thigh bone, which wa& but little changed, its articular cartilage still r^xiaining perfect. The ligamentum teres was eMupletely torn through, and the capsular li^ment partially lacerated. The pectinalis and adductor brevis muscles had been torn,
2 B 4
'»
.'it i3C iJLXcri by tendon, the psoas, ^ -i» czsTJos, and py riformis muscles,
1: rfc :»=^n «;ipposed that the ligamenturo -.r^e? "»Ti z*:z lacerated in this dislocation, I :h.e dead subject, the head of the ':•: ir:iwn over the lower edge of cin. if the capsular ligament be ^T-cei -^i^*: the round ligament remains jurtLTSC. but as the dislocation occurs wit I nc tiiirhs are wide apart, and the :^;;^n:e-^: j? uroa the stretch, when the head ■: .He bcct' :5 thrown from the acetabulum .>: ii^ace'c: is torn through before the dislo- rXLXii :> sXiaplete.
1 1 t^lc^^c; cases the reduction of this dislo-
,-icoiz :v.dy be easily accomplished by the
i»uc«-.n^ uieans. The patient being placed
ipt^a ijs back, and his thighs being sepa-
twvc 1^ widely as possible, pass a girt be-
-%cci :i< upi^er part of the injured limb and
V .^««icc^twtti ^ and let the ends be fixed to
i >.;3i,s.^c iti the wall of the room ; then grasp
■V .i *.i''C of the dislocated extremity, and
j:iw ;.w luub over the sound one, and thus
.'K' N\tvl of ihe bone will slip into its proper
^ o ;\ ri.uinsr the patient upon a bed, so
.>.i, .'its oi :':*.c beii-iM>sts is received between
v \;: : v^i" the thighs, and then forcing
vo *.:tib across the sound one, will
» ». •»
also effect the same purpose. Homeiunes, liowever, it will be found necessary to place a second girt or bandage round the pelvis beneath that which I have already described, and the ends of this second girt should be fixed to a hook or staple on the sound side of the patient, to prevent any lateral motion of the pelvis at the time that the injured extre- mity is drawn across the sound limb, other- wise the motion of the pelvis following that of the limb may prevent the reduction.
Should the dislocation have existed for ofiong
three or four weeks before any attempt is "^•'■"b-
tDade to reduce it, the patient should be
placed upon the sound side, and his pelvis
fixed by one bandage, whilst another is
placed under the upper part of the dislocated
thigh, and connected to the pullies above so
as to act perpendicularly ; the surgeon should
then press upon the knee and leg to prevent
I their being drawn up with the superior por-
! tion of the thigh bone, at the same time that
an assistant elevates this latter part, by draw-
, ing the cord attached to the pullies. Great
J care must be taken not to press the leg and
( knee too much, or the head of the femur will
I be forced backwards into the ischiatic notch, p the power of the lever which is employed iP'TCry great.
Ligaroentiiiu teres torn.
Rcdiictioii if recent.
but lia< '
iliacus were a It]) teres becar boiK
.* .=r •» .".aiinunicated to
tlu* i\h 111 \\
I
c itty, received an _• I ynsequence of a fall . . jBeavnunng to stop the .jm. -m tsnj with him. Be- ^is after the acci- X -Wfir, in Essex, was lacencand Mr. DanieU r Jlr. Potter at the time, Tj *t; rie case. HI! oiiizjed limb, it was ^^ . T rnsf jnriits longer than the
separated, and
itru; ccrward; when the
csflBrsyvan!^ 11 scuid. his body was
Hti 3i:?iry being thus ex- 1115 i:ujwing means were I .rtcct iiif »iuction of the dislo- Itfe *auKSC JtfTTu: n?bust, some blood 3Af£ met iifi inn. but as this did .,utt:^ TMU« lis powers, a solution -ir -attic "%:» iCtTen to him. He ^dL-»A M US a4ce, near to the edge i2» . tM. ^^ - -^ >triii^ passed round his •ssa- .u'T'--'"* m^'-iiii the frame of the ^,^ rr.cc. s: IS to prevent any :^ ^ii'- . 1 >econd girt was
.f<el%«
n
^/
379
Miised between the thighs^ and §xed to be pullies above the upper part of theinr pred limb. Whilst the ext^sion was making Mkv Potter rotated the limb^ and drew the lltoe towards that on the sound side. When iuf$e means had been continued for ibmit Ml minutes, the effects of the tartar emetic became excessive, and in five mmutes after-' rtifds the head of the bone returned to its original socket with a snap ; the patient Mraa Hw placed in bed, and the injured parts l^pported by a roller. He speedily recovered tihtuse<tf his limb.
-i: ■ ■ . .: .
^riOfthe Dislocation backwards, or into the :•
Ischiatic Notch.
'fdn?. describing this dislocation, some'sur- common
. . . description
pmm have considered the head of the os wrong. Anoris as being thrown backwards and downr Urnds ; ' which must have arisen from their Ubiscollecting the natural position of the os itiKiminatam in the skeleton. This notch ^ikkik gives passage ^to the pyriformis muscle, liA^o to the gluteal, ischiatic and internal pudental arteries, with the sciatic nerve, is Manrally situated a little above, as well as Itttiiiid the acetabulum, so that the head of ^ thigh bone when displaced into this
380
SitoatioB of bone.
Difficult to detect.
space, is placed upwards as well as back- wards, with respect to the acetabulum ; and this you must carefully bear in mind.
The head of the os femoris in this disloca- tion is situated on the pyriformis musch^ between the edge of the bone which fionns the upper part of the ischiatic notch, and did sacro sciatic ligaments. i
Of all the dislocations of the thigh, this k the most difficult to detect, because the length of the limb is but little altered, and the chan^ in the position of the knee and foot is not no marked as in the dislocation upwards. It is also more difficult of reduction because the head of the bone is placed deeply behind the acetabulum, and requures to be lifted OYtf the edge, as well as drawn towards it. signi of. The dislocation is marked by the following signs : — ^The limb is from half an inch 4x> one inch shorter than the sound one^ but rarety more than half an inch. The natural piO|6e^ tion formed by the trochanter major is di- minished, and is inclined towards the ace- tabulum, but still remains at right an^ with the ilium. The head of the bone' csi only be felt in very thin persons^ and then not very distinctly. The knee and foot are turned inwards, and the great toe rests against the ball of the great toe of the sound limb. When the patient is erect the toe touches the
]
381
ground^ but the heel does not quite reach it, and the knee is bent and projects a little for- wards. The motions of the joint are in a great degree prevented, admitting but of flight flexion and rotation.
f There is in the collection at St. Thomas's DisMcUooof Hosfutal, an excellent specimen of this injury, which I met with accidentally in the dissect- kig room. The original acetabulum is en- tirely filled by a ligamentous substance, so that it could not have ^gSLin received the head of the femur ; the capsular ligament is torn anteriorly and posteriorly ; the round ligament ia torn through ; the head of the bone rests in tiie situation I have before described; but there is not any appearance of an endeavour to form a new socket for its reception. A oew capsular ligament surrounded the head <^- the bone, but it has been opened and tamed down to exhibit the head, with the lacerated portion of the ligamentum teres connected to it.
, This displacement occurs from the applica- Canse. tiou of violence when the thigh is bent at f^t angles with the body, so that the knee 18 forced inwards.
r The reduction, which is extremely difficult. Reduction. ia best effected in the following manner : — Place the patient on a table upon his sound side, and fix the pelvis by passing a girt
382
between the pudendum and inner part of the thigh, and making it fast to some firm point; then apply a wetted roller round the limb above the knee, and over it buckle the leather strap, and place a towel under the upper part of llie injured thigh. The extension should then be commenced with the aid of the puttie*^ so as to draw the dislocated thigh forwards iH a direction over the middle of the sound oiakO/ measuring from the pubes to the knee ; wheal this has been continued for a short time^ ad assistant should elevate the upper part <^ the bone, by drawing the towel with one httiMl> whilst he presses on the pelvis^ wiA flwi other ; and by this means he will lift the boti6 over the brim of the acetabulum. A round towel passed under the upper part of the thigh, and over the shoulders of the assista&t, wil allow him to employ more force for this puf-^ pose, by raising his body at the same time that he rests both hands upon the pelvis ^ the patient. - ^
Another I havc kuowu another method succeed in
" *' effecting a reduction of this dislocatiem, although the one I have described is the best. Case. A man, aged twenty-five, was admitted
into Guy's Hospital, under the care of Mr. Lucas, on account of a dislocation of his thigh backwards. An extension was made by
383
means of the puUies, drawing the limb in a line with the body, and at the same lime thrusting the trochanter major for^vards with the hand ; the redaction Svas accomplished in about two minutes.
The reduction is generally indicated by a s snap which takes place when the head of the hone returns into the acetabulum ; but when the muscles have been some time contracted, and when an extreme state of nausea has been produced by bleeding, and the tartar emetic, the reduction is not accompanied by any noise, as in the following case, the particulars of which were given to me by Mr. Worts, a dresser to Mr. Chandler, at St. Thomas's Hospital.
James Hodgson, aged thirty-eight, a strong muscular man, was admitted into St.Thomas's Hospital, on Tuesday, February 8, 1820; his left thigh being dislocated backwards. On account of the great swelling which ex- isted at the time of his admission, the nature of the injury was not considered sufficiently evident, and merely evaporating lotions were applied. On the i2th the patient was seen by Mr. Chandler and Mr. Cline, and the latter thought it a case of dislocation. On 14th Mr. Chandler requested me (Sir
sdey) to see the case, when I immediately ilared it to be a dislocation into the ischi-
384
atic notch, and directed that the man should be bled, as he suffered considerable pain, and the tension about the injured part was still very great. On Saturday the 19th, the pain and swelUng havmg subsided, means were employed to effect the reduction. After bleeding the patient largely, and giving him the tartar emetic, the bandages and puUies were applied as I have already directed, »id the extension conducted in. the same mannor. The extension was continued for about t^ minutes before any attempt was made to raise the head of the bone, but it was then tried^ and at the same time the limb was rotated by turning the knee outwards. After the expi- ration of a quarter of an hour, the appeannce of the hip became much altered, and of its natural shape; but as no snap had been heard, the same means were continued for twenty-five minutes longer, when, in conse- quence of the strap above the knee beccHning loose, the puUies were removed, and it was then discovered that the reduction was ac- complished; but' it had occurred widiout either the bye-standers or the patient being aware of it.
Of the Dislocation on the Pabes.
This is more readily detected than any i other of the dislocations of the thigh.
It generally happens by the foot slipping ( unexpectedly into some hollow, whilst a per- son is walking, the body being at the time bent backwards, so that the head of the os femoris escapes forwards.
The following signs usually indicate this s displacement ; the injured limb is an inch shorter than the sound one ; the knee and foot are turned outwards ; but what renders it so evident, is the readiness with which the head of the bone can be felt a little above the level of Poiipart's ligament, upon the pubes, on the outer side of the femoral artery and vein, it there forms a round hard swelling, which moves when the thigh is bent.
Although so easy to distinguish, yet 1 have p known three cases in which the injury has been overlooked, until too late to afford re- lief; this could only have arisen from great carelessness, or excessive ignorance.
A preparation from one of these neglected i
I cases, which I had an opportunity of dissect- ing, is preserved in the museum at St. Thomas's Hospital. It presents the following appearances: — The acetabulum is in jrart VOL. iir. 2 c
386
filled by a new deposit of bone» and is in part occupied by. the trochanter major, but both are very much altered. The capsular liga- ment is very extensively torn, and the liga- mentum t^res entirely divided. The head of the bone is placed on the pubea under Poupart's ligament, which has been thrust up by it ; the iliacus intemus and psoas magnl]^ muscles, are stretched over the neck of the bone, and upon them is the anterior crural nerve. Both the head and neck of the bone are flattened, and the latter rests in a new articular cavity formed for it upbn the pubes, above the level of which the head of the femur is situated. The edges of the new acetabulum project upon each side of the jieck of the bone, so as to confine it laterally, whilst Pouparfs ligament confines it upon the fore part. The femoral artery and vein pass close to the inner side of this cavity, for the cervix of the femur.
This injury might be mistaken for ^ fracture of the neck of the bone, but only through great carelessness and inattentipo. Redaction ijij^^ reduction of the dislocation may be
accomplished in the following way : — ^Place the patient upon a table on his sound side; then pass a girt between the pudendum and the upper and inner part of the injured limb, and fix this to a staple rather before the line
387
of the patient's body. The wetted roller, strap, buckles and puUies, should then be placed above the knee, as before described for other displacements. The extension is to be made backwards and downwards. The
I application of the towel at the upper part of he thigh, and lifting the head of the bone }ty it, over the edge of the acetabulum, is
pttlso necessary in reducing this form of dis- ■placement.
The following case, which will illustrate te mode of reduction, occurred under the u-e of Mr. Tyrrell, at St. Thomas's Hospital. Charles Pugh, aged fifty-five, was admitted c»se. hto St. Thomas's Hospital on the 23rd of January, 1823, with a dislocation of the right high, which had been produced by a blow tapon the back part of the thigh, from a cart Srheel, at the time he was making water at be corner of a street, and unprepared to lesist the violence. The head of the bone lould be distinctly felt below Poupart's liga-
Rlient, immediately to the outer side of the femoral vessels. The foot and knee were kimed outwards, with very little alteration the length of the limb. The thigh was tot flexed towards the abdomen, and was iearly immoveable, admitting only of slight ptiduction and adduction, also a little rotation utwards, but not at all inwards. It was
388
speedily reduced by the following means :— The patient was placed on his left side, a broad band was placed between his thighs, and being tied over the crista of the ilium on the right side, was made fast to a ring in the vrall. A wet roller having been put on above the right knee, a bandage was buckled over it, and its straps attached to the hooks of the puUies, by which a gradual extension was made, drawing the thi^h a little backwards and*dowhwards. When this extension had been kept up a short time, another bandage was applied round the upper part of the thigh, close to the perineum, by means of which the head of the bone was raised, and in the course of a few minutes the reduction was easily accomplished. The patient had not been bled nor taken any medicine; he suffered but little after reduction, and was able to walk without pain or inconvenience five or six days afterwards. ofA^S Pr^ni what I have observed respecting the Scation**" comparative frequency of the dislocation of the thigh, I should think the proportion in twenty cases -about as follows : — twelve on the dorsum ilii; five in the ischiatic notch ; two in the foramen ovale ; and one on the " pubes. Formerly Considering the frequent occurrence o^
over-look- , ^^ ^ ^ ^
^d. these dislocations, it is extraordinary tha.^
389
they should have escaped the obseirrations of former surgeons ; it can only be accounted for by the difficulties which existed in the pursuit of morbid anatomy. I was informed by Mr. Cline, that Mr. Sharpe, a surgeon of Ouy's Hospital^ possessing considerable emi- nence, and author of a " Treatise on Surgery," did not believe that these displacements ever took place.
There is great pleasure in contrasting the NowreadUy present state of professional information with '^**^"* • that which existed fifty years, ago. Our provincial surgeons now readily detect these injuries, and generally succeed in reducing them. Let us never, however, forget that it is to the knowledge of anatomy, and more especially, of morbid anatomy, that we are indebted for this superiority ; and therefore we should never neglect or lose an opportunity of pursuing our investigation on these points, if we wish to increase our reputations as surgeons, and practise our profession with credit. ?
Injuries liable to be mistaken for Dislocations
of the Hip.
Of Fractures of the Os Innominatum.
In these cases the application of the force
2 c 3
.^. itMQct: a dislocation, increases liM patients sufferings, and des- _«. .'iwiMibility of recovery, if any »^ cxfiited.
d iracture occurs of the os innomi-
.««itca extends through the acetabulum,
Of' the OS femoris is drawn upwards,
.^ lie sochanter major is turned a little
t%»iM\is; thus the leg is somewhat shortened,
^ :tM knee and foot are a little inverted,
-MAUOim^ the appearances produced by a
;d4iJv:;iCion into the ischiatic notch.
'kttea the sacro iliac junction is broken
tf^Mi(ca» and the pubes and ischium are
Kitur^» the limb is in a great degree
^;iiMieued ; but the position of the knee and
^Jwi is^ not altered.
Phc^c injuries do not affect the motions of '.^^ utp JK>iut so much as dislocations, and a vi^^(»itu$ can be felt if the limb be moved ^lUa the hand rests upon the crista of the tUum.
I haw* soon three cases of fracture of the o«L iuiK^minatum, somewhat resembling dis- IwsUK^ns, two in which the injury extended thunt);:h the acetabulum, and one in which ihsi oa\ ity remained uninjured ; the following^ .uv |M*nwi|\\l features of these cases.
lu the vear 1791. a man was admitted into ^1 ritxMuas s Hospital, on whom a hogsheac^
391
of sugar had fallen. When examined, his right leg and foot were found inverted, and the limb appeared shorter than the left, by itwo inches. Whilst making a gentle exten- sion to endeavour to bring the injured limb to an equallength with the perfect extremity, 1 crepitus was discovered in the os innomi- Batum. The patient was exceedingly pallid, kds muscular power extremely feeble, and he appeared rapidly sinking. He expired the same evening. The following appearances presented themselves when the body was examined : — The deep part of the acetabulum was broken off, so as to allow of the escape ■of the head of the thigh bone from the cavity ; iie neck of the bone was firmly embraced by the tendon of the obturator internus, and by tdie gemini; the junction of the piibes at the [symphysis had been separated, and the bones Were nearly an inch apart ; the ilium, ischium ind pubes were fractured, and the fracture extended through the acetabulum ; the left , kidney was much injured, and about a pint •ef blood was found extravasated into the cavity jof the abdomen.
In the second case, which also was in St. ^ ^Thomas's Hospital, the appearances of a dis- location backwards existed. The patient "died upon the fourth day after the receipt of tthe injury; and on examination after death, 2 c 4
3J>2
xicture of the innominatum was through the acetabulum
anmae it into three parts ; the head of
deeply sunk into the cavity
in which the acetabulum into Guy's Hospital in If 17, August the 8th. Mary rT!'ffc:is. £»£ ciirty, had her pelvis caught ncTT'S'si L :an wheel and a post; — when ioziiiei. jijsz lie hospital, she was pale, t=*ii«s. ant iiff aeces passed off involuntarily. Jn rreciinr 3:^2 right os innominatum a dis- liR^r: inicau'a izc crepitus could be perceived, jia 51*5 TOsCserjor superior spinous process miiiic:^^ 3ivDci above its natural situation. ■?*:^ i%u>K iff^^eared driven in towards the
UV^w^ ^
£ upon the right side below the j;as. -^iJ. rfce pelvis was fixed by a broad .\u4UUi^. jasi ^"^^ opium was administered. SK: i«w: 3acl ihe evening of the 24th, and ^^>•v^wx•^ *-<* *5ttk ttom the effects of a large >ivv^«i, >»-ju.ca rbrmed over the seat of extra- .-.^iUJWii j^vu che right side.
!V >vcy ^-as inspected the next day,
t ivi -la ^.v:vu^ve fracture was found extend-
., .:t»ci*$;a :bo body of the pubes and the
,..x»v*x A VIC :5?v.'hium on the left side; the
^.\ .liiiu ^ j;.?^ ^^^'t^rated from the sacrum at
393
the sacro iliac symphysis, witli a portion of the transverse processes of the sacrum which were torn from the sacrum with the ligaments ; the left sacro iliac junction had also given way, but only to a sufficient extent to admit the narrow extremity of the handle of the scalpel between the bones.
I have known several cases of simple fracture of the innominatum recover.
Of Fractures at the upper part of the Thigh
Bane.
^ •
. These injuries have been frequently mis- Mistaken
. . . ♦ ^ "^ , for dtsloca-
taken for dislocations of the hip, and the dis- tion. tinguishing marks are sometimes with diffi- culty detected.
Three species of fracture differing in their Three nature and result^and requiring distinct modes *p®*^®* of treatment, are met with at the upper part of the femur, and have been generally classed uider the indiscriminate appellation of frac*- tare of the cervix femoris. Want of proper anatomical investigation by dissection, has given rise to this confused classification, and ias led to the disputes respecting the pro- cesses which nature employs to effect a cure. , Thus one surgeon declares that they cannot ^ united, whilst another asserts that the
394
eure is as easily performed as in fractures of other bones;
The opinions I am about to offer to you, are the result of extensive observation on fki living, who have suffered from tiiese injuries; of numerous examinations of the <]bad body ; and of many experiments which I have i^er** formed upon inferior animals. ^ent*ac. Thcsc accidents are of such frequent oc- corrence. curreuce^ that the wards of our hospitals arc seldom without an example of them ; whilst scarcely two cases of dislocation happen th^« in* the course of the year, although the build* ings contain about nine hundred patients.
The different species of injury are as follow: —
First. — ^That which takes place through the neck of the bone entirely within the cap- sular ligament.
Secondly. — ^A fracture through the neck of the thigh bone at its junction with the tro- chanter major, external to the capsular liga- ment.
Thirdly. — Fracture through the trochanter major, beyond the cervix femoris.
Of Fracture of the Neck of the Thigh Bone within the Capsular ligament.
