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Text of LONDON MEDICAL SOCIETY. April 9, 1827

Page 1: LONDON MEDICAL SOCIETY. April 9, 1827


shell, and thus guaids itself from furtherinjury. A snail, when touched, withdrawsitself within its shell; but if a little quicklime be sprinkled upon it, so that it. nolonger affords a secure residence, it is throwninto violent agonies, and endeavours to availitself of its locomotive powers, in order toescape the danger. The common earth-worm endeavours, in the first instance, tocontract its dimensions as much as possible;it then renders its integuments as tense asits frail texture will admit, in order to de-fend itself against " the heedless tread ofman." The hedgehog, when alarmed, drawsits body together, expands its prickles, and,in this way, bids defiance to its adversary.But, in the vegetable world, we meet withno such provision. This sensitive plant,for instance, when it contracts on the appli-cation of a stimulus, is in just as defencelessa state as ever - it is incapable of makingresistance ; and this, I may observe, fur-nishes .one of the strongest argumentsagainst a fanciful hypothesis maintained byDr. Percival of Manchester, and the cele-brated Dr. Darwin, namely, that plants werepossessed of the faculty of perception ; thatthe grass, in fact, which we crush beneathour feet, is sensible to impressions of pain.’1 render objects so completely helplessand unprotected exposed to incessant suffer-ing, would be inconsistent with that good-ness, benevolence, and merciful attention toour wants, so strikingly displayed in all theworks of a loving and bountiful Creator.


April 9, 1827.

Dr. HASLAM, President, in the Chair.

The resumed Discussion on Bony Union of Frac-ture (if’the Neclc of the Thigh Bone within theCapsule.

THE minutes of the preceding meeting liav-ing been read, Mr. 1 YRRELL rose amidst acrowded audience, and said he thought Mr.Amesbury had overlooked some importantpoints in his observations upon the patlio-logy of fractures of the neck of the thighbone. Mr. Amesbury stated, that he be-lieved that want of apposition and rest wasthe principal cause of non-union in fractureswithin the capsule. He (Mr.Tyrrell) thought,on the contrary, that Sir A. Cooper hadshown that the principal cause was insuf-ficiency of nourishment in the pelvic por-tion of the bone. Mr. Tyrrell then madesome observations upon the mode of exa-roining the fractures which occur ia the neck

of the thigh bone. He thought that gêl1tlé-men might be misled by symptoms resem-bling those which are observed when theneck of the thigh bone is fractured, andwhich he believed sometimes occur in otherinjuries. He had a case which he conceivedwas fracture of the neck of the thigh bone,but he afterwards found there was no frac-ture at all. Mr. Tyrrell, in reverting to thespecimens of reputed fracture of the neckof the thigh bone shown to the Society byMr. Amesbury and Mr. Langstaff, said thathe had seen such alterations in the state ofthe neck of the thigh bone in old people,that he (Mr. Tyrrell) doubted whether anyfracture had taken place in either of thespecimens shown to the Society by thegentlemen above mentioned, and we iin-

derstood him to say, that he thought thatneither of these bones had been fractured

through the neck. Mr. Tyrrell thought Mr.Amesbury had also overlooked the influenceof the synovia, which he (Mr. Tyrrell) be.lieved would assist very materially in pre-venting union, both by its presence betweenthe fractured surfaces, and by distendingthe capsule of the joint, so as to keep themseparated from each other.Mr. AMESBURY said, in answer to Mr.

Tyrrell, that he was sorry he (Mr. Tyrrell)was not present at a former meeting of theSociety, when the subject of fractures of thethigh bone was under consideration. If hehad then heard the observations which fellfrom him, he would have been spared thetrouble of making those remarks which theSociety had just heard respecting his opi-nions upon the subject of union by bonewithin the capsule. He would repeat, forthe information of Mr.’Tyrrell, and for thosegentlemen who had not heard him. Mr.

Amesbury stated on that occasion, that thecause of non-union within the capsule, wasreferrible to the modes of treatment corn-

monly adopted. The means usually em.ployed were not calculated to preserve appo.sition and rest, and to their inadequacy inthese respects, we must attribute the fre-quent occurrence of non-union in thosecases. Splinters of bone entirely denudedand lying loose, will accept of union, pro-vided they are not deprived of their vitality ;and he, (Mr. Amesbury) saw no reason whythe pelvic portion of the bone, when there isfracture of the neck within the capsule,should not unite by bone more readily thana denuded splinter, seeing that the pelvicportion is not only supplied with a suf-ficient quantity of nourishment for its sup-port, but also with a sufficient quantity toproduce an ossific deposit upon its fracturedsurface, as is shown by the increased den-sity of the bone at this part. With respectto the specimens of what he called fractureof the neck within the capsule, he should

