of 3 /3
663 attended with much pain ; aud in habits i of little or moderate irritability. But, when extensive or severe, even without being attended with pain, it occasions I more or less of general disorder, differing according to the state of system at the time, and other circumstances. As the leading symptom of this general disturb- ance, is increased heat, this state altoge- ther has been called, in general language, fever; and as it is the consequence of a previous disease (inflammation), it has been called symptomatic fever (pyrexia:) it being supposed that fever might take place independent of inflammation ; when it was called idiopathic or original fever : this however, I shall endeavour to show, is not the case. It has been also called constitutional disorder, or, the constitution sympathizing with the part, general in. flammation—or symploms of irritation.- (This subject will be resumed in our next lecture.) LECTURES ON SOME PRACTICAL POINTS OF SURGERY DELIVERED TO THE Students of the late Borough Dispensary, BY MR. ALCOCK. LECTURE X. Of Fractures. Gentlemen, fractures of the shoulder blade are less frequent than, from its exposed situation, might be expected ; but when it is consi- dered that the bone moves freely and ex- tensively upon the chest, and that the only point of firm resistance is that form- ed by its union with the clavicle, you may trace, in the yielding nature of the con- nexion of the scapula with the chest, the cause of the rarity of fracture of the sca- ptila. The acromion, the most exposed point of the scapula, sometimes is fractured by a direct blow upon it, as by the falling of a heavy body. The thin covering at this part, consisting of little beyond the inte. guments, admits of the easy and effectual examination of the acromion, and if frac- ture exist, it can scarcely be overlooked or mistaken. The raising of the arm by the action ofitsmuscles is impracticable, whilst the fractured portion of the acromion is drawn downwards by that part of the deltoid muscle attached to it. The treat iiietit consists in pressing the humeru upwards, so as to prevent the fragment from falling below its natural situation, and by bandages and compresses (or other apparatus) fixing the upper extremity to the chest, so as to prevent the motion of £ the parts upon each other. Fracture of the neck of the scapula is also of very rare occurrence, so much so, that a hospital surgeon of great expe- rience, and one of the Court of Exami- ners, has stated that he had only met with one instance of it during a period of 45 years. It is occasioned either by a di.. rect blow upon the shoulder, in a di4 rection downwards and inwards, or by a fall upon the shoulder, the shock being communicated through the head of the humerns to the neck of the scapula. The falling down of the head of the humerus so nearly resembles the displacement by dislocation, that it has happened even in a metropolitan hospital, that the pullies have been used to reduce the supposed dislocation, several weeks after the acci.- dent, when, on further inquiry, it was found that the fracture of the neck of the seanula had been ascertained bv other surgeons at a comparatively recent pe. riod after the accident. The stiffering attendant on forcible extension under such circumstances, may be conceived; but cannot be described! When the fracture is recent, it is not difficult to restore the limb to its natural position ,and the retaining it by compresses and bandage, so as to fix immoveably for the time the upper extremity to the chest, requires no more skill than what is ne- cessary in the treatment of fractures of the clavicle, or other accidents, which require perfect rest and apposition of in- jured parts. Fractures of the humerus, if transverse and lower than the insertion of the del- toid muscle, are the most simple in treat- ment, and generally successful in result of any of the fractures of the limbs ; on the other hand, oblique fractures at the upper part of the bone have been mis. taken, and permanent lameness has been the consequence of inefficient treatment. There is often, accompanying such acci- dents, considerable swelling ; but still the diagnosis is sufficiently distinct on careful examination, if the natural relation of the parts be well known, and the deviation from that natural condition of the parts be carefully observed. Perhaps a point

LECTURES ON SOME PRACTICAL POINTS OF SURGERY

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Page 1: LECTURES ON SOME PRACTICAL POINTS OF SURGERY