Ymb^sklv' "^^^ following appearances are usually pro-
t«<icd.
39$
duced by this fracture : — ^the limb becomes shortened one or two inches ; this arises from the connection between the head of the bone Itnd the trochanter major being destroyed^ so that the latter loses its support and is drawn lip by the action of the glutei muscles, as far as the capsular ligament will admit of; and it therefore rests upon the edge of the aceta- bulum, and a little upon the ilium above it. This difference in length is readily detected by placing the patient in a recumbent posture <uid comparing the situation of the malleoli ; the heel of the injured extremity is usually found resting in the hollow between the in- ternal malleolus and the tendo achillis of the sound limb ; but this is not always the case. For a short period after the receipt of the injury, this shortening may be made to dis- appear by a very slight extension of the limb, but it again reappears immediately that the extension is discontinued. This may be again and again effected, until the muscles acquire a fixed contraction, which cannot be subdued but by very great force.
Another indication of this accident is the limb eversion of the knee and foot, from the action of the powerful and numerous rotators out- wards, which have but very feeble opponents ; the obturatores, the gemini, the pyriformis, the quadratus,. the gluteus maximus, the
W«4 ,*%<^^
■I •! 1
».s »
and the triceps, all assist in the 01 the limb outwards ; whilst only a lie glmeos mediuSy with the minimus ma. ciie tensor Tagins femoris act as antago- nnscies^ or rotators inwards. The ever- ts ;iQme considered as depending on Qi the limb, and not upon the coatraction; but the resistance ay the rotators outwards, when an tux » made to turn the limb inwards, >ux&ciea4aT proTe the true cause of the ever- Ufae inrersion is also in some degree by that portion of the neck which :«»mim^ ^mached to the trochanter major, tfiL wojadbi nests against the ilium.
(^ jOMtming of the limb, and the ever- ^Qiit v/£ tfte knee and foot, are the two princi- 4^ TnsiriK^ which attract the attention of the
WliBea the femur is dislocated upwards, si^vr^^^M ol"^ the knee and foot is prevented by tilicr iifMii sum! neck of the bone ; but the sepa« t<iC«w v^^ these from the trochanter in the case v^i if^KCucw allows of a ready eversion. I i%t^v itt\>wa the limb inverted in a case of ii ;jfcvHUjrv ot the cervix femoris, but this must sV :VK^^ ^^ ^^ extremely rare circum-
tUv uAiur^* of this injury is not well marked '/., u\H\\ >v*iuc few hours after the receipt of the
injury, as the muscles do not acquire a fixed contraction for some time ; it is firom this cir- cumstance that the injury has been mistaken for dislocation, and that the patients, even in the large hospitals, have been submitted to useless and painful attempts to reduce the displacement.
After the receipt of this injury, the patient ^"^^.^ ^^ suffers little or no pain whilst at rest in the recumbent posture, but rotation of the limb, more particularly inwards, creates much suffering from the fractured end of the bone rubbing upon the synovial membrane, which lines the capsular ligament. The pain is most acutely felt at the upper and inner part of the thigh, near the insertion of the psoas and iliacus internus muscles, into the tro- chanter minor.
The limb can be moved in all directions, but the flexion creates pain, and is accom- plished with difficulty, particularly if the thigh be directed towards the pubes ; if the knee be carried outwards when the thigh is flexed it is accomplished with more ease, and without producing much pain.
The trochanter major of the injured side Trachanter
major pro-
projects less than that of the sound side, as jectsiess. it has lost the support of the neck ; it is also drawn up towards the ilium, and is therefore higher than that of the perfect limb.
398
Patient
examined
erect.
Pain on standing.
Crepitnt.
Most fre- (juent in females.
In old age.
To be perfectly satisfied of the nature of the injury, the patient should be examined in the erect as well as in the recumbent posture; he should be made to stand, which he can do with assistance, and endeavour to bear his weight upon the sound extremity when the shortening of the injured limb is distinctly seen, the knee and foot are everted, and &t prominence of the hip is lessened.
In attempting to rest upon the nni^nmd limb, the patient experiences great painincon- sequence of the stretching of the psoas, iliacus intemus and obturator externus muscles, as well as by the pressure of the fractured portion of the cervix upon the capsulur ligament.
The fracture is not indicated by a crepitus on motion whilst the patient is recumbdnt, as in other fractures, but it can generally be felt, when the limb is extended to the original length and then rotated; the crepitus may sometimes be discovered on the mere elonga- tion of the extremity, but it is most distinct if it be turned inwards.
Females are more liable to this accident than males, which may be accounted for by the powers of the constitution being generally weaker, and the natural position of the neck of the thigh bone more horizontal.
The period of life at which this injury oc- curs, is another circumstance worthy of con-
sideration, as it seldom takes place but ai'fia advanced period of life. We find it described as happening in young persons, but in these cases tlie injury has not been really confined to the cervix within the capsular ligament, and thus so much confusion has arisen with respect to the true character of the accident. During a period of forty years, for which I have attended St. Thomas's and Guy's Hos- pitals, and in my private practice, which has been more than my share, I have seen be- tween two and three hundred cases of fracture of the cervix femoris, within the capsular ligament ; yet in very few instances have I known it take place in persons under the age of fifty years. It is most frequently met with between the ages of fifty and eighty, at a time of life when dislocation very rarely takes place. I have, however, seen a case of the iScture at the age of thirty-eight, and a case of dislocation at sixty-two.
The liability to the different forms of injury Rpa at the different periods of life, is owing to the changes which are taking place in the bones as well as in the other structures of the body, according to the balance of the arterial
Eibsorbent systems ; during youth the I of the former preponderates, and hence lurce of growth ; in middle age the two rve an equilibrium of action, and thus
400
but little alteration occurs ; in old age the absorbents exceed in activity the arteries, from which a diminution arises, but tins is rather from a disease of power in the arteries than an increase in the absorbents.
Change in Thus the iucreasc of the bones takes place in youth, until they acquire that bulk, weight, and compactness which characterises them at the adult period, and which they for some time retain, until they become gradually light and soft in the advanced period of life : even the neck of the thigh bone undergoes a con- siderable change from an interstitial absorp- tion, by which it becomes shortened, and dtoed m iu angle with the .haft .f the b<»e, the head often sinking beneath the level: of the trochanter major, instead of being above it. This alteration gives the idea, upon a superficial inspection, of there having been formerly a fracture which had united.
Period of The pcrfod at which these alterations take
change *
varies. placc. Vary in different individuals, as we find the general appearances do, which in- dicate old age, and which are as strongly marked in some at sixty, as in others at eighty years of age.
It is from these changes, however, that the nature of injury varies generally at the differ- ent periods of life, as from the different states of the bones, that violence which would
401
n-oduce dislocation in the adult, occasions fracture in the old person ; and when dislo- cation does occur at an advanced period of life,it is in those persons who have particularly strong constitutions, and in whom the bones have not undergone the changes I have described.
The very slight causes which often occasion Caaiet vnj fracture of the bones in old persons, is a proof how much this altered state predisposes I
to such injury. The most frequent cause of the fracture of the neck of the thigh-bone, in London, is a sudden slip from the foot to the carriage pavement; which, although only a fall of a few inches, yet it is suihcient to produce this serious accident. It is also often occasioned by a slight fall upon the tchanter major; and I have known it pro- ced by the toe catching in the carpet, or linst some projection in the floor, at the lie that the body was suddenly turned to side. It is particularly necessary to loUect the very slight causes which give rise s injury, and to be on your guard respect- ' it, otherwise it could hardly be supposed bt an accident of so serious a nature could kso easily produced. Vith respect to the mode in which these opii «tures of the neck of the thigh bone vnthin oi [ capsular ligament unite, much difference I vol-. III. 2 i>
A
402
of opinion exists; it is asserted by some surgeons, that these fractures imite like those occurring in the other bones of the body ; but from the numerous dissections which I have had an opportunity of performing in these cases, I firmly believe that, as a ge- neral rule, the transverse fracture of the cer- vix within the capsule does not unite by bcme; such is the opinion I have delivered in my lectures for these thurty years, and which has been from year to year strengthened by fur- ther observations and fresh dissections. Win! of In all the examinations which I have made nyMnon. ^^ these cases, I have seen but one in which a bony union had followed a transverse frac- ture of the neck of the bone within the cap- sular ligament. I do not, however, mean to deny the possibility of a bony union, or to maintain that it cannot take place, but it is an exceedingly rare circumstance. Con- sidering the various modes in which a frac- ture may take place, the degree of violence which may occasion it, and die extent of mis^ chief to the surrounding parts, which may accompany it, it would be presumptuous in any one to maintain the impossibility of a bony junction; the bone may be broken without the fractured ends being separated frt^m each other, or without any laceration or it» )>erio$t^um» or the reflected ligament
403
Blch covers its neck ; and again, the frac- f be in part within, and in part without the capsular ligament; under this latter circumstance, I well know that an ossific union might be produced; and I have had the opportunity of seeing more than one.
I shall now point out several circumstances c irfiich in my opinion tend to prevent an b ossific union afler a transverse fracture of the neck of the thigh bone within the capsular ligament.
In the first place, a want of proper apposi- y tion of the fractured extremities of the bone " may in many cases have considerable effect in preventing the union by ossific matter, as we find that a proper junction does not take, place between the broken portions of bone, in any part of the body, when the extremities are much separated from each other.
In the case of a boy, from whom a portion c of the tibia was removed in consequence of its protruding from compound fracture, but in whom the fibula remained uninjured, so that the ends of the divided tibia could not he brought into contact, no bony union took
A case somewhat similar occurred in the c kistol Infirmary, under the care of Mr. inith'J A portion of diseased tibia, between 2 o 2
404
two and three inches in length was rembved, leaving a space to that extent between the ends of the bone ; and six weeks after tiie operation the boy was able to walk about without much difficulty, and it was supposed the ossific union had taken place; but in consequence of his death 'from small pox, sm opportunity occurred of examining the limb, when the larger part of the former space was found to be occupied by a thin ligamentous substance, without any bony deposit.
Experi- This is also confirmed by experiments which I have made on other animals. I took out a portion of the radius of a rabbit measur- ing seven-eights of an inch in length, after which the ends of the bone did not unite to each other, but formed connections to 'the ylna; in a second experiment, I removed a portion of the radius from another rabbit, measuriDg only one-ninth part of in inch, : but with the same result. Also a portion' of the OS calcis being separated and dr&M^ above its natural situation by the action €i the gastrocnemius muscle, only united by ligament.
Motion of In the fracture of the cervix femoris it is
^^'^' extremely difficult to keep the limb in a
. . proper and steady position, as the most
trifling change in position produces ' some
motion of the part from the contraction of
406
the powerful muscles which pass from the pelvis to the thigh. Were this, however, the only difficulty, it might possibly with much care and attention, be in a great mea- sure obviated.
Even in those cases in which the length of want of the limb is properly preserved, another cir- presBure. cumstance I conceive may operate to prevent the bony union, which is the want of pressure of one portion of bone upon the other, when the capsular ligament remains entire. This arises from the secretion of a large quantity of synovial fluid into the capsule, which dis- tends the ligament, and prevents the proper contact of the broken bones. After the inflammatory process has subsided, and the eEFusion of ligamentous matter has taken place from the synovial membrane, then this fluid becomes absorbed.
In other fractures where the bones are HoiT, surrounded by muscles, the broken extremi- ties are kept pressed together by the action of these muscles ; but in the fracture taking place through the neck of the thigh bone, the muscles can only act upon one portion, and that in such a way as tends to separate one from the other.
That pressure is essential to the bony Preisnre
. , eueDtiaL
union, IS proved by the exammation oi those
t:ase5 in which the fractured ends of the bone
2 D 3
tion.
406
overlap each other, when a proper osi^fle deposit is found on that side where they press upon each other; whilst on the o^osite sides, where no pressure exists, scarcely any alteration can be perceived. Again, in those cases where the actions of the nmsdes sepa- rate the fractured ends of a bone, as we frequently find, union does not take place until the surgeon plrodUdes the necessary pressure by artificial means ; as by the appli- cation of a belt, which buckles tightly round the limb. Deficiency A third circumstauce, however, tends prift- cipally to explain the want of bony union; in these cases, it is the deficiency of ossific inflammation in the head of the bone» wiiieii separated from the cervix; it iiS then only supported by the vessels passing, firom the ligamentum teres, which are minute add few in number. In the perfect state^ the head and neck of the femur are chiefly sopptkd with blood by the vessels of the cmioelli of the cervix, and by those of the reflected membrane which covers it. If, therefore, in cases of fracture the reflected membrane be torn through, which it generally will be, the chief source of supply to the head of the bone, and that portion of the neck con- nected with it, is cut off*, and there is not sufficient organic power remaining to pro-
407
uce ossitic matter ; thus we 6nd that ' icarcely any change takes place in the head the bone, similar to that occurring in [iDther bones when fractured ; there is merely jlayer of ligamentous substance thrown out, I covering the surface of the cancellated tcture.
On examining these injuries by dissection, we usually find the following appearances : — The head of the bone remains in the aceta- ulum connected by the ligamentum teres, fhere are upon the head of the bone, very . white spots, covered by the articular itilage. The cervix is sometimes broken irectly transversely, at others with obliquity. he cancellated structure of the broken sur- ce of the head of the bone, and of the ervix, is hollowed by the occasional pressure F the neck, attached to the trochanter, and cnsequent absorption ; and this surface is pmetimes coated partially with a ligamentous leposit. The cancelli are rendered firm and smooth by friction, as we see in other bones which rub upon each other when their articular cartilages are absorbed, giving the surface the appearance of ivory. Portions of . the head of the bone are broken off, and these |(are found either attached by means of liga- ment, or floating loosely in the joint, covered hy a ligamentous matter ; but these pieces 2 P 4
408
do not act as extraneous bodies, so as to excite inflammation, and thus produce their discharge ; not more than those loose portions of bone covered by cartilage, which are found so frequently in the knee, and sometimes in the hip and elbow joints. With respect to the neck of the bone which remains attached . to the trochanter major, the most remarkable cii'cumstance is, that it is in a great degree absorbed, but a small portion of it remain- ing; its surface is yellow, and bearing t&e character of ivory, if the bones have rubbed against each other. Some bssific depost- tion I have seen manifested around this small remaining part of the neck of the bone; and upon the trochanter major, and thigh- bone below it, in some examples of this fracture. ..-..rj
li^mllt '^^^ capsular ligament, enclosing the head thickened, and ncck of the bone, becomes much thicker than natural; but the synovial membrane undergoes the greatest change from inflam* mation, being very much thickened, not only upon the capsular ligament, but also upon the reflected portion of that ligament upoii the neck of the bone, as far as the edge of the fracture. Increase Within the articulation, a large quantity of
of synovia. , . . •
serous synovia is found; by which term I mean to express, that the synovia is less
40fe' -
fntilaginous, and contains mofe serum th&h usual ; this fluid by distending the ligament, separates for a time one portion of bone from the other ; it is produced by the inflammatory process, and becomes absorbed when the irritation in the part subsides. I do not know the exact period at which this change takes place, but I have seen it in the recent state of the injury. Into this fluid is poured a quantity of ligamentous matter, by the adhesive inflammation excited in the synovial membrane, and flakes of it are found pro- ceeding from its internal surface, uniting it to the edge of the head of the bone. Thus the cavity of the joint becomes distended, in part by an increased secretion of synovia, and in part by the solid eff'usion which the adhesive inflammation produces ; the membrane re- flected on the cervix femoris is sometimes separated from the fractured portions, so as to form a band from the fractured edge of the cervix to that of the head of the bone; bands also of ligamentous matter pass from the cancellated structure of the cervix to that of the head of the bone, serving to unite, by this flexible material, the one broken portion of bone with the other.
The trochanter is drawn up more or less in Ossificde- different accidents; and in those cases in !'i"rh(>"y which it has been very much elevated, 1 have boue.
410
knOwa a considerable osstfie deposit take place upon the body of the thigh bo]ie» be- tween the trochanter major and the trochan- ter minor. When the bone has been mace- rated, its head is much lighter and more spongy than in the healthy state, ej^ceptiiig on those parts most exposed to friction^ where it is rendered smooth by the attrition^ wiueh gives it a polished surface. In most It may therefore, be considered as. a g^Mral
cases no J' » o
oMific principle^ that ossific union is not prodiKsed in these cases; nature makes sonve cffiorto to effect it on that portion of the fracture attached to the body of the bone^ ■, but scarcely any upon the head and portion of the cervix separated with it. .
Notonw This want of ossific union does not appear
in the hip *^*
joint. to be merely confined to the firacture of the cervix femoris, but also occurs in the fractures of the condyles, of the os humeri and cwonoid process of the ulna, and other articular pro- cesses, when broken off entirely within the capsular ligament.
These opinions, which I have for many years delivered in my lectures, have been confirmed by many cases in which I have had an opportunity of dissecting the injured joint, and also by the result of the experiments which I have performed on other animals, and in which I found only a ligamentous
4U
union occur when the fracture was confined to within the capsular ligament.
The cases of fracture of the cervix femoris may be confounded with those dislocations of the hip in which the limb is shortened ; viz. those occurring on the dorsum ilii, the iftchiatic notch, and on the pubes ; the ever- sion of the knee and foot, with the greater mobility of the limb will distinguish them from the two former ; and in the latter in- stance, the readiness with which the head of the bone can be felt in the groin, renders the case sufficiently obvious.
They may be also confounded with the cases of fracture external to the capsular ligament; but if the surgeon be sufficiently attentive to the following points, he will readily distinguish the difference : — the age of the patient, the length of the limb, the cause of the injury, the feeling of crepitus, the great extravasation of blood, and the degree of suffering; for the fracture of the cervix, generally occurs at an advanced age ; the limb is shortened, the cause of the injury very slight, there is not any percep- tion of crepitus until the limb be elongated, and the degree of suffering is very trivial.
In the treatment of the fractures of the jw^^he thigh bone, within th^apsujar
Confound- ^^^^ cd with dis-
IdcationB.
With othcB^^H
{
412
ligament, I have tried numerous and variow means, to endeavour to effect a bony unkHH and I have known other sui^eons adopt many ingenious plans with the same view, but all without success. v. >
The double inclined plane has been em- ployed with numerous contrivances to. ke^ the injured limb extended, and to suj^rt the fracturied portions in contact^ also to fxre^ vent as much as possible, the motions of the pelvis. The straight position, wi& various modifications, has likewise been emiploy^; indeed, I scarcely know any form of mechat nical treatment which could be adopted, which has not been tried, for the purpose of aiding the bony union in these cases* I Imve not, however, yet witnessed one sin^e ex- ample of such a imion, which was not doubtful, as to its being entirely within the ligament. Case. In a convict at Sheemess, who could be
completely controlled, the limb was^pt steadily extended for six months, yet^ it united only by ligament.
I am aware that instances of success have been published ; but I cannot give credence to such cases, until I see that the authors are aware of the distinction between fractures within, and those without the capsular liga-
413
ment; and that they are likewise acquainted with those changes in the head and neck of the bone, which occur in advanced age.
Not having found or known any mode of treatment succeed in effecting an ossific union in these cases, and having repeatedly seen the patient's health much injured by the trials which have been made, all that I now direct to be done, is, that a pillow should be placed under the limb for its whole length, and a second rolled up, put under the knee, and that the limb should be allowed to remain upon these for ten days or a fortnight, until pain and inflammation have subsided ; the patient should then be allowed to rise and sit in a high chair, to prevent much flexion of the limb, which would be painful. In a few days more he should begin to walk with crutches, and after a time a stick should be substituted for the crutches, and in a few months he will be able to use the limb with- out any adventitious support ; when he com- mences to bear the weight of the body on the limb, he should be provided with a high heeled shoe, which will much assist him.
The period and degree of recovery in these
cases, depend much upon the bulk of the
patient ; as the very corpulent patient will,
for a long time, require the aid of crutches,
^D others less bulky, a stick only will be re-
Treatment
meDded,
414
quired; and in very spare persons such assistance is only necessary for a very short period ; but unless a shoe be worn having i sole sufficiently thick to remedy the diminish- ed length of the limb, the patient has a con- siderable degree of lameness. In doabt. Should any doubt exist as to the fractilre being situated external or internal to the cap* sular ligament, the case should be treated as for the former injury, which I shall presently describe, and in which ossific union majrbe^ procured. Aowtiaiu The surgeon should be very cautious in necMMry. the Opinion he gives respecting the result of these injuries, as when the fracture is tfaais-' verse, lameness is certain to follow * but in various degrees, which cannot at first be estimated.
In very aged and infirm persons, this acci- dent sometimes produces fatal consequences, from the exhausted state of the constitutioii, and from the coi^em^it in the attempts at unidi.
ikM.
JFWKsterer pf the Cervix to the Capsular L
wtijMijj H The symptoms produced by this injury, ' are» in many points, so similar to those
415
accompanying the former injury, that great attention is necessary to distinguish them. Such a distinction, is, however, highly im- portant, as the result differs so materially, an ossific union being readily produced when the injury is external to the capsular liga- ment ; whereas, in that which I have already described, such a union rarely, if ever, takes place.