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not occupy the time of the Society, by at-tempting to persuade the gentlemen whodoubted that these specimens had reallybeen fractured within the capsule, andthat they were now united by bone ; butlie wished the Society to bear in mind theprincipal facts which had been related -in Ithe history of the cases from which thesespecimens were taken, viz. that each of 111fthese persons, who had no other affectionbut such as arises from age, met with a

slight accident, such as we find often pro-duces fracture of the neck of the thighbone, and immediately after the accident,each of them was found to have retractionof the limb to a considerable extent, amount-

ing, in Mr. Chorley’s case, to about twoinches, evertion of the foot, and an inabilityto bear upon the limb. I say, Sir, (said Mr.Amesbury,) I wish the Members of the So-ciety to bear these facts in mind, and to ex-amine the specimens, in both of which theywill see a distinct line of ossific union, andin one, great displacement of the head of thebone, and then, Sir, they may draw theirown conclusions. I do not conceive thatthe presence of the synovia between thefractured surfaces, will have much effect inpreventing union by bone in fractures withinthe capsule, any more than in the fracturesof other joints. In fractures of other joints,the synovia must often get between thefractured surfaces ; but this does not pre-vent union from taking place. The disten-tion of the capsule, which sometimes occursfrom the effusion of a large quantity ofsynovia and serum, arising in conse-

quence of the inflammation which comes on

very soon after the accident, I am disposedto consider of little moment; for though itis possible that other fluids may have theeffect of distending the ligament, so as torender the capsule of the joint preternatu-rally capacious, yet I see no reason whythose effusions should not be absorbed afterthe inflammation has subsided, as wellwithin the capsule of the hip joint, as inthe capsules of other joints. We see greatdistention of the capsules of other joints,from the effusion which takes place subse-quent to fractures of those parts of boneswhich enter into them ; but this effusion istaken away in a short time, and why shouldnot the absorbents of the hip-joint be equallyactive ? As soon as the effusion is removed,there is no mechanical power acting so uponthe ligament, as to have any effect in keep-ing the fractured surfaces separated fromeach other.

Mr. Amesbury having made these obser-vations in answer to Alr. Tyrrell, stated thathe had on a former evening promised theSociety, that he would submit to their in-

spection an apparatus which he had con-

trived for simple fractures of the upper thirdof the thigh bone, for compound fracturesof the thigh, and certain diseases of thehip joint. He had had this apparatus con-veved to the Society, but should confinehis observations respecting it to frac.

tures of the neck of the thigh bone. Hehad, on a former evening in that Society,made a broad assertion, that the means comemonly employed in the treatment of frac-tures of the neck of the thigh bone, were notof a nature calculated to bring about thoseresults which it is the surgeon’s businessto obtain. J think, Sir, said Mr. Amesbury,that it is a duty which I owe the Society,to offer them something more than a meieassertion in proof of the accuracy of whatI ventured to advance in general terms. Ishall, therefore, throw out a few observa-tions upon the modes of treatment usuallyresorted to in the management of thesecases.

We are told that when we are called to acase of fracture, we should place the fracturedends in their proper situation, and keepthem there ; but surgeons appear to forgetthat this last indication resolves itself intoseveral, differing in number according tothe situation of the fracture: In fracturesof the neck of the thigh-bone, we have com-monly retraction of the thigh, which shouldbe prevented ; this is one indication we haveof evertion or invertion of the foot ; this alsoshould be prevented: we see that the tro-chanter drops ; this then requires to be sup-ported : we see that motion of the fracturedends occurs, whenever the limb or the bodyis moved; this too should be guarded against.These, then, are four indications, to whichwe may add another, that of keeping thefractured surfaces closely applied to eachother. All these indications should beanswered, otherwise we have no right to

expect that the fractured ends will unite,even in the most favourable cases, by theinterposition of bone. Now, let us see howfar these indications are answered by theusual plans of treatment. The first that Ishall mention, is that of drawing the in-jured limb down, and confining it to theother, by meaus of a bandage passed round,the ancles and feet. By this plan, it is in-tended to make a splint of the sound limb,so as to prevent retraction, and to preventevertion or invertion of the foot. Here wesee only two indications answered ; no at-tempt is made to keep the fractured surfacesin apposition, nor is there any provision toprevent motion of the fractured ends, whichmust take place whenever the patient raisesthe body to answer the calls of nature.Another plan is to place a hoard at the footof the bed, and lay the patient upon the bed,so that the foot of the sound limb shall rest