663

attended with much pain ; aud in habits iof little or moderate irritability. But,when extensive or severe, even withoutbeing attended with pain, it occasions Imore or less of general disorder, differingaccording to the state of system at thetime, and other circumstances. As the

leading symptom of this general disturb-ance, is increased heat, this state altoge-ther has been called, in general language,fever; and as it is the consequence of aprevious disease (inflammation), it hasbeen called symptomatic fever (pyrexia:)it being supposed that fever might takeplace independent of inflammation ; whenit was called idiopathic or original fever :this however, I shall endeavour to show,is not the case. It has been also calledconstitutional disorder, or, the constitutionsympathizing with the part, general in.flammation—or symploms of irritation.-(This subject will be resumed in our nextlecture.)

LECTURESON SOME

PRACTICAL POINTS OF SURGERY

DELIVERED TO THE

Students of the late Borough Dispensary,

BY MR. ALCOCK.

LECTURE X.

Of Fractures.Gentlemen,fractures of the shoulder blade are less

frequent than, from its exposed situation,might be expected ; but when it is consi-dered that the bone moves freely and ex-tensively upon the chest, and that theonly point of firm resistance is that form-ed by its union with the clavicle, you maytrace, in the yielding nature of the con-nexion of the scapula with the chest, thecause of the rarity of fracture of the sca-ptila.

The acromion, the most exposed pointof the scapula, sometimes is fractured bya direct blow upon it, as by the falling ofa heavy body. The thin covering at thispart, consisting of little beyond the inte.guments, admits of the easy and effectualexamination of the acromion, and if frac-ture exist, it can scarcely be overlookedor mistaken. The raising of the arm by the

action ofitsmuscles is impracticable, whilstthe fractured portion of the acromion isdrawn downwards by that part of thedeltoid muscle attached to it. The treatiiietit consists in pressing the humeruupwards, so as to prevent the fragmentfrom falling below its natural situation,and by bandages and compresses (or otherapparatus) fixing the upper extremity tothe chest, so as to prevent the motion of £the parts upon each other.

Fracture of the neck of the scapula isalso of very rare occurrence, so much so,that a hospital surgeon of great expe-rience, and one of the Court of Exami-ners, has stated that he had only met withone instance of it during a period of 45

years. It is occasioned either by a di..

rect blow upon the shoulder, in a di4rection downwards and inwards, or by afall upon the shoulder, the shock beingcommunicated through the head of thehumerns to the neck of the scapula. Thefalling down of the head of the humerusso nearly resembles the displacement bydislocation, that it has happened even ina metropolitan hospital, that the pullieshave been used to reduce the supposeddislocation, several weeks after the acci.-dent, when, on further inquiry, it wasfound that the fracture of the neck of theseanula had been ascertained bv othersurgeons at a comparatively recent pe.riod after the accident. The stifferingattendant on forcible extension undersuch circumstances, may be conceived;but cannot be described! When thefracture is recent, it is not difficult torestore the limb to its natural position,and the retaining it by compresses andbandage, so as to fix immoveably for thetime the upper extremity to the chest,requires no more skill than what is ne-

cessary in the treatment of fractures ofthe clavicle, or other accidents, whichrequire perfect rest and apposition of in-jured parts.

Fractures of the humerus, if transverseand lower than the insertion of the del-toid muscle, are the most simple in treat-ment, and generally successful in resultof any of the fractures of the limbs ; onthe other hand, oblique fractures at theupper part of the bone have been mis.taken, and permanent lameness has beenthe consequence of inefficient treatment.There is often, accompanying such acci-dents, considerable swelling ; but still thediagnosis is sufficiently distinct on carefulexamination, if the natural relation of theparts be well known, and the deviationfrom that natural condition of the partsbe carefully observed. Perhaps a point

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projects at the upper and anterior part ofthe shoulder, and there is shortening ofthe limb; with loss of power to move thelimb, and pain on passive motion beingused. Crepitns may generally be distin-guished, and the rotation of the humerusmoves the lower fragment, whilst the up-per fragment remains stationary.