When the fracture occurs external to the signsof. ligament, the injured limb is but little shorter than the other ; the foot and knee are everted, the rotundity of the hip is lost, and the patient experiences much pain at the hip, and about the upper and inner part of the thigh.
These marks are also found when the fracture takes place internal to the capsular ligament.
The following are the principle signs by puiingsirfi- which the nature of these injuries may be detected:— 1st. The fracture external to the capsule occurs frequently at an earlier period of life than that which takes place internal to the joint ; although I have known it produced after fifty years of age, yet it is usually found under that age. 2nd. The injury is generally occasioned by much greater violence, as by severe blows or falls, or the passage of laden Carriages over the pelvis, whereas the internal f^racture is tlie consequence usually of very
416
slight cause. 3rd. The crepitus in the frac- ture external to the ligament^ is readily felt when the limb is slightly movedf and gene- rally without drawing it down. 4th* The degree of suffering is much greater, especi- ally on moving the limb, if the injury be ex- ternal to the capsule, as the rough eztranily of the bone penetrates the suitonndi^ muscles ; the limb also is much more swoUeD, and the constitutional irritation is considerable. 5th. There is great extravasation of Uoed,. generally, in these cases.
DiMection Jq dissecting these cases, the fradxure is generally found at the root of the neck of the bone, external to the capsular ligament ; but its seat and extent varies very much in diffid- ent examples, and the degree of shortening of the limb, depends upon the form of the fracture, and upon the extent of laceration of the surrounding soft parts, so as to admit of retraction.
compu. Sometimes the fracture external to the capsular ligament, is complicated with injury of the trochanters.
Case. Mr. Travers has an excellent specimen of
this form of injury taken from a patient who was under his care in St. Thomas's Hospital. Richard Norton, aged sixty, was admitted into the Hospital on the 24th of January^ 1818, in consequence of severe injury of his
417
, occasioned by a fall upor fltone of the foot pavement. The limb of the injured side was shortened, and the knee and foot everted; the swelling about the hip was very great; the limb could be moved freely in all directions, but not without creating much suffering ; and when moved a crepitus could be distinctly felt in the situation of the trochanter major. When the swelling had iu great measure subsided, the limb was con- fined by the application of the long outer splint, and two thigh splints well bedded. In March the splints were removed, when the limb was found to be a little shortened, but the hip had regained its natural appear- ance. About a month after this, he began to use his limb, walking with the aid of crutches. He was afterwards placed under the care of the physician, on account of Iiis general healtli being defective, and he died suddenly, "being seized with spasms in his chest.
On examining the hip after his death, the DiMnciion. fracture was found to have extended through the trochanter, some way down the bone, and it had apparently united with very slight deformity, but on macerating the bone, the head and neck became loose on the body of the femur, they could not, how-
ter, be perfectly separated, as a shell of Z__
418
bone had formed, confining the head and cervix.
The preparation which Mr. Traverse was so kind as to send me, presents the folloW'^ ing appearances^ the head and cenrix of the bone had been separated from the tr(H chanter major and body of the femur. The upper part of the bone had been obliquely split, so as to receive the cervix into its cancelli. This fracture had divided the pos^ terior portion of the trochanter majw from the body of the thigh bone, and the tro^ chanter minor had been removed with it Union had taken place between* the Jfrac^ tured portions of the trochanter, at a slight ' distance from each other, and thus a holbw was left into which the cendx femoris was received, but it had not been united hf ossific deposit, as it became loose from the maceration. <
Mnoid- Mr^ Oldnow of Nottingham sent me two cases. specimens of this fracture, in which the necks of the bones were fractured at their junctions with the trochanter major. The trochanter major itself had been brok^i oC and the trochanter minor formed a distikict fracture. The bones had become re-united, the cervix femoris to the shaft of the bonCr and the trochanter minor a little higher than its natural attachment. The trochanter major
419
was in one specimen re-united to the body of the bone, but not in the other. Thus the thigh bone was at its upper part divided into four parts ; the head and neck of the bone formed one part ; the trochanter major a second ; the trochanter minor a third, and the body of the bone the fourth.
Thus this fracture unites by bone in a similar manner to the friicture of other bones external to the capsular ligaments, because the bones can be brought into apposition, and are confined together by the surround- ing muscles, and the nutrition of each ex- tremity of the bone is well supported by tile vessels which proceed to it from the surrounding parts.
This in some measure explains the dif- D'fferepce ference of opinion respecting the union of acooanted the fracture of the neck of the thigh bone. In the internal fracture, the bones are not applied to each other, and the nutrition of the head of the bone being imperfect, no •ssific deposit is produced ; but in the ex- ternal injury, the bones are held together by the pressure of the surrounding soft parts, and are easily kept in apposition by external bandages and splints. Generally a long period cateicu- is required to produce a perfect union in these cas^, and many months elapse before the patient acquires a free use of the limb. 2 E 2
420
/)
Fracture through the Trochanter Miffor.
Nttiire«f. ' An oblique fracture sometimes oc<^r8 tiirough the trochanter major, without anjf: injury to the cervix of the thigh bone.. Thift accident takes place at all periods of life, and its symptoms are as follow. <;
Signs of. The limb is but little shortened, and some^ times its length is not altered ; the .£dot i(i generally benumbed; the patient cannot turn himself in bed without , ass^tancei and any attempt to do so creates excessive pa^i.^ The portion of the trochanter coimected to: the shaft of the bone, is either drawn foir^^ wards towards the ilium, or it folia towards the tuberosity of the ischiuitn, being, in general, widely separated from the superior portion, or that which remains connected tio the neck of the bone. The foot is gr^tly everted, and the patient is unable to sit .oil account of the violent pain produced by^tiie position. From the separation of the frac^ tared extremities of the bone, crepitus* /can- not often be detected, unless the : limb be very freely moved.
^^' The eversion of the foot, and the altered
•igiM. position of the trochanter major, are the chief distinguishing marks of the injury.
Ossific union readily takes place in these "aite by cases, more quickly than in the fracture through the cervix feraoris, and the patient recovers a very good use of the limb.
The first case which I recollect seeing of Cwe. this injury, was about the year 1786, in St. Thomas's Hospital, under the care of Mr. Cline. The limb was extended over a pillow, rolled under the knee, and splints were applied on each side of the limb ; a firm union took place, and the man was able to walk extremely well. After being dis- missed from the hospital, he was attacked with fever, of which he died. On examin- uig the seat of injury after death, the frac- ture which had extended through the tro- dianter major, was found firmly united with ^tery little deformity.
^PThe following are the particulars of a ^iise which I attended with Mr. Harris, of Reading.
July 20th, 1821, Mr. B., aged 51, a gen- Ca.c. tleman residing about six miles from p.eading, fell from his horse, and injured his left hip; he got up immediately, and walked a few steps, but soon found that he was incapable of bringing his left leg forward, and he felt a severe pain in the hip. He was conveyed home in a cart, a distance of about four miles, and Mr. Harris visited him about 2 f. 3
J-J
422
two hours after the accident, when/ the fol« lowing circumstances were noticed. He could not discover any crepitus on rotating the limb ; it was of equal length with the sound one ; the foot was not turned inwards or outwards, and the patient could retain it in any position in which it was placed. A good deal of swelling existed about the hip, and Mr. B. complained of some pain; he could bear the limb to be moved without much increase of suffering, excepting whm the injured limb Was drawn across the sound one, when the pain was greatly augmented. Under these circumstances, Mr* Harris gave it as his opinion, that there was not either a fracture or a dislocation.
On the 22nd, Mr. Ring, of Readiiig, saw Mr. B. and on examining the limb, con-*' firmed the opinion of Mr. Harris.
The patient was kept at rest, knd leeches, with evaporating lotions, were employed to reduce the swelling of the hip.
On the 26th, an acute attack c^ hepa- titis, rendered active treatment necessary; and during this time, the limb remained much in the same state.
August 14. Mr. Ring again examined the limb, and whilst moving it, thought he felt a crepitus. On the following day, Mr. Harris also felt and heard the crepitus.
423
The case being, however, still obscure, Mr. Brodie was sent for; on his arrival, the particulars of the case were communicated to him, and he minutely examined the in- jured limb, but for some time was doubtful as to there being a fracture, until, upon ro- tating the limb very extensively, he distinctly felt the crepitus ; he was, however, much surprised to see, that the patient could, when standing, bear very considerably upon the injured limb, and he considered the case as very obscure, the usual symptoms of frac- ture, except the inability to move the lirab> being but little marked or entirely wanting.
Mr. Brodie applied a long splint, with a bandage from the toes to the hip, which he directed to be worn for a month ; and at the same time, ordered the limb to be kept per- fectly at rest.
But little alteration having taken place in the case at the end of the month, Sir Astley Cooper was requested to visit Mr. B. After hearing the history of the case, he proceeded to examine the limb. First, looking to the relative position of the ex- tremities, as the patient lay upon his back, he placed his hand under the trochanter major, which he found had dropped from its natural situation, and raising it toward the cervix, he readily detected the crepitus, 2 K 4
424
and agreed with Mr. Brodie, and Mr. Harris, as to the nature of thei injury, viz. a fracture of the cervix femoris, where it unites with the trochanter major.
The following plan of treatment was adopted by Sir Astley, with- a view of re-^ taining the trochanter in its proper position^ whilst the patient could remain perfectly at rest in the horizontal posture.
A mattress was made of horse hair, about five inches thick, very smooth, and this Was covered with a sheet. A part of the mattress was made to draw out on the oppo* site side to the fracture, so that when the natural evacuations took place, there still should be no motion of the body; before drawing out the piece of mattress, a board of two feet long, and six iaches wide, shaped like a wedge, was insinuated under the buttock of the right side, the twa ends of the board resting on the mattress, thereby preventing the nates from sinking, at all, into the opening, when the piece of mattress was removed> the board was of course taken away, when the portion of the mattress was replaced. Upon the bedstead, was first placed a thick smooth board, sufficiently large to cover the bottom of the bed, and on that was placed the mattress, thereby preventing any sinking by the weight of the body.
4M.
A bandage, made in the following manner, was applied to support the trochanter : — a broad web, sufficient to go round the body, over the hip, was furnished with two straps and buckles to fix it with, and the belt was made of a greater width at that part, which was to be placed under the injured trochan- ter ; the whole was lined with chamois lea- ther, and stiitfed ; a pad of the same leather was made, about six inches long, three broad, and three thick, gradually tapering to a point; this pad was placed immediately under the injured trochanter, so that when the bandage was buckled on, it passed into the hollow beneath that process, forcing it upwards and forwards into its natural posi- tion. Another thick pad, about eight inches square, of a wedged shape, was provided, and this was placed under the upper part of the thigh of the injured side, after the application of the bandage.
The patient was placed on his back, the
limb resting on the heel ; and to prevent
the possibihly of any motion of the foot,
and of the body, a wide board was fixed
to the bed posts, at the foot of the bed,
jffith two pieces of wood padded and fas-
kdtcoied to it, between these the foot was
^uecetved, and the least lateral motion pre-
^■nented. A cushion was placed between the
426
foot board, and the sole of the sound foot, so that by gentle pressure, the patient could prevent his body from slipping down in the bed«
This mode of treatment was steadily pur- sued for a month, without much inconYe«r nience or suffering to the patient ; the band*' age being from time to time tig^tened« Until the expiration of three weeks,, tlie patient said he could occasionally still fed the crepitus, but after that period, this sen^i sation entirely disappeared ; he complained of some pain in the direction of the ircH chanter, and the limb became somewhat aedematous.
Sir Astley Cooper again visited Mtm B* a little more than a month frmn his .first seeing him, when he was of opinion tibat union had begun, and directed a continuance of the same treatment, which was therefore persevered with for a further period of about ten weeks ; Sir Astley seeing the patient once in this time.
It was not until fourteen or fifteen weeks from the commencement of this treatmrat, that the bandage was removed for m(M than a few minutes, or that any material alteration was made in the plan. It was then taken ofi* for about two hours ; when the trochanter was found to retain its posi-
427
Bbj
lion, and from examinatioa of the ps considerable thickcoing could be discovered about the trochanter.
After this, Sir Astley desired that the bandage should be re-applied every day for an hour, and directed friction to the limb from the foot upwards. Mr. B. from this time, rose every day, and was soon ab!e» when supported by his crutches, to move his hip joint freely ; but the limb continued much swollen, and the motions of the knee joint were extremely limited. By steadily persevering with friction, and passive mo-i tion, Mr. B. has since obtained a free use of the extremity.
A peculiar form of fracture of the trochanter Fracture at 1 major, in which this process was separated at the part at which it is naturally united by cartilage as an epiphysis, occurred under the care of Mr. Key.
The patient, a girl about sixteen years of ca>e. age, fell in crossing the street, and struck her hip against the curb-stone. She rose directly, and walked home without much suffering or difficulty, but experiencing afterwards con- siderablepaiujShewas taken to Guy's Hospital on the sixth day after the accident. On ac- count of her constitutional symptoms being muchmore severe than those usually attending tjury to the hip, she was placed under the
42d
« Dn Bci^t, at whose request Mr. the limb, which he found ereited, and in s^pearance iaif aa inch longer than the sound : EC could be moved in all direc- cntt dbiisctkxi caused great pain; not jTcpitus Of displacement could be dis- tuid her having walked both before admission into the hospital, rxse CO a supposition that fracture did esse Her constitutional suffering ra- ittnm;sed, accompanied with general about the abdomen, and she died 4iK oiie ojttth day from the receipt of the jtiurv.
JLiKT indu Mr. Key first examined the ^t:tt oc mtanr externally, with attention, but sMuifti QiiH liiscover any deviation from the wGural state.
Ott ^jjipoeiug the capsule of the joint after- >iiiii:^a cavity vras discovered by the side vH cfate pectineus muscle, passing backwards 4jiiii downwards towards the trochanter utiii!i<;r» and containing some pus : it extended iKhiiui the bone to the large trochanter. v.hi cutting through the ligaments, and dis- LWiifcting the head of the bone, a fracture vkdi^ Ar^t perceived at the root of the tro- V a^AuMT major- This fracture had separated i;>c uwhauter from the neck and body of
429
the bone, without tli^ tendons attached to die outer side of the process having been mjured, so that a separation of the fractured pKNTtions could not take place^ on vrhich account. the nature, of the accident had hot been detected during the life of the patient. .
»•
: Of Fractures below the Trochanter.
> f -When tiie thigh bone is broken iust below Difficult to
^ *' manage.
ike .trochanter major and minor, much diffi- enlty exists in effecting a good union, and if the treatment be ill*managed, great defor^ mity is the consequence. The fractured extr^Qoity of the superior portion oi the boae. is drawn upwards and forwards by the action of the psoas, iliacus internus, and pectineus muscles, and any attempts by pressure to obviate this position of the bone, only increases the suffering of the patient, without effecting the desired purpose.
In the treatment of such a case, two prin- Treatment. dpal circumstances require attention: first, to elevate the knee, by placing the limb over a double inclined plane, and secondly, to raise the body so as to place the patient in nearly a sitting position ; the degree of ele- vation of the limb or of the body must de- pend on the approximation of the fractured
430
ends of the bone, and the surgeon must carefully ascertain that the proper relative position of each portion of the femur is restored, before he proceeds to apply the splints and bandages to retain them in this state. A strong leather belt lined with some
« soft material, and made to buckle round the
limb, answers better in these cases, than the common splints.
s^dmen ^ preparation in the museum at St.Thomas's Hospital exhibits the mode of union in db ill-treated case of this kind, and illustrate the necessity of careful attention to the points I haye mentioned, viz. : the relatxatioii of the psoas, iliacus intemus, &c. by elmt^ ing the body, and the raising of the inferior portion of bone to a line with the superior.
i,
431
LECTURE XLIV.
I
Of Dislocations of the Knee.
The frequent and great violence to which stroctnre ;. this joint is exposed, also the form of the ^ ''***" articulation, the cavities on the head of the tibia being very shallow, would render it extremely liable to displacement, were it not ifor the extent of articulating surface, and the exisitenoe of numerous strong ligaments, which connect the os femoris, the tibia, and the patella.
Dislocations do, however, sometimes occur from excessive violence, or from great relax- ation of the connecting ligaments.
Of Dishcation of the Patella. The patella may be dislocated in three Three
'I*.* • xj* 1 1 forms of*
directions ; — ^viz. outwards, inwards, and up- wards.
The external displacement is the most External, common ; in which case the patella is thrown upon the outer condyle of the os femoris, where it occasions a great projection, which
432
circumstance, and the incapacity of bendiag^ the knee joint, sufficiently mark the naturae/ the injury.
caim of. Persons who have naturally an injj^ation of the knee inwards, are most liable to this injury, and it is usually produced by a M at the time that the knee is turned inwards and the foot outwards, so that the action of the muscles, in endeavouring to prevent the fall, draw the patella over the external con- dyle of the thigh bone.
internau The displacement of the patella upon the internal condyle, is much less frequent, and generally happens from a fall upon a pro* jetting body, by which the patella is struck upon the outer side, and, forced inwards at the time that the foot is turned in the same direction. Ligament • Uuless the ligament has been relaxed from previous disease, it will be torn in either of these dislocations.
The reduction, in either case, may be accomplished in the following manner : — TmtMAt. Place the patient in the recumbent pos- ture, and let the leg be raised, by lifting it ut the heel, so that the extensor muscles of the thigh maybe relaxed as much as pos- sible ; then press down firmly the edge of the patella, furthest from the articulation, by which the opjx>site edge will be raised
433
over the condyle, when the • action of the miiscres will quickly restore the bone to its natural situation.
Th^oUowing plan was adopted by Mr. cwe. Geoi^ Young, in a case of the external dis- location:; which he could not succeed in re- ducing by other means. He placed the inkle of the limb upon his shoulder, which ^ve him considerable power in^ extending the knee joint, when grasping the patella with the fingers of his right hand, he pressed iJbe outer edge of the bone with the ball ei his lefit thumb, and thua forced it into its place.
After the reduction^ the limb must be kept Aftertroat at rest, and the part kept moist with an eva- porating lotion ; after three or four days, bandages may be employed. The motions of the joint are soon restored, but a degree of weakness remains for some time.
Very slight causes produce the lateral dis- From re- location, when much relaxation exists, but the reduction is very easily accomplished, and it is necessary to employ a laced knee cap^ with a strap and buckle above and below the patella, to prevent a recurrence of the accident.
VOL. III. 2 F
434
OfHk Didocatim of the Patella upwards.
b tkk displacement, the ligameiitum pa- is torn through, and the patella is dimwn vpiwBids upon the fore part of the thigh bone.
The nature of this injury is extremely wefl narked, by the elevation of the patella, the fireedom of its motion laterally, and the depressioQ above the tubercle of the tibia from laceration of the ligament : the patirat cannot support himself upon the limb, as the knee immediately bends when he attempts to do so. The accident gives rise to a con-
»
siderable degree of inflammation.
The treatment required for this injury, in the first place, will be to reduce the inflam- mation, by the application of leeches and evaporating lotions, at the same time that the limb is kept extended, and the body ele- vated, to relax the muscles, and prevent as much as possible the elevation of the patella; after from four to seven days, a roller should be placed upon the limb, from the toes to the knee, to prevent swelling, and a splint should be fixed behind the knee, to prevent any motion of the joint ; a leather strap should then be buckled around the lower |vttrt of the thigh, just above the patella, and
to this should be attached another strap, which should pass on each side of the leg, under the foot, by which the circular strap may be drawn down so as to restore the patella as near as possible to its natural position, and thus approximate the lacerated ends of the ligament, to allow of union.
With great attention, the union will be ^'* '"«•»■
^ Hon, unian
perfect; passive motion may be carefully perfect, iployed at the expiration of a month.
■The degree of recovery depends upon the Degree of „ J 1 I recovery,
igth or the ligamentous union, bemg per- fect when the lacerated extremities are kept in contact during the union, and the powers of the limb being diminished in proportion to their separation. A dislocation of the patella downwards has Dislocation
, -11 II downwardly
been mentioned by some surgeons, but I have not seen any injury deserving such a title. Sometimes the tendon of the rectus muscle is torn through, in which case a de- pression can be felt above the patella, but the bone itself retains its natural situation. The same position of limb and body is ne- cessary^in the treatment of this injury, as in the dislocation upwards, and a pad should
applied over the ligamentum patella, and
ifined there by a roller.*
* In 3 cuse of this nature which ( 2 F 2
' under my
436
Of Dislocation of the Tibia at the Knee Joint.
Four formft of.
InwArdt.
Gate.
The superior extremity of the tibia may be displaced in four directions, viz. : out- wards, inwards, backwards, and forwards, but only the two latter are complete dislo- cations, as in the two former instances the articular surfaces of the tibia, and of the condyles of the os femoris are still pardy in contact.
These lateral dislocations occur but set« dom.
When dislocated inwards, the head of the tibia forms a large projection on the inner side of the joint, the internal condyle of the femur rests upon the external semilunar cartilage, and the external condyle projects to the outer side.