against the boards A cord, connected with

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the foot of the injured limb, is passed througha hole in the board ; and to this cord is ap-pended a weight to keep up extension.Here we see, that provided the patient con-stantly keeps the sound limb straight, ex-tension may be kept up, and that is all.Thus, then, we perceive, that by this modeof treatment, only one indication is answered ’’,,out of five that have been mentioned. Thefractured surfaces are not kept in appositionnor at rest, any more than when the feet are ’tied together. A third plan is to place asplint on the outer side of the sound limb, towhich it is fastened, and extending fromthis in a transverse direction, another pieceof board, which is situated at the bottom ofthe sound foot, and long enough to allow ofthe foot of the injured side to be connectedto it, so as to keep up extension of the in-jured limb. Here again we observe thesame inattention to apposition and rest,which we noticed in the other modes of treat-ment that have been mentioned. A fourth

plan is to apply the splint invented by VI.Boyer. By this, extension may be kept upin some degree, but rarely sufficient to pre-serve the injured limb of the same lengthas the sound one; for the strap, passinground the thigh over the injured part, pro-duces so much pain, that the patient is, inmost cases, unable to bear the pressure re-

quired to keep the injured limb of its properlength. This apparatus, too, has a tendencyto force the fractured surfaces from one

another. Upon these considerations, there-fore, it is objectionable ; besides, it answersonly one indication,-viz. extension of thelimb. Apposition and rest are not at-

tempted, when this apparatus is employed.The fractured surfaces are not kept to-

gether, nor is motion of the fragments pre-vented ; when the body is moved, or thelimb is moved, motion takes place in thefracture. A fifth contrivance employed inthese cases, is the fracture box or doubleinclined plane. By this contrivance, wemay prevent invertion or evertion of thefoot ; and we may keep the limb in the bentposition, which position is the most ad-visable, because it prevents the knee frombecoming stiff, but we cannot keep up aproper and regular extension of the limb.The limb is kept in a proper position;but the pelvis, by its gravity, sinking intothe bed or mattress upon which the patientlies, carries away with it the pelvic portionfrom that portion of the neck of the bonewhich is attached to the shaft. This appa-ratus, therefore, is no more calculated to

preserve apposition, than either of the otherplans of treatment I have mentioned, nordoes it keep the fractured ends at rest ; for,whenever the pelvis is moved, motion is

produced in the fracture, in consequence ofthe pelvic portion moving with the pelvis,

while the shaft of the bone remains at

rest. These, Sir, are the plans of treat.ment which have been resorted to with aview to produce bony union in frac.tures of the neck of the thigh bone withinthe capsule; and because bony union can.not be produced by such means, we are toldthat bony union cannot be produced at all.Sir A. Cooper having found that he has notbeen able to produce union with these con.trivances, and that his friends have failedto do so as well as himself, he has come tothe conclusion, that we should not attemptto procure the union of a fracture withinthe capsule. He recommends us not toconfine our patients more than a few days.He advises us to place a rolled pillow underthe knee, and to keep the limb upon it for afew days, and then to let the patient get up.Here Mr. Amesbury showed a diagram, il.lustrative of the evils which must occur tothe patient when this plan is resorted to,and said, that the body gravitates towardsthe foot of the bed, and carries with it thepelvic-portion ; and the pillow yielding, thethigh gravitates towards the pelvis, so thatwe have two forces constantly operating,independent of the action of the muscles,to cause the fractured surfaces to pass eachother. Mr. Amesbury was sorry to men-tion Sir A. Cooper’s name, as connectedwith this practice, but his name was sowrapt up with it that he was obliged to doso. He regretted much that Sir A. Coopershould have recommended this plan of treat.ment, as well for his own sake as for the

profession and the public. This was a planof treatment which, in his (Mr. A.’s) opi-nion, was not only useless, but must beoften very injurious. It was well known,that in many cases of fracture of the neckwithin the capsule, the close coverings areonly partially divided, and that in some theyare but little injured. In such cases, from themode of treatment recommended by Sir A.Cooper, those slips or portions of the closecoverings which are not torn through at thetime of the accident, will probably becomeabsorbed in consequence of the constant

pressure of the ragged ends of the fracturedbone against them. Strong pressure, weknow, is calculated to produce absorptionof ligament, and even of bone in other parts,and why not produce it here ? And whenwe add to the pressure the friction of theserrated edges of the fractured ends againstthe close coverings of the neck of the bonewithin the capsule, there is too much rea-son to fear that absorption, or laceration,would be the consequence, and thus a frac-ture, of the most favourable kind for the

patient, would be converted into one of themost unfavourable ; so that it is nearly thesame to the patient whether a completedivision of the close coverings is produced

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by the force which occasions the fracture,or by the powers which are, according to thisplan of treatment, suffered to operate sub-sequent to the occurrence of the accident.