Several years ago, a case of obliquefracture of the humerus, near its head,occurred, by a boy, subject to fits, fallingfrom a rock. He was taken up in a stateof insensibility, and his head was muchinjnred ; when he somewhat recoveredfrom the shock, he was nnable to give anyclear account of the accident. The stir-geqn upon whom the responsibility of thecase rested, considered the swelling aboutthe shoulder and upper part of the arm,which was very great, as merely muscu-lar tension, and directed a cold lotion.Two days afterwards, the shortening ofthe arm, measured from the acromionto the olecranon, was one inch, comparedwith the sound arm. No crepitus wasobserved, and the surgeon thought thehumerus safe. On the fourth day theswelling was diminished. but still therewas preternatural fulness under the pec-toralis major, and some degree of hollow-ness behind. On the llth day, crepitnswas observed on moving the arm. No treat-ment relating to the arm. On the 19th

day, the surgeon upon whom the responsi-bility rested, wds nearly persuaded of theexistence of fracture of, the humerus, butnot sufficiently to act upon this opinion,as he considered the point (the upperend of the lower fragment) to be loose,till another surgeon convinced him thatit only moved on rotating the humerus.Gentle extension was made ; but unionhad so far taken place, that no elongationwas effected. Twenty-four days afterthe accident, though the part was firmenough not to yield to any moderate ex-tension, he had no power to raise the arm,but could move it backwards and for-wards, yet not sufficiently forwards torender him capable of using the hand inthe positions requisite in his business.that of a shoemaker. A consultationwas holden, and the question was soonnarrowed to a simple choice, either toleave the unfortunate patient lame dur-ing the remainder of his life, or to at-tempt to separate the imperfect union,that the parts might, by subsequent care,be restored to their natural position. Thelatter was determined upon, one of theconsultants having witnessed a neglectedfracture of longer duration attended withlameness, which had been restored tothe condition of a useful limb by similar

means. The refracturing of the part wasnot so easy to carry into effect. Exten-sion was of no avail; but on using a ,

towel, passed under the place of union,as a fuicrom, and the arm as a lever, the ’

bone gave way. This was repeated be-fore the disunion was slIfficientlyeffected,and the point, which since it had unitedmoved on the axis of the upper part andhead of the bone, describing a large cir-cle when the arm was rotated, nowmoved on the axis of the lower part of thehumerus, the point itself having merelyrotatory motion. Extension restored the!imb nearly to the same length as thesound arm. It was retained, in situ, bysplints, compresses, and bandages. Theresult was perfectly satisfactory, althoughlesser difficulties occurred from time totime, owing to the same cause which hadproduced the omission of efficient treat.ment in the first instance ; he recoveredthe perfect use of the arm, and cotildwithout inconvenience move it in everydirection.

I could adduce other instances in whichan imperfect diagnosis in the first instanceand consequent inefficient treatment,were productive of permanent lamenessand deformity.

In oblique fractures of the upper partof the hnmerns, the chief points to beattended to are lst. to make the necessaryextension, to restore the natural positionot the fractured portions; 2ndly. to sup-port the parts in contact by compresses,bandage and splints, so as to prevent thefractured surfaces from passing beyondeach other ; 3rdiy. to relax the muscleswhich operate most powerfully in the

displacement of the fragments, that theleast force may be required to counteractthem ; and 4thly. to arrange the appara-tus in such manner that the examinationof the fractured part may be made, fromtime to time, without disturbance of thefracture,that the favourable progress maynot be guessed at, hut ascertained ; or ifany deviation occur, that it may be cor.rected, lest permanent injury remit.

Fractures of the condyles require greatcare to guard against inflammation of theelbow jomt ; but, with proper attention,terminate as favourably as other frac-tures. To relax the muscles attached tothe condyles, the bending of the fore-armnpon the arm, to a right angle, is all thatis necessary, whilst perfect steadiness ofthe limb must be preserved, by splintsand compresses, till union take place.Fracture of the fore-arm may be simply

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that /If the radius or of the ulna; or ofboth these bones.