The first case of this injury which I re- collect seeing, was brought into St. Thomas's Hospital, during my apprenticeship th^^, when I remember being struck with three
care in St. Thomas's Hospital, I found considerable advantage from the application of a pad over the upper portion of the rectus muscle, it was confined by a roller, and assisted materially in approximating tbe lacerated ends of the tendon ; the patient recovered with perfect use of the limb. — T.
Circumstances respecting it ; first, the great deformity of the joint — second, the little force necessary to reduce the displace- ment— third, the slight degree of local or constitutional suffering which followed, the recovery being complete in a few weeks.
When displaced outwards, the tibia pro- o jects upon the outer part of the joint, the internal condyle upon the inner side, and the external condyle rests upon the internal semilunar cartilage, the deformity produced being as great as in the former case.
The reduction in either instance may be r readily effected by direct extension, and but little diminution of power in the joint follows. I believe that, in both these dis- locations, the tibia is rather twisted upon the femur, than forced merely inwards or outwards, so that the condyle of the os femoris is thrown somewhat backwards with respect to the head of the tibia, as well as laterally.
■ When the patient is first allowed to use ' the limb after an accident of this kind, the joint should be supported by a bandage or a knee cap, as from the injury to the ligaments, it remains feeble for some time, although the recovery ultimately is nearly ■perfect.
2 F 3
438
Dislocation of the Tibia forvmrds.
^ When this accident occurs, the following mppearances will be presented^ when the patient is in the recumbent position. The head of the tibia projects forwards, and the inferior part of the thigh bone is depressed, being thrown a little to one side as well as backwards : the patella is drawn up by the action of the rectus muscle. The circu- lation through the popliteal vessels is ob- structed by the pressure of femur posteriorly, so that arteries below cease to pulsate, and the foot feels numbed from pressure upon the ner>'es. CMb A man named Briggs was admitted into
Guy's Hospital, in the year 1802, under the care of Mr. Lucas. He had a dislocation of the tibia forwards, in one extremity, which presented the marks I have described, and a compound fracture of the tibia, with a dislocation of the head of the fibula existed in the opposite limb. The extent of mis- chief attending the compound fracture, ren- dered it necessary to amputate that extre- mity. The dislocation in the other extre- mity was easily reduced, by extending the tluf»h from above the knee, and by draw- ing tho leg from the thigh, inclining the
tibia a little downwards. The patient re- covered.
Dislocation oftlit Tibia bachvards.
This injury occasions the following marks, signiof.
A projection of the condyles of the os fe-
moris anteriorly, a depression of the liga-
I mentum patellte, the head of the tibia is
I seated behind the condyles, and the limb is
' shortened, the leg being bent forwards. My
friend, Dr. Walsham, sent me the following
particulars of a case which was under his
care.
Mr. Luland, a very robust and muscular Cwe. man, had his shoulder and knee dislocated in consequence of being thrown from hia cart, in January, 1794. The head of the tibia was completely dislocated backwards, reaching behind the condyles of the femur into the ham ; the tendinous connexion of the patella to the rectus muscle was rup- tured ; the external condyle of the os femoris was very protuberant; the leg was bent forward and shortened, and there was a depression just above the patella. The pa- tient felt most excruciating pain when the limb was moved, but there was not any ^considerable suffering when it was at rest. W 2 F 4
440
It was icduced by the following mjeans:-^ Tjvq men extended upwards, one from the zroin. ;innther from the axilla, whilst two ottiers extended the leg from a little above :iie ankie» in the opposite direction ; and ihey ijprtidually increased the force of their exteiifiiuiw till the bone was reduced. At chfi ame of extension. Dr. Walsham di- rtH:ted the head of the bone to its natural s^tundon. A loUer was afterwards placed aver the knee, the limb was laid upon a {idlow> and an eTS^Kurating lotion was coa^. scaatLy applied. In this state, the patient reinaiiwi for a fortnight free from pain, when the Doctor gently moved the joint every other daLy> as far as he could, without creating paitt. In about a month, Mn Luland began to walk on crutches, in ten weeks he was able u^ $it at the dinner table, and in .five uiouths> had perfectly recovered the use of limb.
0/ Furtidl Lusntion of the Thigh Bane frm the Semilunar Cartilages.
The ligaments of the knee joint some-' umcti^ become so much lengthened from ^^\Uvmo relaxation, or from an increased \vvtvUv>u into the joint, as to permit the
441-
■semilunar cartilages to glide upon the sur- fece of the tibia, when pressure is made by the femur on the edge of the cartilage. The nature of the 'accident was first accu- F'"' »>£-
scribed by
rately described by Mr. Hey, of Leeds, who Mr. Hbj. was so justly celebrated from his high pro- fessional attainments ; he also suggested an ingenious and scientific mode of treat- ment, which is generally successful.
The displacement is most frequently oc- cmiiMof, easioned by a person when walking, catch- ing the toe against some projecting body, whilst the foot is everted, pain is imme- diately felt in the joint, and the limb can- not be straightened. I have known it also produced by the bed clothes, obstructing the motion of the foot, when a person has been turning in bed. The explanation of the accident is as follows : —
The semilunar cartilages, which receive Expiann- the condyles of the femur, are united to the '""' " ' tibia by ligaments ; and when these liga- ments become extremely relaxed or elon- gated, the cartilages are easily pushed from their situation by the condyles, which are thus placed in contact with the head of the tibia, and when an attempt is made to extend the limb, the edges of the semilunar carti- lages prevent it. L> The mode of reduction is, to bend the ReJucHoi..
442
limb as much as possible^ so as to ^oiable the cartilage to slip into its aatund position firom the pressure of the femur : the cartilage being thus replaced^ the Umb can be again properly extended, and the condyles are tigdixx received upon the cartilage.
I have, however, known this plan to &il in effecting the desired object, as Hie fcdlow-* ing case ^U show.
caie. A lieutenant in the army, who had been
repeatedly . the subject of this injury, and who had been as often relieved by the means above recommended, had a recurrence oi the accident whilst turning in his bed ; he came to town, but the former mode of treatmekit, although repeatedly tried, did not succeed in reducing the dislocation ; he afterwards went to Mr. Hey, of Leeds, but without obtaining relief.
After A knee cap, made to lace closely upon the
joint, will generally prevent any further dis- placement; but, in some cases, this is not sufficient.
Case. Mr. Henry Dobley consulted me, in con-
sequence of his suffering frequently from this accident, which could only be prevented by the addition of straps to the knee cap, one of which, of considerable strength, passed just below the patella.
Case. In another case, that of a young Iady>
443
also frequently the subject of this dislo- cation, the accident could only be prevented by a linen bandage, having four rollers at- tached to it, which were tightly bound above and below the patella.
I have seen some cases of this kind, in Effects or. which a very great alteration has taken place in the form and size of the joint, in consequence of a chronic inflammation at- tending them. The following is an account of one: —
Lady D. in falling, twisted her thigh in- Case. wards, so as to occasion great pain in the knee-joint. On attempting to extend the limb, she could not move the knee-joint ; but, after pressing the thigh outwards, and leg inwards, with some force, she found her- self capable of straightening the extremity. For a fortnight after the accident, the joint was extremely weak, and she could hardly bear it to be moved. She then began to stand upon the limb, supporting herself by crutches ; but when she bore much upon the injured limb, it suddenly bent back, and this produced considerable pain and swell- ing, at the time she felt the condyles slip from the semilunar cartilages upon the head of the tibia. This occurred repeatedly dur- ing a period of fifteen months after the acci- dent, and each time greatly retarded her
444
recovery. Three months after this^ she had so far improved^ as to be able to walk with the aid of a stick only, when, in elideaTt)!!^^ ing to raise herself from a soia> her left knee gave way, as if the bone had slipped from its place ; the thigh bone being at the same time twisted outwards ; this produced great pain and swelling, and she was again un- able to stand upright. Her joints were all remarkably flexible, and when a girl, she often experienced a sensation of having dis- located her knees, but from this she soon recovered. When I saw her, both knees were much enlarged from effusion of synovia into the cavities of the joints, she could not stand without support, and was unable to straighten the limbs. To relieve her, blisters were applied, and for some time kept discharging ; after they were allowed to heal, pressure was employed by means of bandages, which were occasionally re- moved, to allow of friction. She derived most benefit from the internal use of the pilul: hydrarg: submuriat: comp: and the decoct: sarsaparillsB comp: and externally firom the friction. Dissection In the disscctiou of these cases, the liga- joints. ment is found extremely thickened; small ligamentous and cartilagenous bodies are hanging from it; part of the articular car-
445
tilage is absorbed, and part presents thick projecting edge. After maceration, the edges of the condyles are found to be* much increased by deposit of bony matter.
Of Compound Dislocations of (he Knee.
This accident is of very rare occurrence; veryn I have only once seen such a case, which required immediate amputation ; aad I scarcely know any form of injury which would so urgently call for operation.
On the 26th of August, 1819, I was sent Case. for by Mr. Oliver, of Brentford, to see a Mr. Pritt, in consequence of severe injury to the knee, occasioned by a fall from the coach box of one of the mails. On examining the limb, I found a large aperture in the inte- guments, on the outer side of the knee joint, through which the external condyle of the femur projected, so as to be on a level with the edges of the skin. The inferior part of the OS femoris was thrown behind, and to the outer side of the head of the tibia, the bone was twisted outwards, so that the internal condyle was situated upon the head of the tibia, whilst the external condyle was turned backwards and outwards. We succeeded in replacing the bones with much difficulty.
446
but as soon as the extension ceased^ they retamed to the same position as I have ^bove described.
In consequence of the great severity of the injury, the difficulty of the retaining the bones in their natural situation, and the patient being of a very irritable disposition, I immediately proposed, and with his coa* sent, performed the operation of amputation. Great constitutional suffering followed the operation, but under the judicious treatment of Mr. Oline, who visited him during my absence from town, he gradually recovered.
DiBiection, On dissecting the limb after the opera- tion, I found great extravasation of blood into the cellular tissue surrounding the joint; the vastus intemus was extensively lacerated, just above its connexion with the patella; the tibia projected forwards, and the patella was situated to the outer side of the knee. On the posterior part, both the heads of the gastrocnemius extemus muscle were torn through, and the capsular ligament so completely divided, as to admit both the condyles of the femur through it.
Attempt Should a case of compound dislocation of
to save the
umb. the knee occur, in which a very small wound only existed, admitting of ready closure, it would be right to attempt the preservation of the limb.
447
Of Dulecatiom of the Knee from Ukeratun,
FrcMU the chronic diseases of joints^ not c*w« »^* only the synovial membrane and articular cartilages suffer from ulceration^ but in some cases the capsular, and also the peculiar ligaments become ulcerated, so that the con- nexion between the bones is in a great mea- sure destroyed, when the muscles which par- ticipate in the irritation, contract and gra- dually displace the bones producing gr^t distortion of the limb.
This is most frequently seen in the hip joint; but it is not uncommon to find at the knee the tibia drawn out of its proper Uiie, with respect to the femur from the same (sause. / Occasionally, the distortions thus pro^ Extraordi-
nary distor-
4ucQd are very remarkable. Mr, Cline am** tion. putated a limb in St. Thomas's Hospital, in which the following alteration had taken place from chronic disease in the knee joint. The leg was placed forwards, at right angles vnth the thigh, so that, prior to the operation, it projected before the patient when he was standing. On examining the joint, the pa- tella was found anchylosed to the femur, as also the tibia to the fore part of the condyles of the thigh bone.
f'lcn :2aT je ione i:i the early stage of am lisease. "d Trevent deformity, by the rn-.f-^' 1 f ?ciiiii3. izd the use of internal
:iie puiv : Ipecacuanhas corap : a MTTwm^sa f^aaoL imtzbiiitY.
■ - *a'
'.V Pnczurss •}/ the Knee Joint.
L ^auil luw cp?ceed to describe the frac* ixre* -v^ca vHtcut ia the bones formmg the
V. *-
F^ictuTts of the Patella.
The 3ic« ccmmon fracture of this bone, * TiiT:?^^rsety : sometimes, however, it is wrntea "cc^lcndinally ; these fractures may ie itdier siaiple or compound, but the latter
>*"i^!i tricmred transversely, the superior ^i%nt:ca ,*i' b<*ne is separated from the inferior i^'iK vfnwn up by the action of the rectus »:i8?c xic or^neus muscles, which are inserted itce :c. The lower portion of the bone re- Tt.i. !> •:: *r> natural situation, connected to .:tv: ;ci:.v.:i:':iv.ni patellae.
l"V .vv^crw of separation will be found io ; <^ -. v^.v, half an inch to five inches, and
.449
depends upou the extent of laceration of the capsular ligamcDt, and tendinous aponeu- rosis covering it.
The nature of the injury is readily recog- nised, on examination, by the fingers, when pressed between the two portions of bone, sinking nearly to the condyles of the femur; by the situation of the upper portion of bone, and by its free lateral motion upon the fore and lower part of the thigh bone ; the patient cannot extend the limb, nor can he support the weight of the body upon it when stand- ing, as the knee immediately bends forwards from the loss of the support of the extensor muscles. The injury, if simple, is attended with but little pain, and is not productive of much constitutional suiFering.
A few hours after the receipt of the accident, the part becomes tumid from extravasation of blood, and the surface presents a dis- coloured appearance from ecchymosis, thisj however, subsides in a few days, but the joint enlarges from an increased secretion of synovia, and from effusion in consequence of inflammation. As the portions of the bone are separated, no crepitus can be felt, as is usual in other fractures.
Two causes are found to produce this injury: — First, Falls upon the knee, or blows upon the patella, when the patient is
VOL. III. 2 (i
y
'it: ictioa of the extensor :• ae. _=. any sudden effort
a r-r-: - srenii i gentleman, who
•r. .IT-- — ? r^ifLa by an effort he
:v ■ ir >ji>ir : -rid falling, after hav-
>. vv _ iii^ v^o met with the same
. .r:.. : i^-r-r'^nin:^ to save herself
— ^ ::- Ticrj lesiiending some stairs,
=• '.-^ T.II.-:-. rtr leii :x> near to the edge
:- ^••Jt-'T iAtnordinary, that the
. - . iir niiscitrs alone is sufficient
:— v-.i ra-Torf. bm a little attention to
■^ ^r-'-'*..:"^ lui: 2rcde of action easily ex-
^_;a. i.z ui:t. Wien the knee is bent,
•r titt ,i > in-vn down on the end of the
•.::ik'^ .-^i^ i ^tf Srciur, and the upper edge
:t xur irj^^^z forwards, so the muscles
>,,:. A.1 11 1 ^^^ ^th the patella, but at
v-^'. jJi^^iT^^ '^"^ ^^- ^^d more particularly
..tifi i^ ::nnfr rcrt:on.
•^ i:!:i;ii .1 these cases is generally .,.. .^..,LU5< wriedier the portions of the ^•v.rji xiw Sf nearly approximated, or ..- • ^ ,Mri:iC. Soon after the accident, . -.•• > -Vii*^ out, and fills the space be- ,.,v-t :K iiv.'^nred ligament and broken , - ^ I ,vi:v:\ but this soon becomes ab-
451
sorbed, and its place is occupied by adhesive matter thrown out in consequence of inflam- mation ; this soon becomes organised by vessels from the edges of the injured liga- ment, and a structure, similar in its character to ligament, is thus produced, by which the parts divided by the injury are again united. Sometimes this new structure does not com- pletely fill up the space formed by the sepa- ration of the portions of bone and ligament, but it has apertures in it; but this most frequently occurs when the separation is feery great, or when the limb has been moved ■too soon after the accident.
K, On examining the seat of injury, some DUiecUon. Btne after the accident, I find that the pa-
■tlla itself undergoes but little change, the •
H^erior portion has its broken surface very ^^H
Hktle altered, being only rather smoothed ; ^^H
Plhe upper portion has its fractured surface ^^^H
covered with some ossific deposit, so that ]^^H
there is more ossific action in the superior ^^H
than in the inferior portion of the bone. ^^^|
The articular surface maintains its natural ^^^|
appearance. ^^H
By experiments on the rabbit, I have Enperuneai^^^l
been able to trace the mode in which this ^^H
injury is repaired ; in each experiment I ^^^|
divided the patella, by placing a knife on ^^^|
the bone, and striking it gently with a mallet, ^^^|
452
having first cut throv^ the int^^umeiitSi which I drew as much as possible to one side, so that when allowed to resume thw natural situation after the division of the patella, the wound was not opposite the fracture. ^|w^^j^^ Examining the parts forty-eight hours after g^j^j^J^ the division, I found the portions of bone separated to the esctent of three quarters^ of an inch, and the intervening space filled with coagulated blood. Eight days In a sccoud experiment, examined eight •«''• days after, most of the blood was absorbed,
and adhesive matter deposited in its place. Fifteen A third, examined on the fifteenth day,
dayt after*
the adhesive matter had become smooth and somewhat ligamentous.
Twenty- A fourth, examined on the twenty-second
after. ^ day, the new lig^ament was perfect.
Five weeks A fifth examined at the expiration of five weeks,'and injected, showed the organisation of the new ligament, which was chiefly sup- plied by vessels from the original ligament, and by a very few vessels from the bone.
Union by In repeating these experiments upon the ^*^^°^* rabbit and dog, I could not succeed in pro- ducing a bony union, although I could keep the fractured pieces in perfect contact.
Bony I believe, however, that ossific union may
union. *
now and then be produced ; in a case which
453
' with Mr. Chopart at Paris, there was every appearance of such a junction, and Mr. Fielding of Hull has published another
ol i
Although in a large majority of these cases, I believe the union to be ligamentous, yet it is extremely desirable to make the iM ^^J ligament as short as possible, as the degree of recovery of the power of the limb is in proportion to the approximation of the frac- tured portions of the patella, or according to the shortness of the new ligament, for as the superior portion of the bone is separated from the inferior, by the action of the rectus muscle, so the muscle becomes shortened, and its power consequently diminished. "When, therefore, the intervening ligament is very long, the person cannot walk fast without a halt, and is in constant danger of falling.
In the treatment of the transverse fracture ' of the patella, the patient should first be
iced in bed upon a mattress, with the ijured limb extended, behind which a hol- low splint, well padded, should be applied ; the heel should be elevated a little, and the body raised, in order to relax, as much as possible, the rectus muscle, and thereby prevent it from drawing up the superior the fractured bone. The limb 2 G 3
■ee ^^zS^ in
■ " I
re Treatment. ^^^H
454
should be fixed to the splint to prevent its slipping, and the surface of the joint should be kept constantly moist, with an evapofatiiq; lotion. If there be much tension or paia succeeding the injury^ the application of leeches will be necessary, with a coirt]nuan(^ of the evaporating lotion. In a few days, the swelling and pain will subside, under this plan of treatment, after which the ban- ds^es may be applied to approximate the portions of bone« The surgeon should be very careful not to apply the bandages before the tension has been reduced ; I have known severe suffering and inflammation produced by their too early application, so much so ia some easels as to threaten a sloughing of the integuments. conunoD The most common mode of using the
bandage. ^
bands^es is as follows : a roller is first applied from the toes to the knee, to prevent swelling of the leg; two pieces of broad tape are then placed on each side of the patella, in the direction of the limb, and two rollers are next bound round the extremity, one above, and the other below the knee joint, confining the pieces of tape, and having the two portions of bone between them; the ends of ttape on each side are afterwards turned over the rollers, and tied so as to bring the rollers nearer to each other, and
:iired bone
Uic splint is
limb, to pre-
^ iiit, the heel is
supported nearly
iiode rather different. Another
mode.
ulc, and which consists
-lur strap around the lower
igh, immediately above the
)ii of the patella, and having
attached to the former on each
•iiough to pass under the sole of
by which the circular strap can
a down, and with it that part of the
II bone connected to the tendon of the
is muscle; the splint and the position
attended to as above-mentioned.
It is necessary in the adult to continue Penodof
^ confinement,
this treatment for five weeks, and in elderly persons for six we^ks, before any motion is allowed ; it may then be employed passively^ but very cautiously, until it be ascertained that t}ie union is sufficiently firm to bear it without risk, when it may be continued from day to day until the joint can be completely flexed.
Passive motion is very essential to pro- Passive mo- mote the return of power in the muscles and *®"®"®" ** • joint, as without it many months will elapse,
2 g4
md the pttsnt stfll be ixicapaUe of flezng ±6 'imb. Wlfli pMsnre modoa is to be empioyed, die polieiit shoold be aeated upon I iigb stDoi or table, in sucb a manner that die edge of tbe seat reaches as fin* as the lam* so that the \tg can be depressed with- JVC the thigh ; this is to be dime with coor lidex^l^ care at first, nntil a slight degree It Tnotxon has been ac(|mred, when the pa- ::enc axay^ by swinging the kg, and directing his mrnrf to the contraction <tf die rectos and exterior nxnscies, gradually restore the fimc- tions of the j<xnt. If the onion has takai place with a diortened state ci the rectos muscle, and die porticMis €ji bone are joined by a kmg intenrening ligament, the mosde does not recoTer its volantary power nntfl it h;i$ been again elongated, which is d<me by bendinsr the knee.