Mr. Amesbury now called the attentionof the Society to the plan of treatment re-commended by Mr. Harrold ; by the con-trivance which he recommended, as farback, as he believed, 180.5, all the indica-tions which Mr. Amesbury had mentioned,might be answered. He thought, how-ever, that the contrivance which Mr.Harrold had recommended, was far morecomplicated than was necessary to answerthese indications ; he therefore regret-ted that Mr. Harrold had not simplifiedhis apparatus, which Mr. A. thought hemight have done if he had reflected moreupon the subject. Simplicity should beadhered to as much as possible ; but ifhe were asked what he meant by theterm simplicity, as applied to a piece ofmachinery for surgical purposes, he shouldsay, it is that which answers the same in-tentions by the fewest means. To illus-trate this point, he would say, that if oneapparatus contains twenty parts, anotheronly two ; the one with two parts was to bepreferred, if they were both found to answerthe same intentions. He objected to Mr.Earle’s bed, because it is more compli-cated, he conceived, than is necessary, andbecause it does not allow of being adaptedto the exact length of the thigh bone, whichhe considered a point of great impoit-ance. Mr. A. now exhibited and explainedhis new bed for fractures of the upper thirdof the thigh bone; compound fractures ofthe thigh, and certain diseases of the hip,and of the knee-joints. Mr. A. said that hedid not claim for this new contrivance anynovelty in principle. If any merit were at-tached to him, it was only on account of theimprovement in its mechanism, which im-provement consists in its greater simplicity.Mr. A. now explained upon a diagram oflarge size, the manner of using his frac-ture bed, for fractures of the neck of thethigh bone, and demonstrated the manner inwhich the apparatus may be made to an-

swer all the indications which he stated in aformer part of his remarks, before we haveany right to expect bony union will be com-monly produced in fractures within the

capsule.Mr. Amesbury concluded by observing,

that he did not expect that his contrivancewould be adopted for a considerable time,for it so happens that the profession isnot very fond of taking up any thing new.A great many years usually elapse be-fore the public are allowed to reap the ad-

vantage of any new invention or improve-ment, however valuable it may be. Dr.

Spurzheim had been demoMtrating the

structure of the brain for upwards of tenyears ; but though his mode of describing itis considered on all hands to be the best andthe only scientific plan, yet that plan isnot adopted. Dr. Blundell published hisvaluable observations upon transfusion tenor twelve years ago, yet it was not till lastyear that the subject was taken up, so thatthe public might obtain the advantageswhich it offers; and he would say that thepublic were indebted to that Society for themanner in which that subject was taken upin the winter of t825 and 1826, and to THELANCET for the publication of their discus-sions, for all the advantages which they ?Jowenjoy from what was published so long agoby Dr. Blundell. Mr. A. said, he liked thespirit of the Society as it was now constitut-ed. It should be their business to investigateprinciples, doctrines, and plans, withoutany regard to the persons from whom theyemanated, and if they found them good, theyshould sanction their introduction, and ifbad, they should endeavour to prevent thepublic from being injured by them. Thiswas the feeling, he thought, which now ex-isted in the Society, and he trusted it everwould be as long as he had the honour to bea Fellow of it.AGENT LEMAN, whose name we could not

learn, made some remarks which he willfind answered by referring to our former re-ports ; and others, which we did not un-derstand. However, he will have an op-portunity of explaining himself at the nextmeeting, as it was agreed that the discus-sion on fractures of the neck of the thighbone should be resumed.


To the Editor of THE LANCET.

SiR,-During Dr. Spurzheim’s demon-stration of the brain, at the Bristol Insti-tution, the following occurrence took place--That convolution pointed out as the or-gan of justice, was remarked by the Doctorto be unusually small ; one of the medicalmen present, wishing to ascertain thecharacter of the man, made’ inquiries, andfound he had died in the poor-house, andthat by inventing gross falsehoods, and

practising various deceptions, he obtainedrelief several times, and was otherwiseknown for his want of conscientiousness.Your impartiality in admitting facts relativeto phrenology in your Journal, induces meto send you this, and should you deem itworthy of insertion, will much oblige

Sir, your constant reader,A PHRENOLOGIST.

Bristol A prill1, 1827.