Fracture of the radius generally occursby the shock of a fall being received uponthe wrist, and the arch of the radius b°ingbroken, as happens in fracture of theclavicle. Pain on moving the hand andipability to perform pronation and supi-nation, together with the deformity, cre-pitus, and particularly the yielding of thelower fragment when the upper part ofthe bone is kept steady, are sufficient toafford certainty of the nature of the ac-

cident. If neglected, the hand remainingprone during the period of union, thepower of supmation is lost, or nearly so,and great inconvenience results to the

patient in consequence. A young lady inthe country fell, and in attempting to saveherself the wrist of one hand receivedthe shock ; she complained of pain in thefore-arm and was unable to move it. Toher mother, who was a very intelligentlady, the deformity was so obvious thatshe at once concluded the arm (fore-arm)was broken, but the surgeon who examin-ed it did not discover the fracture, and notreatment beyond the use of lotions wasadopted. Some months subsequently thepatient came to town ; the supination ofthe hand was so nearly lost, that she couldnot convey a spoon or fork to her mouth;there was considerable irregularity at thepoint where the fracture had taken place.It was obvious that, by persevering ex-

ercise in attempting to perform alternate-ly pronation and supination, a considerableimprovement in the use of the hand mighthe effected; but the difficulty was infinding exercise requiring these motionswhich should combine amusement ; thiswas however contrived, and she graduallyregained the full use of her hand ; butnot till after many weeks of daily per-severance.

In the treatment of recent fracture of Ithe radius, care must be taken to keepthe hand between pronation and sl1pina-tion, that is with the thumb upwards ;the bent position of the elbow is essen-tial to the comfort of the patient Thespints should not extend below the lowestpoint of the ulna, lest, by pressing thehand upward, the arch of the radius bederanged by forcing the fragments toonear the ulna.

Fracture of the ulna is much less fre-quent than that of the radius. The treat-ment is essentially the same, viz. to relaxthe muscles, to restore the displacedfragments, and to retain them by com-presses, bandage and splints, in their

natural position, in easy.and steady con-tact.

The same treatment is required whenboth bones are fractured ; but when thefracture is near the wrist, without greatcare, both on the part of the surgeon andof the patient, deformity is likely to re-sult.

Fracture of the olecranon has been bysome surgeons and anatomists consideredincapable of osseons union. Of the prac-ticability of perfect union, under favour-able circumstances, I have no doubt; butif the parts be not kept steadily in con-tact for a sufficient length of time, unionby ligament is the usual result, and theweakness of the limb is proportionateto the length of the adventitious ligament.

I have had patients in whom the unionwas so complete, that the point of frac-ture after union could scarceiybe traced,and in whom the limb was as unseful as

before the accident; whitst with a head-strong patient, who, in spite of remon-strance, never refrained kiom using thearm, I have known tho- detached portiondrawn upwards a full hand’x-breadth

above the elbow, upon the back of thearm.

There being but one muscle, the tricepswhich is inserted into the olecranon, andcapable of displacing it, it is obvious thatto relax that mnscle is essential to the

retaining of the detached fragment in itsproper situation ; this is effected by ex-tending the fore-arm so as to render itnearly stratght. The assi-tance of com-press, bandage, and a splint to preventflexion of the elbow will be requisite ; butas I have, in the same votnme which con-tains the essay on Education, entered intothe details respecting the fractures of the

olecranon and patella, I need only de-

monstrate the mode of applying the ap-paratus in addition to what I have therestated.

Mr. A. referred to the mode of fixingthe arm to the chest, in the treatment ofthe fracture of the clavicle, as admittingof any required modification in the treat-ment of fractures of the scapula; anddemonstrated the mode of putting upfractures of the arm, fore-arm, and of theolecranon.