A VDone woman who had suffered finom transrerse fiactore dt both patellae, was brought to my house, in consequence d w>l baring recoTered any power of flexing the limbs. Passire motion was employed and she was directed to extend the limbs, when they had been flexed by the suigeon ; m this Rianner, after persevering for some tinu\ ?he craduallv recovered the use of tho loini^. The pain created by the passive o*v*thvv .uui the very gradual benefit de-
rived from it, make patients averse to ita continuance, but it is perfectly essential to recovery.
Of the Perpendicular Fracture of the Patella.
This injury, as the former is attended with considerable effusion and swelling of the soft parts.
Having seen several cases in which the ^ union had only been effected by ligament, and not being aware of any circumstance that should prevent ossific junction, I made several experiments upon dogs and rabbits, the result of which was as follows :—
Having produced fractures in a manner i somewhat similar to that already described, for occasioning the transverse division of the bone, sufficient time was allowed for the process of cure to be completed, when the bones were examined, and found to be joined only by ligament, and the two por- tions considerably separated from each other, . from the pressure of the condyles of the femur upon the inner surface of the patella when the knee was bent.
1 therefore made another experiment, and )-tbe -patella -in a dog, but in such a-
458
manner, that the tendon above, and the ligi* meat below, remained uninjured, so that there could be no separation of the firactaied portions ; in this case, I found that a perfect ossific union took place. i|i»k«iby It appears then, that in either, the lon- gitudinal or transverse fractures, when the portions of bone are separated, that a liga- mentous union takes place ; but if these pcff* tions remain in contact, diat th^ stay be united by b<»ie.
Mr* Manyat had kis patella bndcea into thrw pQftioii8» by m ftll from kia gig, the booft was divided by m tnnsnrene ftactoie, and the kiwer piece again divided fay m per* peodicular fracure; tte tnnsvcne fiactnie umMd by ligaf t odhf , vrkibt the peqien- dMilar fracMre jomed fay bime.
i6aMwtd tkepalsBaof aidog;aqpanitiiig il iiij|# liMr iNnms byacracial dmaQii,iio ^MapM iMik plMit K^^Mi^,^ &e fwoaaDerior |W«^iV miinligt «9^ eMk olker, mar «d the
M^ <^idh #^i«t ^ IW MMMMK tit lki» MiiiiMn coHBsts in
If^riii^ ik^ Mi^ m as ii ■ai.ndiil positkiii, xntftk 41 ihM^K^ c$fidE0£ MSKTMiT^ la pievoit 4^ :tt!k^<>^it ve ciie istfe juaat; in apptying 4^ ^tiijNMftaiji: ^MWL lotCL laie sveDing and
padded on each side of the patella should be buckled around the joint, the straps passing above and below the patella.
Of Compoimd Fracture of the Patella.
When this accident is attended with ex- Extencrf I
mischief.
tensive laceration, and much contusion of the surrounding soft parts, it will be right immediately to amputate the limb ; but should the wound be small, so that its ed; can be readily approximated, and not accom- , panied with such mischief as is likely tO' occasion sloughing ; an attempt should be made to preserve the extremity.
The principal object in the treatment, i to produce adhesion of the edges of the wound ; to eft'ect which, all our efforts should be directed. The application of sutures is necessary, not only to assist in the imme*' diate approximation of the edges of thftjl wound, but to prevent their after separatioQi i which is otherwise liable to take place j from the escape of synovia, and the lax ] state of the integument, besides the sutures)! 1 strips of adhesive plaister should be placed; and the part kept cool, by the evaporating
L lotion. Poultices or fomentations must not be Used, as they prevent the adhesive process.
460
in St. Thomas's Hospital, under 1 Mr. Birch, had fomentatjons and pmutices onployed, after an injury ci tiiis 3anire^ in which bat a small wound comma- 3icaied the joint, — ^he died in consequence vjt euesaiTe aHistituti(mal irritation, pro- duced by suppuratiTe inflammation, which took friace in the joint.
The following case, which was under the eve of Mr. Dixon, of Newington Butts, wiD fuDy explain the mode of treatment I woold recommend.
Mr. Redhead, aged 39, of a spare habit, was thrown from his gig, June 18, ISIO^ uriien his knee, striking against the wheel of a cart, produced a compound fractuie oi his patella. At Mr. Dixon's request, I Tisited the patient in the afternoon of the day on which the accident had occurred, and on examining the joint, I found a wound
00 the fore part, which readily admitted my finger into the joint ; the patella was broken into several pieces, one of which being de- tached, I removed. From the habit of the patient, and his not having an irritable con^ stitution, we determined on attempting to j>rvser\'e the limb. I accordingly brought
1 ho edges of the wound together by the apiUication of a suture, taking care not to iu\ Uule the ligament; I then further secured
461
i closure of the wound b] sive plaister, and over the whole, i placed a roller very lightly, which was to be kept constantly moistened with spirit of wine and water. The leg was placed in an extended position, and he was ordered to live on fruit. The suture was not removed until the 30th of June, as he did not at all complain. At the expiration of a month, Mr. R. was allowed to leave his bed ; and in five weeks from the accident, passive motion was com- menced. He gradually recovered the perfect use of his limb.
In the year 1816, a case happened io Guy's Hospital, in which the knee joint was opened by ulceration, some time after the occurrence of a transverse fracture of the patella, which had united by a ligament about three inches in extent; the patient, a woman, was admitted into the hospital, in consequence of having numerous ulcers on various parts of her body, one of which was seated in the integument, immediately over the new formed ligament, uniting the broken patella ; this ulcer became sloughy, and ex- tended through this ligament into the joint, in which excessive inflammation and suppu- ration occurred, which destroyed the patient.
1
L
462
Of Oblique FrMtures €f the Comfyks of the Os Femorii mto the Knee Joint.
sifMof. Either the external or the mtarnal con- dyle of the femur may be separated by fiac^ ture from the rest of the bone, producing much deformity of the knee jcmit, and giving rise to great swelling, which circumstances, together with the feeling of crepitus wh^ the joint is moved, indicate the nature of the injury. In either case, the same mode of treatment is required.
Treatment ^^'^ injured limb is to be placed upon a pillow in the extended position ; leeches and evaporating lotion are to be employed, until the infianmiation is subdued ; after whiek, a piece of stiff pasteboard, about a foot and a half in length, and of sufficient width to evelope the posterior and lateral parts of the knee joint, as far as the sides of the patella, is to be applied wet, and secured by a roller ; this, when dry, adapts itself to the form of the joint, and best confines the frac- tured portion of bone. In five weeks, pas- sive motion should be employed to &dli- tate the recovery of the motions of the arti- culation.
Compound Compound fracture of the condyles of the OS femoris is a rare accident ; and in the old,
fracture.
or irritable, is most likely to be attended
with fatal consequences, unless the limb be
removed. In young persons, or in those
not of an irritable constitution, a cure may be
effected, unless the opening be very exten-
3, or attended with much surrounding
ichief.
I A boy was admitted into St. Thomas's c«se,
bspital, in September, 1816, under the
ire of Mr. Travers, having a transverse frac-
e of the femur, just above the condyles,
1 an oblique fracture of the external con-
yle, with which a small wound commu-
icated ; the limb was placed in a fracture
'px in the semi-flexed position. The patient
offered but little from constitutional dis-
^rbance, although the integuments over the
loured condyle ulcerated, so as to expose
^e bone, which was removed in November,
consequence of its losing its vitality.
lifter this, the limb was placed in the
aight position, as anchylosis was deemed
bavoidable, but the lad recovered with a
Iferfectly useful joint.
y Obliqite Fracture of the Femur, just above ^ the Condyles.
The consequences of this injury are often couequence,
sry lamentable, producing great deformity
A
464
of the limb, and destroying, in a great mea- sure, the motions of the knee joint.
The injury is generally produced by a fall from a height upon the feet, or upon the knee when the joint is very much flexed. SMoiMtt Mr. Paty, surgeon of Bouverie Street, ■iMd. Fleet Street, has a preparation, showing the great deformity consequent on this injury, it was taken from a subject brought into the dissecting room at St. Thomas's Hospital Before dissecting the parts, it appeared that the femur had been fractured just above the condyles, and that the inferior part of the superior portion of the Ixme projected as far as the upper part of the patella, being only covered by the ddn; the size of the bone was much increased. On examining the seat of injury, the end of the saperior portioa of Ixme was found to have pierced the rectus muscle» through which it coor tiaued to protect* The pateDa could not be drawn vfiwards, as it was sti^iped by the extrtttiity of the bone* The condyles of the fitmur and the infanw portioQ ai bone had been drawn upwards and backwards by the 4ICIMI of the oiwdes^ behind the inferior IvuTt of the $upenor poitioQ, and had united
liHkf^eftdetti 01 the defonnity in this case, iW ^^"4x^41$ ivT the knee-joint must have
465
been very limited, as the rectus muscle was ^m hooked upon the projectingf extremity of bone ^H anteriorly, which also prevented the ascent ^H of the patella.
The best mode of treatment to obviate Beitm these great evils, is first to flex the joint as meat. much as possible, to liberate the rectus muscle at the same time supportingthe condyles over some fixed body, to prevent their receding, and afterwards the limb must be firmly ex- tended, to prevent retraction. ^H
The following cases will explain the diffi- ^1 culty of effecting these objects ; the first was under the care of Mr. Welbank, junior.
A gentleman of middle age, a tall and caie, powerful man, was thrown from his gig in June, 1821. The medical attendant, who was called to see hira, found him lying on a bed, to which he had been carried, with his right leg bent across the left at an angle. ^_ At first view, it appeared that there was a ^H lateral dislocation of the knee, a deep hollow ^H was seen on the outer side, in the situation ^H of the condyles, and above it a sharp pro- ^H jection. On examining more attentively the ^H seat of injury, an oblique fracture of the ^H femur was found just above the condyles ; ^H considerable effusion existed in front of the ^M joint, around the patella, which could not be ^M distinctly felt. After the fracture had been
VOL. nr. 2 h
466
reduced, which was readily effected by slight extension, a ridge could be felt just above the patella, which, upon a superficial exa- mination, might have been mistaken for a transverse fracture of that bone. If the limb was flexed, a great deformity resulted from the projection of the upper portion of the fractured bone, which disappeared again on extending the limb. The sensation of crepitus was very indistinct.
The extremity was placed in an extended position, and secured by the application of short splints, for the space of a week, during which time means were employed to reduce the inflammation of the capsule, consequent on the injury. After this, a long splint was applied on the outer side of the limb^.ficoiii the trochanter major to the foot, and a shorts one on the inner side, from the middle of the thigh to the middle of the leg; these were firmly confined by bandages, and the limb was supported upon an inclined plane. In consequence of frequent variation in the projection of the upper portion of bone, weights were subsequently appended to the foot, to keep up a constant extension^ which appeared to be advantageous.
In September following, the union was thought to be sufiiciently firm, and the pa- tient was carefully removed to Eastbury,
Herts, in a litter-carriage, with his limb still in the same position. It being found, how.- ever, that alteration of posture, or any at- tempt to flex the limb, produced a greater projection at the seat of fracture, the former plan of treatment was continued for another fortnight. Upon a further examination after this period, a degree of lateral motion could yet be felt, and the projection of the fractured bone was still increased by bend- ing the knee, indicating that the union was not yet firm, in consequence of which the limb was again placed at rest, and a circular belt was tightly bucltled around it at the seat of injury, to press the fractured parts together, and to maintain them in firm appo- sition. In the middle of October, the pa- tient was first allowed to get up, the union being then complete, and he has since gra- dually recovered the use of the limb, so as to be able to walk without assistance, but he has little power of bending his knee, the upper part of the patella being caught gainst the projecting portion of the femur, which is still evident. The limb is somewhat shortened, and the thigh inclined outwards.
Mr. Kidd, who was tall, muscular, and Caie.
in weight fifteen stone, fell from a height of
twenty-one feet, and by the severity of the
concussion, fractured his thigh bone ob-
2 H 2
408
liquely, just above the condyles, and the lower part of the superior portion of the bone penetrated through the rectus muscle and integuments, appearing just above the pa- tella. He was immediately carried home, and I was requested to see him by Mr. Phillips, Surgeon to the King's Household, who had been called to him. The project- ing extremity of the superior portion of bone was sawn off, and the fracture reduced, when the edges of the wound were carefully, bmught together, and the limb was placed over a double inclined plane. The wound healed without difficulty, which was ex- tremely favourable. The accident occurred ou the 9th of November, 1819, and on the 30th, splints w^ere supplied to press the bones together. December 23, the limb was pkccd iu an extended position, which was continued until the beginning of February. Th<^ pulient >Kms then allowed to sit tip i but \>u n cawM exmminatioa of the limb, the uuk>u of ilie tincture was ascGrtaiined not to b<^ <v>m|itiHi^> and a katker bandage was lh<^ixM^^«v (4;jioed aromid tdie injured part, aih) l^iil)y Imckkd^ to secure the bones in ;i^ |M\^}vr jx^iiiMi. t>a the 3id oi May, the x^u^N^x xxA^ x-^^Tjd IK> be ocwnfiete, and a few x^\>. AiVo^^ ;V itiCfidw^ >«tsi remored, the U^^^^ KNi^^ ^ji^^j'^vctioi 3>y a pillow. He was
still tmable to leave his bed in consequence of the great swelling of the leg, and some ' degree of superficial ulceration from the ap- plication of the leather bandage. On the 19th of July, he was removed from London to Kensington upon a litter. A considerable period elapsed before the swelling of the :fimb subsided, or before he was able to be inoved to a sofa. At the end of January, he *ras on crutches for the first time, and took iliis first walk out of doors, near the close of 4he following month.
After union was complete, the inferior part ^the upper portion of the bone, which had leen broken, continued to project, its size ras very much increased, and the patella ras fixed to its extremity, to which also the iskin adhered.
I have had an apparatus constructed, Apparatns hich, I think better calculated to preserve "un. the limb in a constant state of extension, lUian that employed in either of the above It consists of a straight splint, long (enough to reach firom the upper and inner part of the thigh, as far as several inches below the sole of the foot ; the upper ex- tremity is hollowed and padded,, so as to in between the scrotum and thigh, against side of the pnbes ; and the lower part resembles that described and employed by 2 II 3
■ M in
■ the si Hresem
470
Bayer; having a boot which fixes by the sole, to a bolt projecting at right angles from the splint; the bolt is connected with a screw, let into the lower part of the splint, and on turning this screw, the bolt is carried upwards or downwards, according as the screw is moved to right or left. After hav- ing liberated the rectus muscles from the broken extremity of bone, by bending the knee as before directed ; — the limb is to be extended, and the apparatus applied on the inner-side of the limb, in the following man- ner : — ^The upper padded end being placed between the scrotum and thigh, against the side of the pubes ; the foot is to be received into the boot, and confined there by closing the firont with a lace in the usual manner, or with straps and buckles ; then by turning the screw, the bolt connected with the sole of the boot, and consequently the boot and foot are made to descend, thus a powerful mode of extension is afforded, the upper part of the splint being fixed against the pelvis, the whole force of the instrument is exerted upon tbeUmb*
O/Fructwrt oftkt Head of the Tibia.
KaiHf^vf. A frsWture sometimes occurs obliquely through the head of the tibia into the knee
471
joinf, in which a mode of treatment vej;y siaiilar to that recommended for the oblique fracture of the condyle of the femur is neces- sary ; viz. an extended position of the lirnb^ in which the extremity of thigh bone tends to keep the fractured bone in its proper situr ation ; the application of a piece of wetted paste board, and a bandage. Passive motion should be employed early.
Should the fracture not extend so high as if not con- the joint, the semi-flexed position of the the joint, limb over a double inclined plane will be best, as the weight of the leg then counteracts the efforts of the muscles, which would otherwise draw up the inferior portion of the broken bone.
Of Dislocation of the Head of the Fibula.
This accident may occur from violence or Causes, relaxation of ligament. I have only seen one case from the former cause, which was ac- companied with a compound fracture of the tibia, requiring the removal of the limb.
The displacement in consequence of relax- From re. artion is more frequent ; the head of the bone slips backwards, it can be easily replaced ; but unless confined in its proper situation, it is directly dislocated again.
2 H 4
*it^ •■
•i ^.A
i-Li.C3=sr* '
1^ '.^x. 'resEonsst is to pn ji la^^masm it sviiot line: "lus maT I
, ; .'•■'TTcn z -inni^ in h
T* - y^ Mil
478
LECTURE XLV.
On Dislocations of the Ankle Joint.
This articulation, which is formed by the strength of
the joint.
tibia, fibula, and astragalus, with their carti- lages, and synovial membrane, is so strongly protected by the form of the joint, and the numerous ligaments connecting these bones, that great violence is necessary to produce a dislocation, and when this does occur, it is generally accompanied with fracture, the ligaments often affording more resistance than the bones.
The tibia may be dislocated in three dif- Three ferent directions, viz. inwards, forwards, and outwards ; a displacement backwards is also said sometimes to take place. Cases have likewise occurred in which the foot has been thrown upwards, the astragalus being re- ceived between the tibia and fibula, in con- sequence of the ligament, which unites these bones, giving way ; but this is only a severe form of the internal dislocation.
474
OfShmpk Dislocatian of the lUia, mmanb.
This is the most commoii erf the dinloratioiig <rf the ankle. The malleohis intennis fanx a projectioii under the skin, on the inner side of the foot, and the integument is ao much distended as to a{^>ear in a hoisting state; — the foot is turned outwards, so tiiat its inner edge rests npoa the ground, when tiie patient is er>eci, — adqfMressicm exists aboTe the outer ankle, but there is otherwise mndi swelling; a crepitus can be usuaDj kit about three inches aboTe the external mafcofais cm moTii^ the foot, which can be dooe laterally without difttcutlT, but the motioa creates violeiit
^<ttM<^ TW ap(>iew^AD» upim examining die seat fnf iiaiwT bv d^§siectua» aire die foflown^:— the ettd ^mT t&e ubci tecs iqwrn the ianer skle ^l"^ thp( asscn^a^B^ ; imsiead <rf oo its upper WticdbiKXT stance : aaai if die arridenthas iKViMtt^ oraft a pinsiia jnnpiag from a con- $iii!ca^«^ ^:!Kfiif^ ^ jtfwisr €ad of the tibia >ii)b^tx^ xc :;^ vVHiisi^ni^L :iL> c^ mbdta by liga- )ii!i>it^ :c^ ^^&:;^it >^ ioii cefnam^ attached to tW ivM^u,. ^niici ^ iTijc r-iccir^ Jorom two V ".V\v .ov^K^ jjX"^^ iii^ I2iiij!ci3&. and the sStskA H*i ;ac >^ixr?cr Tvcccir >:£ ^e fibula is ;^i^*^v\i^ iv^*«^/j: 4^iVit :;K arroe^ <acnte of the
476
astragalus, occupying the natural situatioa of the tibia ; the inferior portion of the fibula with its maleblus remains in its natural posi- tion, and the ligaments connecting it to the tarsal bones are uninjured.
The most frequent cause of this accident Caniii. is jumping from a great height, or it is some- times produced by the foot being caught whilst a person is in the act of running, with the foot turned out, so that the foot is fixed whilst the body is carried forwards.
The reduction of this dislocation, which Reduciion. should be effected as soon as possible, may be accomplished in the following manner: — place the patient upon a mattress, properly prepared, on the side which corresponds to the injured limb, and bend the leg at right angles with the thigh, so as to relax the gastrocnemii muscles ; then fix the thigh whilst an assistant draws the foot gradually in a line with the leg, and at the same time press the lower extremity of the tibia out- wards towards the fibula, to force it upon the articulatory surface of the astragalus.
Great violence will often fail in reducing Reason of this dislocation, if the limb be kept extended ; when, in the same case, the replacement may be very readily effected after the leg has been bent in the mode I have described,
I he difficulty in the former instance is from
476
the powerftil resistance of the gastonemir muscles.
Treatn^at After the reduction, the limb is still to be kept upon its outer side, being surrounded by a many tailed bandage, and supported upon a well padded splint which has a fdot piece ; a second splint also furnished with a foot piece is to be placed on the opposite side of the limb, or that which is uppermost ; and these splints are to be so secured as to prevent eversion of the foot, and to preserve it at right angles with the leg. The bandage is to be moistened with an evaporating lotion. The subsequent inflammation must be kept within bounds by local or general bleeding as necessary, and the secretions must be attended to.
i^Hrt*Ji tiT About five or six weeks after the accident, the patient may be allowed to leave his bed, liavii^ the jmnt well su{^ported by the appli- C4itioii ct straps of plaister around it. After r^t weeks^ pssave moti<m and firiction 9i)Kmikl be emplovied to restwe the moticms of the jioint.
f V .^StiwMr f>ati[^t^i;'#?; f*f the TTAmt, forwards.
Kr^»«4« ll^i^ ^-vioeDi pr^dxjoe? the following ap-
IHNf^r^ixx^ :^ — ihc ix« ^seems much shortened,
«^v*
toes are poiiited downwards, and the heel projects. The inferior extremity of the tibia forms a large projection upon the middle and upper part of the tarsus, under the ex- tensor tendons, and a depression exists be- fore the tendon achillis.
When examined by dissection, the tibia is *?" ^'*'*'!- found to rest upon the upper surface of the navicular and internal cunicform bones, but a small part of its articular surface still is in contact with the articular surface of the astragalus. The fibula is broken, and the superior portion of the bone is carried for- wards with the tibia; whilst the malleolus externus, with two or three inches of the lower part of the fibula remains in its proper situation ; the capsular ligament is lacerated extensively on its fore part, and the deltoid ligament is partially torn through.
The most frequent causes of this injury Causes, are, a fall backwards at the time that the foot is confined, or jumping from a carriage in rapid motion, whilst the toes are pointed forwards.
To accomplish the reduction, the patient Reduction, should be placed on his back upon a mattress, and the thigh being elevated towards the abdomen, the leg is to be bent at right angles with the thigh ; the foot is then to be ex-, tended iu a line a little before the axis of the
478
leg, the thigh being fixed, and the tibia pressed backwards to its natural position. Treatment When the reduction has been effected, the many tailed bandage, and padded splints are to be applied as in the former case, and the same means adopted to prevent excess of inflammation. The position of the limb should be upon the heel, with the knee bent, and the foot well supported. After five weeks the patient may be allowed to get up, as the fibula will then be united ; and passive mo- tion may be carefully used.
Of the partial Dislocation of the Tibia,
forvmrds.
Niitiireaf. In this accident, the tibia does but half quit the articular surface of the astragalus, resting in part upon the navicular bone, and in part on the astragalus.
Signs of. The signs of the injury are, the pointing of the toes, the elevation of the heel, a great diflSculty in placing the foot flat upon the ground, and ' a considerable loss of power in the movements of the joint. The short- ness of the foot, or the projection of the heel, are not very remarkable ; the fibula is broken. Case. The first case of this injury which I saw,
479
stoat lady at Stoke Newington^ that she had sprained her anUebjaftD. The toes were pomted» and the MfltkwR of the ankle joint entirely destroyed. I attempted to draw the foot fivwaids, and to bend the ankle joint, but I could not succeed. Some years after, 1 gaw diis lady walking upon crutclios, tlie toes weie still pointed, and she could not place the foot flat upon the ground «
I was not, however, perfectly acquainted niMMi(«ii« with the precise nature of the injury she suffered from, until my friend, Mr* Tyrrolli showed me a foot which ho had dissoctotl at Goy^s Hospital, and which he wtu^ 90 kind as to give me. It presents the follow- ing appearances : the articular surface of tho lower part of the tibia is divided into two, the anterior part is seated on the navicular bone, the posterior upon the astragalus; these two articular surfaces formed at tho lower extremity of the bone have been rou- dered smooth by friction; tho fibula had ^been fractured.
The mode of reducing this partial dis- U0du«iioN. placement should be in every respect similar to that reconmiended for the complete dis- location, the same directions for the after- treatment should also be adopted. As the signs of the injury are not very well marked,
ances.
480
great attention will be required in the ex- amination^ and the surgeon should not rest satisfied until the motions of the joint are in a great measure restored.
Of simple Dislocation of the Tibia, outwards.
This injury is usually attended with much more surrounding mischief than either of the former, as it is produced by greater violence; there is more laceration of liga- ments, and more contusion of the integu* ment.
^J^^!*^ The sole of the foot is turned inwards, and its outer edge rests upon the ground, when the patient is standing ; the foot and toes are pointed somewhat downwards, and the external malleolus forms so decided a prominence upon the outer side, by pro- • truding the skin, that the nature of the accident can scarcely be mistaken.
On dissec- Upou disscctiou, the malleolus intemus of the tibia is found obliquely broken from the shaft of the bone ; the inferior portion of the shaft of the tibia is thrown forwards and outwards upon the astragalus before the malleolus : the deltoid ligament re- mains entire. If the fibula is perfect, the three ligaments naturally connecting it to
tion.
481
uptured ; but when the fibula
the tarsus e
is fractured, which often happens, these ligaments are not injured. The astragalus is sometimes brolcen, and the capsular liga- ment is lacerated.
The injury may be occasioned either by a fall or jump from a height, the foot being twisted inwards, or by the passage of a carriage wheel over the articulation.
To etfect the reduction, place the patient Redaction. J upon his back, elevate the thigh towards the abdomen, and bend the leg at right angles with the thigh ; then fix the upper part of the leg and thigh, whilst an assistant ex- tends the foot in a line with the leg, and at the same time press the tibia inwards towards the astragalus.
When reduced, apply the many-tailed TreBtmem. 1 bandage and padded splints with foot pieces, as in the former cases ; but in addition, place a pad over the fibula, just above the outer malleolus, so that when the limb is laid upon the outer side, which is the best position, the portion of bone above the pad may be raised, and the pressure of the outer malleolus upon the injured integument may he prevented.
A similar mode of after treatment to that described for the other dislocations, will he proper, but more depletion will usually be
VOL. ill. 2 I
482
required after this injury, aa the inflammar tiou is generally more violent. Passive mo- tion should be employed after six weeks from the accident.
Of Compound Dislocations of the Ankk Joint.
Natan of. The Only difference between these injuries and those already described is, that in these cases the integuments and ligaments ai^e divided, either by the bone, or by the pres* sure of some uneven and hard body, on which the limb may have been thrown, so as to expose the joint from which the synovia escapes through the wound.
The consequences of these injuries 9se, however, very different from those occasioned by the simple dislocations ; usually the M- lowing effects are produced. The synovia at first escapes through the wound, and in % short time after the accident, inflammatioa commences; this inflammation esteiids to the ligaments as well as to the extremities of the bones forming the joint, and the secretion from the joint becomes much in- creased. In about five or six days, suppura* tion commences; at first the discharge of matter is small, but it soon becomes very profuse. Under this process of suppuratioDi
the articular cartilages become partially or wholly absorbed, but in general only partially ,- the ulceration of the cartilage is a very slow process, usually attended with much constitutional suffering, and is often followed by exfoliation of bone. When the cartilages have been removed, granulations arise from the extremities of the bones, and from the ligaments, which inosculate and fill the cavity of the joint. In some cases, I adhesive inflammation occurs in the com- mencement, and the articular surfaces be- come united without any absorption of the cartilages ; this often occurs in part, but I have seen it extend to the whole surfaces.
But neither the adhesive union, nor the t inosculation of the granulations entirely de- » stroy the motions of the joint, if passive motion be employed sufiiciently early and carefully; and I have seen, in some cases, the mobility of the articulation restored to nearly its original extent; otherwise, the other joints of the tarsus acquire such an increase of motion, as to render the deficiency in that of the ankle hardly perceptible. When the powers of the joint are completely destroyed, it is by a deposit of cartilage, and a subsequent formation of phosphate of lime, as is usual in the reparation of fracture of bones.
2 I 2
484 coMtitii- The various local effects which I have
tional
symptoms, described are accompanied usually with much constitutional suffering. About twenty*foiir hours^ or in two or three days after the re- ceipt of the injury, the patient begins to complain of pain in the head and back, skewing the influence of the accident upon the bram and spinal marrow. Loss of appetite, iduisea, and often vomiting, indica,te disorder of the stomach ; the tongue is white, yellowish, or brown, according to the degree of irritation'; the bowels generally become inactive, from a paucity of the secretions, not only from their mucous surface, but from the glands connected with them, as the liver, pancreas, &c. ; the secretion of the kidneys is much diminished, and of a deep colour; the skin becomes hot and dry, ceasing to pour out the perspirable matter. The action of the heart and arteries is accelerated, the pulse becom- ing hard, and in severe cases it is often irregular or intermittent. The resphradon is hurried in sympathy with the quickened circulation. When the irritation is great, the nervous system becomes further affected, the patient is restless and watchful, and ta the severity of the case increases, delirium subsultus tendinum, or tetanus occur.
Such are the usual effects of local irrita- tion upon the constitution, but the degree in
485
which they are developed depends upon tlie irritability of the system, the powers of reparation, and the extent and violence of the injury.
The cause of the severity of the local and "^^"^^ "'" constitutional symptoms in these cases ap- pears to be the exposure of the joint, and the great efforts necessary for the reparation of the injury under such circumstances, as the simple dislocations very rarely occasion these distressing effects, but the adhesive process repairs the mischief, without givingf rise to either much local or constitutional disturbance. Thus the first principle in the treatment of the compound dislocation is clearly pointed out, viz. : the closure of the wound, and the aiding, by all means in our power, its union, by adhesive inflamma- tion ; so as to prevent suppuration in the cavity of the joint.
Formerly, and within my recollection, it Amputation
T f- i_ . formerly
was thought expedient lor the preservation pertanned. of life, by many of our best surgeons, to amputate the limb in these cases; but from our experience of late years, such advice would in a great majority of instances be now deemed highly injudicious.
The mode of treatment to be adopted in these cases is as follows, and will apply generally to either form of dislocation. 2 I 3
*;««:
vii. ~K to suppress has- ii~ II ^'icsequence exists, ae -wr .keziks. :2se anterior and poste- ^-i iTr IJtely to be wounded.
ic jiTarf T-^ 3«£ ibund most frequently i:'ir?ti. z^r acif zeaendiy escaping; but 1 :i=* i aeeoing arom either, it will be %s:rzMmr^ -^ urcty rwo ligatures, one above Au iiiicrrrr »±uw cae iperture from which 3fc jitt^uiaic jc::ur5. The projecting ex- a^ .4 Hi- Mces are often covered with
smfist against the ground; vsifea Jte i&x:: xsp will be to cleanse them Tfjoi e«wr particle of extraneous ic will afterwards excite nrfti-marion in the joint. Should :tx. viK :« ^^mnvuaied or shattered, all the ^- ■;» 'tfc-f >;ctic<25 must be carefully removed, «:u I :xte "vrToai is not sii^ciently large to ^... Ml ;i rtt -T b^ing taken out without much ^acvicv. :c saooki be enlarged with a seal- ^•« MC 2»f :acisioii should be made in, such 4 ^iitKS«/a. J5 will avoid further exposure of litf \MKC Y!^ woimd will sometimes require .dUCtficfL^ =1 ihe int^^ments are nipped na 2K vci; by the projecting bone, as they , v:.v t >» :: 3any instances liberated with-
-u.
'"^ic ^uccxsa of the dislocation is to be .v-''i:i^^utfi^<^ bv the same means as already
487
descnbed in tKe simple displacements, aim
when reduced, the edges of the wound are
to be very carefully approximated by sutures
and strips of plaister, over which a piece of
lint, dipped in the patient's blood, is to be
placed ; this, when the blood coagulates,
forms, as far as I have seen, the best covering
for the wound. The part is to be further
supported by the application of separate
pieces of linen, in the same way as the
many-tailed bandage, but each portion being
unconnected with the others, so that any
^-■one piece can be removed, and another sub-
itituted for it, by tacking the ends of the old
nd new strips together, before the former
I drawn from its situation ; in this way the
limb is not disturbed by the change. This
ndage is to be moistened by an evaporating
fation. The padded splints are lastly to be
uployed with foot pieces, as recommended
the simple dislocation, but a portion of
pilhat one situated on the wounded side of
the limb should be cut out, in order to enable
the surgeon to dress the wound without
I' removing the splint. The position in which
■the extremity should be placed is the same
in the simple injury, but must be occa-
ksionally varied a little according to the seat
and extent of the wound. con»atu-
The next object will be to prevent or j?.""''"
■2 I 4
488
diminish the constitutional suffering likety to ensue ; in some cases it will be necessary to take away blood generally, but this should be done with the utmost caution, as great power is required to support the after pro- cess of restoration, which will fail altogether if the patient be rendered feeble by the loss of blood or other means. Purgatives should also be administered with great care, as the frequent change of position which the action on the bowels necessarily occasions, tends very much to interrupt or destroy the adhe- sive process, which it is our chief object to promote. I am confident that I have seen many cases of compound fracture prove destructive under such circumstances. The bowels should be emptied as soon as possi- ble after the accident, before the adhesive inflammation is set up, after which a mild aperient may be given at intervals. After Should the patient remain free from pain,
treatmeiit. r '
this mode of treatment should be persevered in until the adhesive process is complete; but should he complain of suffering in thfe injured joint, the dressings must be cau- tiously raised, so as to expose a very small part of the wound, to allow of the escape of any matter which may have formed, but not to disturb any adhesions which have taken place. If the suppurative inflammation has
r
48i>
commenced, the first dressings may be re"' moved, and the surface of the wound be merely covered with some simple dressing. Should much surrounding inflammation arise, it will be necessary to apply poultices on the wound, and leeches upon the limb, at a little distance from it, and afterwards to con- tinue the use of the evaporating lotion over the inflamed surface not covered by the poultice. When the inflammation has sub- sided, the use of the poultices should be discontinued, as they relax the vessels too much, and retard the progress of cure.
In favourable cases, the wound heals in a Period of few weeks with but little suppuration. In those less favourable, the discharge is very copious, and portions of the extremities of the bones exfoliate, rendering the recovery very tedious. Even in the most favourable instances, the patient cannot venture to use crutches before the expiration of three months, and often not until a much more distant period.
I shall now relate a few cases, which will further explain the best mode of treatment, and also show the impropriety of recom- mending amputation indiscriminately in these cases.
In the year 1797, I attended a gentleman cue. with Mr. Battley, who then practised as a
490
surgeon. This gentleman had, in a fit of insanity^ jumped from a two pair of stanrs window into the street, by which he caused a compound fracture €i the ankle joint ; he, nevertheless, got up without assistance, and having obtained admission into the housci he ascended the stairs to his bed-room, and having £sustened the door, got into bed. The door was forced open, as he would not un- fasten it. When I examined the injured Umb, I found that the tibia was dislocated inwards, and that the astragalus was brokea into many pieces, many of which h&ng detached I removed. We then reduced the displaced bone, and having approximated tiie edges of the wound, covered the whole with lint wetted vrith the patient's blood. The limb was placed on the outer side, with the knee flexed, and an evaporating lotimi was freely applied. In three or fyav days after, considerable inflammation took place, but this was subdued by general and local bleeding, with emolient applications to the wound ; extensive suppuration followed, and continued very profuse for nearly two months, when the surface was covered by granula* tions ; at the same time an improvement took place in his mental affection, which became less and less as the wound closed ; between lour and five months from the accident, the
491
; process was complete, and the state of his mind natural. At the expiration of nine months he returned to his employment, but could not walk without the aid of a stick for many months.
In October, 1817, I was called by Mr. cwe. Clarke, a surgeon, residing in Great Turn- stile, Lincoln's Inn Fields, to visit Mr. Ca- ruthers, a young gentleman who had a com- pound dislocation of the ankle joint inwards, occasioned by the overturning of a stage- coach at Kilburn, from which place he had been removed to Lambeth where he resided. The extremity of the tibia projected to the extent of between two and three inches from a wound through the integuments on the inner side. The tibia was broken, a small portion of it remaining attached to the joint by the ligaments ; the fibula was also frac- tured badly. I found it necessary to en- large the aperture in the integuments, before I could replace the dislocated bone. After the reduction, simple dressings were spread over the wound, these were confined by a many-tailed bandage, moistened with an evaporating lotion, and the limb was sup- ported by the padded spHnts, and placed in a semiflexed position upon a quilted pillow. The patient was bled, and took mild purga- tives, with saline medicines. Considerable
492
constitutioDal suffering followed, gmthr exhausted the patient; ab- fixmed in the leg, and some exfolia- piace, much retarding the pro- of cicatrization. These abscesses were frechr opened, and the parts supported by pbister ; the limb was kept cool by weof eTi|MHrating lotion, and the strengl^ igppotted by giving bark and wine. In dke JvMiaiT, 1819, the last exfoliation oc- cmcd» after which the wound healed npidhr, and the patient recovered his health. Mr. Carathtfs has since obtained very con- use of the limb, being able, he [> walk six or eierht miles if neces-
Abbott, of Needham Market, Suffolk, be particulars of the following inte- case, which occurred under his care. )lr. Robert Cutting, aged seventy, cor- pnknU intoaperate, and of a gouty habit, lud lub ankle dislocated in consequence of l^iay durown down in a quarrel ; the end ^' tkie tibia was forced through the integu- Meni$» and protruded about four inches ; the ^tJb^ was firactured a few inches above the K^ia(. and the foot was turned outwards. Ittuiu^iiately he got up, and in struggling to ,4;jaKK he covered the end of the bone with ^at *wi «*>^> ^* which also a considerable
493
quantity got into the joint. He was eon-^ veyed home about four miles in a cart, and Mr. Abbott saw him about five hours after the accident, and recommended amputation in consequence of the extent of injury, and the disordered state of the patient's consti- tution ; but this the patient could not be induced to submit to, therefore the injured parts were carefully and thoroughly cleansed with warm water, the dislocation was re- duced, and the edges of the wound were nearly brought into apposition by strips of linen dipped in the tinctura Benzoini com- posita, without sutures or adhesive plaister ; a thin board, hollowed to receive the leg, and with an opening in the situation of the outer ankle, being well padded, was placed under the outer side of the limb, which was enveloped in a folded flannel bandage, from the foot to the knee ; the leg was laid in a flexed position, with the foot a little raised. The patient was bled to Jxij, and ordered a mild saline purgative every two hours, until the bowels were relieved, with milk broth for his food.
The accident happened on the 25th of April, 1802 ; and he proceeded very favour- ably until the 27th, when he complained of darting pains in the injured limb, and he L*9ra& restless, yet his skin and bowels were
acbag property. Upon unfolding the flannd; some swelling appeared about the joint, and some gleety discharge escaped from beneath the dressing ; the inflammation did not ap- pear much more than necessary, but six leeches were applied at a little distance from the seat of inflammation, which relieved the pain, and the wound was dressed as before. This plan of treatment was conti- nued, and tlie case proceeded most favour- ably ; on the 2d of May, a small quantity of matter was discharged, but without aug- menting the symptoms. After ten weeks, he was moved daily from the bed to a sopha, and about this time the whole of the dress- ings were taken off" for the first time, when the wound was found to be completely cica- trized; previously, only small portions had been elevated at a time, and fresh pieces put on to keep the covering perfect. When exposed, the exterior of the joint presented its usual appearance, excepting a slight en- largement in the situation of the cicatrix ; but this was not more than could be ex- pected. At the end of five months, he was allowed to go on crutches, and bear as much weight on the limb as his own feelings sug- gested to be proper. Being a butcher by business, he afterwajds rubbed the limb with the fluid obtained from the joints of animals,
495
and also frequently placed his foot and ankle in the warm paunch of an ox. Before the expiration of twelve mouths, he could walk without the assistance of a stick, and for many years before his death could walk with perfect ease and freedom. He lived to th^ age of eighty-three.
The following are the particulars of a case sent to me by Mr. Scarr, Surgeon, at Bishop's Storford ; he also sent the patient for my in- spection, after his recovery, so that I had an opportunity of witnessing the happy result of Mr. Scarr's skill.
John Plumb, aged 38, liad ascended on a Cmp. ladder, about ten feet from the ground, with a sack of oats upon his shoulders, when the ladder slipped from under him, and he fell to the ground upon his feet, still retain- ing the load of oats. Mr. Scarr was passing at the time, and immediately attended to tile man. When his stocking had been removed, the tibia and fibula were found projecting through the skin at the outer side of the ankle, and the astragalus was exposed through an opening on the inner side ; both the wounds were clean, and without much surrounding mischief. Mr. Scarr therefore immediately reduced the displacement, and closed the wounds by the application of adhesive straps, and placed the patient in
496
bed, with the limb flexed, and laid upon the outer side. The limb was moistened vdth a lotion of acetate of lead. About jxyj of blood were taken from the arms; some saline medicines administered ; and the anti- phlogistic treatment persevered in, with due regard to his constitutional powers; some abscesses formed, which were opened in the most favourable points, and the patient be- came gradually convalescent in about - six months, without any very urgent symptoms. At the end of twelve months, he was able to resume his laborious occupation a» before the accident. ?!II?^J!!? It has been recommended in the tteatment of bone. q( thcsc cascs, to rcmove with a. saw the projecting extremity of the tibia, before die reduction of the dislocation is attempted; there are some instances in which such a proceeding is absolutely necessary, and many reasons are given for adopting this practice in general. When ne- jhc cascs in which it must be necessarily
cessary. *'
adopted are the following :
First, when the dislocation cannot be other- wise reduced without great violence.
Secondly, when the extremity of the bone is fractured obliquely, so that if reduced it immediately glips from its proper situation, when the extension is discontinued; but
497
*■ after the removal of the point by the saw, it rests readily upon the astragalus.
The reasons assiened for adopting this Beasonsfti plan m all instances are.
First, That the shortening of the bone relaxes the muscles, and diminishes the ten- dency to spasmodic contractions, which so frequently occur when much force has been used to replace the bones.
Secondly, That the adhesive process goes on much more readily from the sawn ex- tremity of the bone than from the natural articular surface, consequently the local irritation is less.
Thirdly, That when the suppurative in- flammation does occur, it is rendered much less, as there is not the same extent, by nearly one half, of cartilaginous surface to be removed by ulceration, and thus by the diminution of the ulcerative and suppurative process, the constitutional irritation is much lessened.
Fourthly, It has been remarked, that those cases have usually recovered quickly, in which the extremities of the bones have been broken into many small pieces, and separated so as to render their removal necessary.
Fifthly, I do not recollect any instance of unfavourable termination, when this practice
VOL. III. 2 K
Notim- portaot.
498
had been pursued ; but I have known loaBy unsuccessful in which^ it had not been adopted, objectioiit rjij^^ objections made to this treatment are,
first, that the limb must be shortened by the removal of the portion of bone, nxA^ secondly, that the joint must afterwards become anohylosed.
Provided we admit that the danger of the case is lessened, which I believe, by the sawing off the extremity of the tibia, the first objection cannot be considered of much weight, more especially as the defec;t isae easily remedied afterwards, by increasing the thickness of the sole oi the boot or shoe. With regard to the seoond objection, I do not imagine that anchylosis is at all a neces- sary consequence, having seen cases in which considerable motion remained aft^r the removal of bone, and recovery of the patient. I know that anchylosis is liable to take place in either mode of treatment, but even then the patient, after a time, walks with very little halt, as the other tarsal joints acquire so much increase of motion. Treaimcnt It appears to me, however, that either th^caie. plan may be adopted, according to the fea- tures of the case, and I should not wish it to be supposed that I recommend the one to the entire exclusion of the other.
their
Pmd
When the dislocation can be reduced t without much force, and the bones retain their proper situation readily, without the
currence of spasmodic muscular action; Bd if the pa'ient be not very irritable, an attempt should certainly be made to effect a cure, without removing the ends of the bones; but if the bones be shattered, or fractured obliquely, so that it will not retain its proper position when reduced, the saw should be employed, in the first instance, to smooth the ends of the bones, when the small separate pieces have been taken away, and in the second place, to make a surface to rest upon the astragalus. I would also rather use the sa-w, than employ great violence to reduce the dislocation otherwise; likewise in those cases where the spasmodic contraction of the muscles renders it ex- tremely difficult to keep the injured joint in its natural position.
I shall now relate some cases, which will afford an opportunity of judging better of the propriety of what I have stated.
Nathaniel Taylor, aged thirteen, was Ci«e. admitted into Guy's Hospital, in consequence of his having a compound fracture of his ankle joint. The injury had been occasioned by a boat falling upon his leg. The end of
E, and the fractured extremity of the __
500
fibula projected through an extensive open- ing ai the outer ankle; the malleolus ex- temus retained its natural situaticm and ligamentous connections. The foot was turned inwards, and hung so loosely, that the 8<de could be placed against the side of the leg. I tried to reduce the bones to their proper situations, but could not effect it, but by ?ery great force, and as socm as the extension was disccmtinued, they again slif^ped firom their places. Under these circumstances, those around me urged me to amputate the limb ; but considmng my young patient to be otherwise in good health, and not of an irritable habit, I determined to presenre the limb if possible. On a further examination, I discovered that the malleolus externus and inferior part of the fibula connected to it, although in its natural position, was very loose, and I therefore removed it, by dividing the ligaments ¥dth a scalpel, and I afterwards sawed off about half an inch of the end of the tibia. I then found that I could easUy replace the bones, and that they retained their positions without difficulty. Having approximated the edges of the wound, I covered it with lint dipped in the patients blood, and by strips of adhesive plaister ; the limb was placed upon (ho heel, and supported by padded splints.
501
Scarcely any constitutional suffering oc- curred, but little suppuration took place, and the wound gradually healed. One abscess formed over the tibia, but did not give rise to any severe symptoms. He was allowed to get up, and to use his crutches after about two months, and at the expira- tion of four months he could walk very well. There appeared to be some motion at the ankle, but the tarsal joints had evi- dently acquired much increase of motion.
In December, 1818, I was called upon case, to attend, with Mr. Jones, of Mount Street, a Mr. West, aged forty, who had severely injured his left ankle, by jumping from a one horse chair, alarmed at the horse's kicking.
When 1 first saw him, the extremity of the tibia projected through a wound in the integuments, at the inner side of the ankle, and a portion of skin was nipped into the joint by the bone, the foot was turned out- wards, but hung loosely. Finding that our patient was of a most irritable constitution, and seeing that great violence must be em- ployed to reduce the bone, and that to effect the reduction it would be necessary to enlarge the wound considerably, I con- sidered it much better to remove the ex- Cty of the tibia, in order to avoid these 2k 3
602
I therefore sawed off a portion of tfctt bone, and then effected the reduction wiftkoot diflSculty, nor was there any dis« pMtioii to further displacement from mus- clar contraction. The edges of the wound were next secured in contact, by the inser- tMNH of a fine suture, and the paut was Oiywed with lint wetted with blood, and a wuiy-tailed bandage. The limb was secured bx the padded splints, and placed upon the outer side, in a semi-flexed position. The ptlient was bled to the extent of Jx, some <^um was given him, and the spirit lotion was freely applied to the extremity. Oa the third day, the foot exhibited slight vesications, and he complained of tensicm, and some pain, but this soon subsided. About the sixth day, the wound began to discharge a serous fluid, mixed with red particles; poultices were employed; the secretion soon became purulent,^ and con^ tinued to increase until the end of a month, when it gradually subsided. At the end of two months, the patient was allowed to get on to his sopha, as the joint appeared firm ; u small wound still, however, existed, from which it was evident some small exfoliation would take place; this did not happen for Nevcral months. During the progress of the t?u«i!. Dr. Pembertbn was consulted in con-
503
sequence of the patient's having an ex- tremely disordered state of stomach ; but, notwithstanding, the symptoms produced by the accident were not more severe than those usually occurring in a common case of compound fracture.
Dr. Rumsey, of Amersham, was so kind as to send me the account of an excellent case of compound dislocation of the ankle, complicated with simple fracture of the thigh bone of the same limb ; the following are the particulars :
Mr. Toison, aged forty, was thrown from cwe. a curricle, on the 21st of June, 1792, and in falling, dislocated his left ankle joint. Dr. Rumsey saw him about two hours after the accident, when he found a large wound at the outer ankle, through which the ex- tremities of the tibia and fibula, with a portion of the astragalus, protruded; for the astragalus had been fractured, and one portion of the bone still remained attached to the tibia and fibula, the foot was turned inwards and upwards, and the skin of the
*pQter side, beneath the wound, was very |»uch confined by the dislocated bones. Dr. Rumsey, deeming further advice necessary, sent for Mr. Pearson, of London, and Mr. Henry Rumsey, his brother, a surgeon at LChesham ; and during the absence of
504
the messengers^ the patient directed Dr^ Rumsey's attention to his thigh, which was then, ascertained to be fractured at the superior part. This circumstance being con- sidered by Dr. Rumsey and his brother as a decided obstacle to amputation, they de- termined on endeavouring to preserve the limb. Finding that they could not replace the bones without excessive force. Dr. Rum- sey determined upon removing that part of the astragalus which was attached to the dislocated bones. Upon separating this por- tion of bone, it was found to be as near as possible the superior half, the fracture having been horizontal through its centre. After this had been taken away. Dr. Rum- sey still found it necessary to divide a por- tion of the integuments, which had been confined by the dislocated bones, before he could readily effect the reduction. The bones being replaced, some lint, dipped in tincture of opium was laid over the wound ; the whole was covered with a poultice made of oatmeal and stale beer, and the leg was secured with padded splints. On Mr. Pearson's arrival, he perfectly approved of the course which had been adopted.
In the night following, the patient became delirious, vomited, and his pulse was full and frequent; he was bled to 3x, and
ordered to take a common saline draught with antimonial wine and tincture of opium every four hours ; the tartrate of potash and manna were given in sufficient quantity to relieve the bowels. He also experienced considerable pain in the ankle and thigh. On the 24th, these unpleasant syraptoras had in a great measure subsided, and a dis- charge commenced from the wound ; he continued the same plan of treatment, with the omission of the antimony, as his stomach was irritable. He continued doing well until the 28th, when the discharge became thin, and he was much troubled with pain and flatulence , in the bowels ; it was therefore considered
P)«eccssary to alter his diet, and on the 29th, he was allowed a small quantity of animal food, some table beer, and port wine ; the bark was also freely taken in substance and in decoction ; lie was much benefited by this change. The discharge soon became very copious, in consequence of which the wound was obliged to be cleansed frequently; the limb was therefore placed upon the heel, as the dressing could not be effectnally accomplished without considerable disturb- ance, whilst it continued on the outer side. After the alteration of position, much more attention was required to prevent further displacement, as the foot had a tendency to incline inwards, causing the end of the fibula
606
to project at the wound ; this waft however obviated, by placing some small wedges between the foot and the fracture box, on the inner side, and others between the calf of the leg and the box on the outer side^ About the 30tb, the use of the poultice was discontinued, and the wound was dressed with dry lint, over which a pledget, spread with the cerat: plumbi 8uperacetati(&^ wag placed, and confined by a bandage to keep up moderate pressure. The bark and opium were continued until the beginning of August^ and the wound gradually healed with only one check from the confinement of matter, the cicatrization being completed about the middle of September. The union ef the thigh bone also went on well, but as the state of the leg prevented the possibility of keeping up sufficient extension, a degree (tf curvature was produced by the junction. The patient was soon able to walk about with the aid of a stick only, and acquired a power of motion in the injured joint nearly equal to that of the sound limb.
Another excellent case occurred, under the care of Mr. Cooper, of Brentford^ for* merly my dresser, who obliged me by send- ing the particulars from which the following account is taken. Case. Thomas Smith, aged thirty- six, a psunter,
dislocated his ankle outwards, by a fell
with a ladder, his foot being caught be- tween two of the steps. Mr. Cooper was fortunately passing at the time, and immediately attended to the patient. On examining the limb, he found that the fibula was broken about five inches above the outer malleolus, and the tibia fractured longitudinally three inches from the joint; the small inferior portion remained attached with the inner malleolus. About an inch and a half of the inferior part of the shaft of the tibia, and tlie broken end of the (ibula projected through a wound in the skin, rather anterior to the malleolus ex- ternus. Mr. Cooper finding that moderate force was not sufficient to replace the bones, he divided a portion of integument, which was pressed in by the protruding bones, and he also removed, with a metacarpal saw, an inch of the tibia, and a small piece of the fibula, after which the reduction was easily accomplished. The edges of the wound were brought together by two sutures, and iurther secured by strips of adhesive plaister ; Over this the many-tailed bandage, and the padded splints were placed to support the limb, which was placed on the heel, and kept cool by an evaporating lotion. In the evening, an opiate was given, and he was ordered some aperient lor the next morning.
508
Some slight bleeding occurred during the following night, but not sufficient to require a removal of the dressings, which were not, therefore, disturbed until the fourth day, when they were taken off, and the appear- ance of the wound was then favourable. On the eighth day, a slough had formed, about five or six inches in circumference ; a poultice was therefore applied to the foot, and the evaporating lotion continued to the limb above; he also took port wine and bark, to support him under the profuse sup- puration which followed. The slough sepa- rated on the thirteenth day, exposing a healthy granulatory surface, after which merely simple dressing was applied. In five weeks from the accident, the wound was perfectly healed ; and in a little more than two months, the fractured bones had become so firmly united, that the patient was able to sit up. In three months he began the use of crutches, and eventually obtained almost a perfect limb.
This man had suffered frequently from colica pictonum, and had an extremely irritable stomach, he was also naturally of a nervous temperament, therefore but ill cal- culated to support the consequences of so severe an injury. He derived considerable benefit from the occasional use of the saline
509
effervescent mixture, and from the free exhibition of opium at night.*
* Although it is perfectly unnecessary to state more cases in coofirmatiou ol' the correctness of 8ir Astley'a opinions respecting the treatment uf these injuries; yet I think the following account of sufficient interest to warrant its relation : —
Timothy Holland, a very stout muscular man, aged about thirty-iive years, employed as a labourer at the London Docks, was standing on the quay, close to one of the swing bridges, when the bridge was forcibly and un- expectedly swung round, and struck his right leg on the outer side, a little above the ankle, occasioning a severe compound dislocation inwards, tor which he was brougltfc to St. Thomas's Hospital, soon after the accident, on tha 23rd of August, 1820.
I was immediately sent for, and on my arrival at the Hospital, found the patient placed upon a bed, with the iiyured limb in the following state.: — About two incheii of the inferior extremity of the tibia projected througb an extensive wound on the inner side of the joint ; thfl internal malleolus was broken off, and remained loosely; littached by the deltoid ligament. The wound extended in two directions, one reaching from about three inches above the joint, a little to the outer side of tlie course of the anterior tibial artery, to the centre of the meta^ tarsal bone of the great toe ; the artery was completely exposed for more than three inches, but had not been, wounded ; the second portion of the wound extended from the former, immediately over the articulation, round the anterior and inner parts of the joint, as far aa the back of the tendo achillis ; the posterior tibial { artery and nerve were also exposed to the extent of aih I ^li, but otherwise uninjured- A portion of the inte-
510
These cases I think quite sufficient to show, that in very many instances, not only
gumenty about four inches in circumference, near the inner mde of the joint, appeared to baye suffered con- siderably, but retained its sensibility. The fibula was fractured about three inches above its malleolus. — Not- withstanding the formidable appearance of the case, I found my patient cool, and willing to submit to any thing I proposed. His composure and tim^ of life, wiien the constitutional powers are great, determined me to attempt the preservation of the limb. On endea- vouring to replace the boi^s, I found it couM be effected without much yiolence, but that they became again dislocated immediately the extension was discontinued, I therefore removed, with a saw, nearly an kick of the end of the tibia, and likewise took away the malleoliis intemua, which was but slightly comiected by ligament The reduction was then easily accomplished, an^ tiie dispositioQ to further displacement no longer existed, excepting that the end of the tibia advanced a little forwards. This I easily remedied, by placing a long narrow splint on the posterior part of the limb, from the upper projecting part of the calf of the leg to the heel, and then fastening a broad piece of tape around the splint and leg, a little above the seat of injury, so as to press the heel forwards, and the eud of the tilHa back- wards. The edges of the wound were brought together and secured by sutures and strips of soap plaister, over which, the many-tailed bandage and splints were applied ; the limb was placed upon the outer side, in a semi-flexed position ; the bandages were kept wet with a splint lotion ; the patient passed a sleepless • night, but was free from pain, his tongue was slightly furred, and bis pulse quickened. These' symptoms became alleviated
Ihe life
611
life of the patient may be preserved without the removal of the injured limb, but that the extremity is, afterwards, infi-
by the action of some aperieDt medicine, and he pro- ceeded very favourably uatil the 30th, wheu he com' plained of considerable pain iu the ankle, and exhibited a good deal of constitutional derangement. The dress- tugs being removed, that portion of the skin which hud been so much injured at the time of the accident was found to be sloughing; otherwise the appearance of the wound was favourable. Some fresh strips of plaister were lightly applied, and covered by a poultice, and he was ordered some saline effervescing medicine. On the dth of September, the suppuration had become profuse ; the poultice was discontinued, and the wound was dressed with the nitric acid lotion over the slough, and simple cerate to cover the whole; the same position was observed, and he was allowed some meat and porter for the tirst time. From this period, only a slight obeck occurred in the cure, by the burrowing of some niatter up the leg, which was relieved, by altering the position a little, and applying a small compress in the direction of the sinus, The wound was completel<f closed by the end of October ; he was then allowed to sit up, but did not venture to bear at all upon the limb until some weeks after. He was discharged froni the Hospital on the -28th of February, 1827, having regained a perfect use of his limb, wearing a shoe with the sole thick, in proportion to the shortening of the leg, with which he walked quite free from any lameness, I repeatedly examined the joint which had been injured, and could discover but a very trifling difference between ' its motions and that of the sorind ankle. — T.
512
nitely more useful than any artificial one
could be, and that it may become nearly as
perfect as previous to the accident.
Ampota- There, are some circumstances, however,
^tne^ which render the operation of amputation
^^^^^' absolutely necessary, and these I shall now
briefly point out. In old per- First, the advanced s^e of the patient, when the powers of the constitution are not sufficient to support the extensive sup- purative inflammation likely to follow the injury, but which the operation of amputa- tion does not expose the patient to. For very Secondly, A very extensive lacerated wound.^* wound, with much haemorrhage, will render it imprudent to attempt to preserve the limb. Svcfhic" Thirdly, Extensive comminution of the tare. tibia or of the tarsal bones, as the astragalus and calcis, will give rise to a necessity for amputation. When only some small por- tions of bone are broken off, they should be carefully removed, and the end of the bon^ be smoothed by a saw.
Fourthly, The dislocation of the tibia
outwards, as it is generally accompanied
with extensive injury to the soft parts, as
well as to the bones, will often require the
Wound of performance of amputation.
artery! Fifthly, The division of a large artery
613
P
with an extensive wound, might render the operation necessary ; but 1 should not, in all cases, recommend amputation on this account, more especially if the injured vessel was the anterior tibia, as I have known more than one instance of recovery, in which this vessel has been secured, and the limb saved. Division of the posterior tibial artery could hardly take place without injury to the large accompanying nerve, which would increase •ibG necessity for removing the limb.
Sixthly ; extensive contusion of the sur- j rounding soft parts, likely to occasion the for- ' raation of large sloughs, would be a reason for amputating ; this will generally happen when the injury has been occasioned by the passage of the wheels of a heavy laden wag- gon over the joint ; or from the falling of a very heavy weight upon the limb.
These arc the principal circumstances which render an immediate performance of amputation necessary ; but there are others which may make it equally proper at a more distant period from the accident.
If mortification ensues, the operation will MorBfio- be required ; it is, however, best in such a case, to wait until the extent of the morti- fication is clearly defined, before the ampu- tation be performed, although I conceive, that when the mortification results from the
VOL. III. 2 L
514
division of a blood vessel, or from other loc^ injury in a healthy constitution, a d>fier^|i); practice may be adopted to that which would be proper if the disease arose from consti- tutional causes. I have known the arm am* putated in consequence of mortification pror duced by a division of the brachial artery at the elbow ; the mortification was extending at the time, but the patient did well, the limb being removed above the elbow^ I» another instance, where death of the foot had occurred in a case of large popliteal aneurism^ the limb was amputated above the swelling, whilst the mortification was still proceeding up the leg, and the man recovered.
Should the suppuration from the joint be greater than the constitution can support, as J have seen it, amputatipn v^U be required to save the life of the patient.
Large ex- Again, wheu Considerable portions oi hone are exfoliating, and keeping up a continued state of irritation, if, they Qmnot be removed without inflicting great injury, the operatiaci of amputation should be performed, .
Deformity Exccssive deformity may result from joeg- ligence on the part of the surgepn, during the union of the wound, so as to make the limb worse than useless to the patient, when it will be necessary to remove it..
Case. Mr. Norman, of Bath, amputjated the leg
Excessive
snppur-
atioD.
of a man in consequence of such deformity. The patient had suffered from a compound dislocation of his ankle inwards, accom- panied with displacement of the astragalus, which was removed. After the union of the wound, it was discovered that the os calcis had been drawn up against the posterior part of the tibia, and had there become firmly united to it, the toes being pointed down- wards, rendering the limb useless.
It has been recommended to amputate '^j'^" when tetanus occurs after this injury, but as o":"", far as my own experience goes, I believe that the operation only hastens a fatal termi- nation. I have only seen one case of tetanus following compound dislocation of the ankle joint, which, in spite of every attention on the part of Dr. Relph, who attended the patient with me, destroyed life.
Although I have not witnessed the per- Notoiiy formance of the operation after the appear- ance of tetanic symptoms, when the injury has occurred in the ankle, yet I have known it tried in several instances, when this formi- dable affection has been produced from other injuries, and it appeared rather to hasten the progress of the disease than to relieve it.
In a case of compound fracture just above case, the ankle joint, producing tetanus, the 2 L 2
516
limb was amputated ; the tetanic symptoms increased, and speedily destroyed the patient. Case. In another instance, when tetanus had
followed injury to the finger, amputation was performed, but without alleyiating the symp- toms, and the man died. I could relate other cases, all showing how unavailing the ope- ration is under these circumstances. Chronic I h^Yt kuowu a fonu of tetanus succeeding tetums. injuries, in which the symptoms have never been very severe, and which has been termed chronic tetanus ; this is sometimes gradually recovered from, although but little be done by medicine, and nothing at all by surgery. The medicine which I have seen most ad- vantage from, has been calomel and opium ; and opium should be applied to the wouhd. ^xceuiye There are some persons who jure naturally irritabuity. g^ exccssivcly irritable, that the slightest in- juries produce fatal consequences; and in others again, possessing originally good con- stitutions, this extremely irritable state may be induced by excess of mental exertion, by intemperance, by great indolence, or other causes, so that very trifling accidents will destroy them . Those persons also, who are much loaded with fat, and especially those who, under such circumstances, are extremely indolent, generally bear important accidents
517
or operations very ill, and frequently perish in spite of the most cautious and attentive treatment.
Of Fractarta of the Tibia and Fibula near.
the Ankle Joint. .
Fracture of the fibula frequently occurs or fibula. about three inches above the outer malleolus.
The patien^t immediately experiences pain svmptoms at thp seat of the injury, which is much in- ^' cir^ased by any attempt to bear the weight of the body upon the limb; and in endea- ypuring to stand, he does not place his foot
•
flat upon the ground, but rests it upon the juQ^ner side, to receive the weight chiefly on the tibia ; the flexion or extension of the foot also augments his suflering. An inequality of the surface of the limb over the seat of frax^ture often exists, and a crepitus is rea- dily distinguished, by placing one ^ hand over. the injured part, and by the rotating the foot at the same time with the other
» • •
hand.
This fracture is produced by a blow upon Causes of.
the inner side of the foot, which forces it outwards against the lower part of the fibu- la : also, by a sudden and violent twist of the foot inwards. It is, perhaps, most frequently
2 L 3
518
occasioned by a lateral fall, when the foot u confined. I broke niy right fibula by falling on my right side, whilst my foot was confined between two pieces of ice : I felt a snap in the bone at the time of the accident, and experienced pain from every yAt of tte carriage in which I was conveyed home.
The treatment necessary for this injury, consists in applying the ^mmy-^ tailed baftd- age^ and to keep it wet for a few diry9 with the spirit lotion; over this bQDidage» the padded splints with foot jneces are to he placed and secored, so as to snjqpwt die great toe in a line with the patella, "^e limb sJiould be laid upon a jmUow on its side in a suu-flexed po^on.
AHhoUgh no great deformity can ju^ise fifMd this accident, <m account ai the sappcnft af- forded by the tiUa, yet a conAderable d^ree of lameness may result, if the case be n^- lected. Dr. Blair, a naval ^ysician, who bad fitactured his fibola, and Ind not pflud propw attenticm to the case, became in con- sequt^Me nnable to walk on flat ground without a lameness ; as the foot ¥ras twisted bv the irre^rular union of the broken bone. iViui^ Fractxire of the tibia often occurs at its iutorior part, either e3rtending into the joint, or $catovi iaimedrateiv above it. If the frac- Uirv enters the joint, but little deformity is
619
produced ; but if above the articulation, the lowei' part of the upper portion of the bone usually projects a little. The foot is gene- jfally inclined somewhat outwards, but the injury is easily detected by the crepitus, l^hich can be felt when the foot is freely moved.
This injury should be treated in every Treatment lespect as the fbrttier, but great <^are must be taken to prevent the inclination of' the foot outwards, and to keep the great toe in a line with file patella. When the fracture takes place obliquely from within* to without into the joint, the foot will be turned slightly in- wards, and the malleolus externus will pro- ject mSwe than usual; it will be necessary therefore, in the treatment) to attend to tbid point, otherwise it will be the same. By placing the limb upon the heel, the proper position of it is more readily observed, but the case will do equally well, with attention, if the extremity be laid upon the outer side.
The observations respecting the compound compound
, , . . -It 1 /* 1 fracture,
dislocations of the ankle jomt, will be found generally applicable to the cases of com- pound fracture communicating with the articulation.
2 L 4
520
Of Dislocations of the Tarsal Bones.
or attm. From the situation of the astragalus, and its very firm ligamentous connexion to the tibia, fibula, calcis, and navicular bone, we could scarcely suppose its displacement pos- sible, and although it is occasionally dislo- cated, yet the injury very rarely, if ever, occurs, without a fracture of one or more of the surrounding bones.
5^^2St" When dislocated, it is extremely difficult to reduce, and if this be not eff^ted, lame- ness to a considerable extent must be the consequence.
I had an opportunity of seeing a patient vtrho was under the care of Mr. James, of Croydon, in consequence of an injury ^o the tarsal joint.
Case. . I found that the tibia was fractured ob- liquely at the inner malleolus, and that the astragalus was dislocated outwards. Every means which Mr. James could suggest had been tried to replace the bone, but it still continued to project upon the upper and outer part of the foot ; so much force had been employed in making extension, that the integument sloughed in part. Conside- rable deformity resulted ; the toes were pointed inwards and downwards, and the
K4i
■ <m1
motions of the joint were in a great measure destroyed,
I attended the following interesting case, with Mr. West, of IlammcTsmith, and Mr. Ireland, of Hart Street, Bloonisbury.
Mr. Downes fell from his horse on the 84th of July, 1820, and dislocated his astra- ' gains. Mr. West, who first saw him, endea- voured to replace the bone, bnt could not succeed; he therefore placed the limb in splints, and kept the part moistened with goulard lotion. The patient was bled largely, and took some anodyne medicine. On the 25th, I visited Mr. Downes, with Mr. Ire- land and Mr. West, when I found the astra- galus displaced forwards and inwards, ac- companied with a fracture of the fibula a little above its malleolus. All my attempts to re- ' duce it proved ineffectual. The skin over it i appeared in a bursting state, so much so, that I felt inclined to divide it and remove the astragalus ; but knowing the resources of nature in accommodating parts under inju- ries, and of restoring the usefulness of the limb, I declined interfering, and the previous treatment was therefore continued. On the 28th, the skin over the bone began to inflame, and notwithstanding the employment of leeches and evaporating lotions, it sloughed ^^n the 16th of August, exposing the astra-
622
galus^ which gradually became loosened and dislodged. A profuse discharge attended this process^ but bark and wine freely given kept up the constitutional powers ; the wound was poulticed. On October the 5th, I re- moved the astragalus, having only to divide some few ligamentous fibred. After this, the wound was dressed with soap plaister, and the patient gradually recovered, being able to walk without the aid of a stick. <
compoand lu compound dislocation of the astragalus, the plan of treatment to be puri^ued has been already pointed out in the history of the com^ pound dislocations of thd ankle joint, from which it is evident, that the whole or a part of the astragalus may be removed, and yet the patient recover a very useful limb. If, however, the astragalus should still remain firmly attached, and can be replaced ; such treatment should be adopted in preference to taking it away.
Case. Mr. H^nry Cline had the following case
under his care in St. Thomas's Hospital.
On the 21st of June, 1816, Martin Bent- ley, aged 30, was admitted into the Hospital, having been severely injured by the falling of some heavy stones upon his legs. An ex- tensive compound fracture of the tibia and fibula existed in the left leg, near the middle, attended with so much mischief to the sur-
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Fioundtng soft parts, that Mr. Cline ampu- tatcd the limb below the knee. On the right side, a dislocation of the astragalus had been produced, occasioning the following appear- i ances ; — the os calcis, instead of projecting at its usual place, formed a protuberance on the outer side of the foot, beyond the external malleoius ; and beneath the malleolus was a considerable hollow ; on the inner side, and below the internal malleolus was a remark-' able projection, the toes were turned out; and the foot was inclined in the same direc- ) tion : the astragalus must have been dislo-' \ •cated inwards, both from the calcis and oh j naviculare, so that its inferior surface, instead of resting upon the upper part of the os calcis, was placed against its inner side. The reduction was accomplished by bending the leg at right angles with the thigh, and ex- tending the foot in a line with the leg, the knee being fixed ; at the same time, Mr. Cline placed his knee upon the outer part of the joint, and pressed the foot firmly against it, forcing the bones into their natural posi- tions. The limb was enveloped in a band- age, and placed as much as could be on the outer side, upon a well padded splint, to which it was secured by tapes. The spirit lotion was applied. On the 1st of July, the
thad some sickness and pain, which was
t
524
relieved by bleeding, otherwise he recovered without any urgent symptoms, and was dis- missed from the Hospital on the 26th of Au- gust, being able to use his limb tolerably weU. Cue. Another case of compound dislocation of
the astralagus also occurred under the care of Mr. Henry Cline, for the particulars of which I am indebted to Mr. Green. The accident, as the former had been produced by the fall of a heavy stone. The foot was turned in- wards; the anterior or navicular surface of the astragalus was exposed by an extensive opening ; a wound on the inner side exhibited the articular surface of the os calcis for the fistragalus. The reduction was made by placing the limb in the same position as for the reduction in the former case; then by extending the foot, and at the same time rotating it outwards.
The patient was a stout,middle-aged labour- ing man, ef not very sober habits, and subject to gout. Extensive erysipelatous inflamma- tion, which terminated in sloughing, and which gave rise to a great deal of constitu- tional irritation, retarded his recovery, which was, however, ultimately complete.
Mr. Green was likewise kind enough to furnish me with the following particulars of a case which was under his own care in St. Thomas's Hospital.
525
Thomas Toms, a bricklayer, aged twenty- < three, was brought to the Hospital on the I4th of July, 1820; he had fallen from a scaffold at the height of three stories, and in his fall the foot had been caught between two of the spikes of an iron railing, and in this way he became suspended, with his head downwards. When admitted a large wound existed beneath the inner malleolus of the left leg, through which protruded the anterior articular surface of the astragalas, which had been separated from the navicular ,1ione. The foot was inclined upwards and feutwards ; the tendons of the flexor muscles Were tightly stretched ; the posterior tibial artery had been torn through, and the accom- panying nerve partially lacerated. Several attempts were made to re-place the dislocated bone, but without success, although the wound was enlarged with a scalpel. As I ■was at the Hospital, Mr. Green requested to see the case, and after a careful examination of the injured limb, I proposed the removal of the astragalus, as much preferable to 'amputating the limb. Mr. Green therefore carefully separated the ligamentous connec- tion of the astragalus, and took it away; a ligature was put upon the posterior tibial artery. The natural position of the foot, Sec.
I
526
edges of the wound were brought together and supported by straps of adhesive plaister ; the limb was placed upon its outer side, on a well padded splint, having a foot piece; the evaporating lotion was applied on the limb. For several days after the injury the patient suffered a good deal from febrile symptoms, and some occasioned pain in the ankle; but when the suppurative process was well established, about the seventh day, all these unpleasant symptoms subsided, and he proceeded very favourably until the end of July, when the formation of an abscess again gave rise to some constitutional de- rangement, which was relieved as soon as th^ matter was discharged. A second collection c^ matter which occurred about the end of August, again retarded his recovery, and he continued in an indifferent /state until the 7th of September, with loss of appetite, and flight hectic; the leg becoming slightly iQ^ematous, but the discharge from the wound (Continuing copious. From that period b^ ]:]»ended rapidly, but little occurring to retard )m recovery, which wa3 complete on the 25th of October. He left the Hospital on the 2nd of November, and has since resumed his business, without any inconvenience, between^" Another form of dislocation of the tarsal
bones"** boucs somctimcs occurs from the falling of
527
heavy weights upon the foot ; by which the five lanterior tarsal bones, together with metatarsus and toes are displaced, the con- nections between the astragalus and navicular, and between the calcis and cuboid, being in a great measure destroyed.
A man was brought into Guy's Hospital, ^*''^* in consequence of an injury to his foot, upon which a very heavy stone had slipped. The fore part of the foot was turned up, whilst the posterior part formed of the astragalus and OS calcis remained in the natural state ; it presented very much the appearance of a club foot. The reduction was effected by fixing the heel and leg, and extending the anterior part of the foot. In five weeks the man had regained perfect use of the limb.
For the particulars of the following interest- ing case of compound dislocation, I am in- debted to Mr^ South. The case was under the care of Mr. Henry Cline, in St. Thomas s Hospital.
Thomas Gilmore^ aged forty-five, a stout case. man, and in the habit of drinking freely, was admitted into the Hospital on the 28th of March, 1815, in consequence of an injury to his ankle, which had been occasioned by the falling of a very heavy stone upon his heel. On the fore and external part of the joint was a large wound, reaching from the middle of
528
the inferior extremity of the tibia to the ex- ternal malieoluSy and exposing the anterior articular surface of the astragalus, for the navicular bone, and also that for the os calcis on the outside ; the tuberosity of the os calcis projected outwards, and the toes were direct- ed inwards, towards the other foot. The natural position' of the parts was restored by extending the foot and rotating it outwards. The edges of the wound were approximated, and retained in contact by the application of straps of adhesive plaister; the limb was placed in a fracture box upon the heel, and linen dipped in cold water was placed over the seat of injury, in consequence of some slight bleeding. During the following night he suffered much from spasms in the limb, and slept but little ; but no urgent symptoms presented themselves. On the 30th, severe constitutional irritation had been set up ; he was delirious, his pulse was very quick ; his skin hot and dry, his mouth parched, and he had rigor. Some inflammation appeared about the wound. He continued in this state until the 2nd of April, ¥rith some exten- sion of tlie inflammation up the leg ; taking every six hours the fever mixture, with some imtiiuonial wine. On the 2nd the severity of Iho constitutional spnptoms had subsided, lull ho coiupiiuned of pain in the wound, and
thelimb exhibited an erysipelatous blush.with some oedema ; a small spot on the leg, which had been bruised, was ulcerated. He pro- ceeded favourably until the 5th, when th© ( constitution became seriously affected, but the symptoms indicated a state of debiUty, and the ulcer on the leg was in a sloughy state, although the original wound secreted a healthy pus. He was ordered the bark in ( decoction. Until the 10th, these unpleasi symptoms were present with little alteration, and the superficial inflammation of the limb extended nearly to the groin, and mattei; appeared to be forming in different parts; | he was allowed a pint of porter, and a grain
if opium twice in the day. After this pe-
id, the inflammation gradually subsided,
■und the constitutional suffering became much
!ssened ; the quantity of porter was in- creased to two pints daily, and subsequently to three pints, on account of his weakness. Several superficial sloughs formed on the lieg, which separated very slowly, not being got rid of until the 15th of May. His appe- tite and spirits varied considerably, but with- out any further serious drawback, he gra- dually recovered, and quitted the Hospital :0n the 12th of September, being then able walk easily with the assistance of a
ack.
,. III. 2 M
530
2f 2!n^.^" I have seen two cases of dislocation of the ncSfoi^"' internal cuneiform bone; the first was in a bone. gentleman, who came to consult me a few weeks after the injury ; and the second was in a patient at Guy's Hospital. Both pre- sented the same characters ; the bone pro- jected inwards, and also a little upwards, being drawn up by the action of the tibialis anticus muscle.
In the first case, the dislocation was pro- duced by a fall from a height ; and in the se- cond, by the fall of a horse, the foot being caught between the horse and the curb stone. In neither instance was the bone re*- placed, but the displacement did not occasion any important lameness. Treatment. I should rccommeud in the U*ea(ment of these accidents, — first, to confine the bone as much as possible in its natural position, by binding a roller around the foot, and to keep the bandage wet with an evaporating lotion, until the inflammation has subsided, and then to employ a leather strap, which can be buckled around the foot, so as firmly to confine the bone until the ligaments are reunited.
Of Dislocations of tke Toes.
These dislocations are common either be- Seat of tweeu the metacarpal bones and phalanges, or between the phalanges themselves. The same treatment should, in such cases, be adopted, as directed for similar injuries to the fingers.
I had a man under my care in Guy's Case. Hospital, who, in faUing from a height, pitched upon the extremities of the toes, and had forced the first phalanges of the smaller toes, above the ends of the metatarsal bones, where they projected very much. Several months had elapsed after the receipt of the injury, which rendered all attempts to reduce the bones useless. The patient was after- wards obliged to wear a piece of cork hol- lowed at the bottom of the inner pait of the foot, to prevent the pressure of the metatarsal bones upon the vessels and nerves.
Of Dislocalions of the Zoiver Jaw.
The dislocation of the lower jaw may be Twofonii»| either complete or partial; when complete, both of the condyles are thrown into the space between the zygomatic arch, and the surface of the temporal bonej but when 2 M 2
532
partial, one condyle only escapes, whilst the other remains in the articular cavity.
Of the Complete Dislocation.
Signs of. When this accident occurs, the patient appears as if in a continued yawn, the mouth being widely open, without any power on the part of the patient to close it. < Some trifling degree of motion often exists, so that the chin can be either elevated or depressed a very little. The chin is advanced, the cheeks are protruded by the coronoid pro- cesses, and a hollow is perceived immediately before the meatus auditorius, on account of the absence of the condyloid process from the glenoid cavity. The secretion of the parotid glands is increased, and dribbled over the chin, and the pain is at first severe.
Causes of. The displacement may be occasioned by excessive yawning, by a blow upon the chin when the mouth is open, or by endeavouring to force any solid substance into the mouth, too large for the ordinary aperture. Mr. Fox, the dentist, informed me that he had known a dislocation of the jaw take place from spasmodic action of the muscles, when the mouth was widely opened to allow, of the extraction of a tooth.
533
The reduction of the dislocation should, as in other cases, be effected as speedily as possible, in the mode which the following lase will best explain.
1 was called by Mr. Weston, of Shoreditch, < to visit with him a madman at Hoxtou, who iiad had his jaw dislocated in an attempt to force some food into his mouth. Knowing that there would be great risk in employing 1 the means usually recommended, I adopted , itiie following plan ; — I had the patient placed iupon his back, with a pillow to receive his head, and in that situation he was firmly held ; then having procured two forks, I ^wrapped a handkerchief round their points, and passed the handles into the patient's mouth, one on each side, behind the molares teeth, and whilst they were held in that situ- ation, I forcibly drew the lower jaw towards the upper, by placing my hand under the chin ; in this way, the reduction was easily accomplished.
■ I prefer, however, the use of corks, instead i ^ofany more solid substance, which is likely to injure the gums ; those employed for stopping the common quart bottles are of about the proper size, and should be placed one on each side of the mouth, behind the .imolares teeth, after which, the chin is to be raised in the manner already described.
I
fi34
^s«p>oy- A long piece of wood is sometimes em-
^"f^- ployed in these cases as a lever^ introducing it between the molares, first on one side, and then upon the other, and each time raising the extremity of the wood furthest from the mouth, so as to depress that part of the lower jaw beyond the molar teeth, and ¥rith it the condyloid process, when the . action of the muscle will draw it into its articular cavity.
^JjJ^ Another mode which will generally suc- ceed if the dislocation be recent, consists in placing the thumbs, which should be well covered, at the roots of the coronoid pro- cesses, and with them forcing that part of the jaw downwards and backwards, and at the time pressing the chin upwards.
Liabiuty When once this dislocation has happened,
to recnr. * *
the patient is very liable to a further displace- ment. Aider the reduction, a bandage should be applied> having four tails, two at each end, and a hole in the centre to receive the chin ; of the tails, two are to be tyed over the head, and two behind the occiput ; and the patient should not be allowed to mas- ticate any solid food, until suflScient time has been allowed for the union of the lacerated parts.
Of the Partial Dislocation.
In this case, the condyloid process on only signs one side is displaced ; the mouth opened, but not so much as in the complete dislocations ; the chin is directed to the side opposite the injury, and thrown out of the axis of the face.
This dislocation is usually produced by a *^='" blow on one side of the jaw when the mouth is open.
The reduction may be accomplished either Rpfiiidion- J fay the cork or the lever of wood.
Of Subluxation of the Jaw.
The condyloid process of the lower jaw, Signs of. is, as I have already described to condyles of the femur to be in the knee joint, some- times displaced from the inter-articular car- tilage of the joint, slipping before its edge; fixing the jaw with the mouth slightly open.
The efforts of the patient alone are usually Redacedu sufficient to remedy the evil, but I have tif^p^tion known it exist a length of time, and after- wards the motion of the jaw and power of
L closing the mouth return.
M The displacement rarely happens but from cause of. J
H extreme relaxation of the ligaments.
536
iv«ttnieiit. jf called upon to relieve a patient under these circumstances^ the force employed should be applied directly downwards, to separate the condyloid process from the tem- poral bone, and thus allow the cartilage to resume its proper situation.
Frequent J have most frequently seen this accident
in yooBg * •'
women, in youug womeu, and have found such reme- dies as will invigorate the constitutional powers, as ammonia and steel, with the shower bath, most serviceable in subduing the tendency to its recurrence.
537
EXPLANATION OF THE PLATES.
PLATE I.
Shewing the Positions of the Limb in the different
Dislocations of the Hip*
Fig. 1. The dislocation upwards upon the dorsum ilii* The limb shortened — the hip projecting — the knee and foot turned inwards^ with the toes resting oyer the metatarsus of the sound limb.
Fig. 2. The dislocation downwards into the foramen ovale. The limb lengthened — the knee ad- vanced and -separated from the other — the toes pointed — the heel does not touch the ground — the body bent forward.
Fig. 3. The dislocation into the ischiatic notch. The limb shortened — the knee and foot a little turned inwards, with the great toe resting against the ball of the great toe of the sound limb.
Fig. 4. The dislocation on the pubes. Projection at Poupart's ligament from the head of the bone, the limb widely separated from the other^ and the knee and foot turned outwards — the limb a little shortened.
VOL. III. 2 N
538
PLATE II.
Skews ihe Mode of reducing the Dielooaiione of the
Hip.
Fig. 5. The bandages and puUies applied to reduce the dislocation on the dorsum ilii.
Fig. G. The bandages and puUies applied to reduce the dislocation into the foramen ovale.
Fig. 7. llie bandages and puUies applied to reduce the dislocation into the ischiatic notch*
Fig. 8. The bandages and puUies applied to reduce the dislocation on the pubes.
END OP VOL. 111.
S. MOLDJ»WOUTH, PRINTER^ Cfi, PATEKKUSTKK ROW, LUKUOM.
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