Page images
PDF
EPUB

founded, and of removing any positive dislike to it, or hardness of believing it on reasonable evidence."

Writing merely to excite enquiry into the truth of a system which he esteems highly important and interesting to mankind, by proving its reasonableness and conformity with whatever is ascertained to be fact in the science of mind, our author has confined himself to arguments drawn from the state of the faculties during health alone. We have extended the argument to the state of the mind during disease, believing that if the truth is discovered, it will be found consistent with the phenomena of mind in every condition, whether of health or of disease. And for the same reason of wishing to excite enquiry, and of not vouching for the truth of the facts from his own experience, the author does not enter upon any of the objections which have been made against them. Had he been either a decided believer, or a decided opponent, he never could have passed them over in silence. This article, intended for the introduction of the subject to the notice of our readers, has already extended to too great a length to admit of our examining the objections in detail. Generally speaking, none of them appear to be opposed to the principles of the science, but all to hinge, more or less, on the difficulties of the enquiry.

XIII.

Quarterly Periscope

OP

PRACTICAL MEDICINE;

BEING THE

Spirit of the Public Journals,

FOREIGN AND DOMESTIC.

Paucis libris immorari of donutriri oportet, si velis aliquid trahere, quod

in animo fideliter hæreat. SENECA. Duo yitia vitanda sunt in cognitionis et scientiæ studio. ***** Alterum

est vitium, quod quidam nimis magnam operam cunferunt in res obscuras atque difficiles, easdemque non necessarias, CICERO,

EXTRA LIMITES.*

On the Treatment of Fractures of the Lower Extremity.

By J. AmesBURY, of the Royal College of Surgeons,

London.t The author states that it is not his intention to give a detailed account of the treatment of fractures of the leg and thigh at present, but merely to throw out a few observations, which he has found useful in his own practice.

He goes on to enumerate some of the principal plans of treatment that have hitherto been adopted by different practitioners; and conceives that the employment of any one of them is attended with dis. advantages to the patient, which materially militate against its use ; and then rapidly proceeds to the consideration of the causes of disa

The great number and length of our Analytical Reviews this quarter has left us no room for our usual Quarterly Periscope ; nevertheless we have given an Extra-limites Periscope, or Analytical Review of an important paper on fractures, by Mr. Amesbury, at our own private expense. We have also to state, that the number of applications which we have had for the insertion of trifling, unimportant,

or self-interested papers, in our Extra Limites, has determined us to fill up that department, in future, with extra-analyses, as on the present occasion—a circumstance that will save us much tedious private correspondence, for which we have not leisure, and render the Journal uniform and homogeneous.

A few of our correspondents, from whom we received some good papers, must take this as an apology for not complying with their wishes.

+ See Quarterly Journal of Foreign Medicine, No. XV.

placement. In these, he thinks, the bones themselves in no way participate. Among these causes the action of the muscles is considered the principal. Every other he conceives to be secondary or accidental. The action which the inuscles exert upon the broken bones is not looked upon as voluntary, but as altogether depending upon their tonic power. This kind of contraction is much increased by every thing that irritates them; and as the fractured ends of the bones, when once displaced, oppose their ragged edges to the inflamed and tender bellies of the muscles, they must be regarded as a powerful mechanical stimulus, which occasions the muscles to contract more forcibly, and increase the displacement and all its attendant evils. From this it would appear that one grand principle in the treatment of fractures is, to place the bones as early as possible in a natural position, and a second is, to keep them from moving and injuring the soft parts.

With due deference to his predecessors, the author conceives every man has a right to think for himself; and from his reasoning, it might be inferred, that no one, however celebrated he may be, is to be considered culpable for not giving the best plans of treatment for the disease or accident upon which he writes. The surgeon does his duty as an author, both to his brethren and the public, if he lays before them the best plans he is acquainted with, or such as he conscientiously believes to be correct. If any one points out a mode of treatinent, which, on fair examination, shall be found preferable to those previously adopted, he confers an obligation on every member of society. He advances the profession one step rearer to perfection, and the honor due to him is not to be taken away by any thing his successors may bring forward. A complex being is not to be viewed at a single glance. Many parts of our profession require for their development the talents of many ages.

Wishing to add something to the general stock, the author proceeds “to offer a few observations, which may tend to throw some light on the mechanical treatment of injuries, of so much interest to the patient as well as to the surgeon."

Speaking of the straight position in fractures of the thigh, he says: -"To judge correctly of the proper position of the limb, in a case of fracture, we must take into consideration the natural form of the fractured parts; and, also, those powers which tend to displace the bone when broken. What then, for instance, is the natural form of the femur? not straight, as the practice of placing the limb in the straight position would indicate, but it forms a segment of a large circle, whose convexity is placed before, and concavity behind. The points of support, therefore, when this bone is placed upon a plane, with its concavity towards it, are at the ends; and the effect of fracture through its middle, would be to divide the segment of a circle, which the thigh-bone forms, into two smaller seginents; and the middle of the bone being unsupported would reach the plane; and the lower edges of the fractured ends will be seen exposed, and ready to prick and lacerate the surrounding textures."

This is, we think, the fairost view that can be given of this prac

tice. It supposes the bone to be uncovered by the soft parts, and
merely broken through the middle as it lies upon a plane; and it
shews that, if the muscles were perfectly quiescent in a case of frac-
tured thigh, the practice of placing the limb in the straight position,
is not borne out by the anatomy of the parts, when the fracture is
through any part that might become thus displaced by the simple
want of continuity, independent of the action of the muscles; and it
is an argument that goes to prove, that the middle of the bone ought
to be supported under all positions and motions of the limb.
We

e now pass on to the consideration of displacement, in fractures of the thigh, as it is observed to be influenced by the action of the muscles, when the limb is placed in the straight position; and this is greatly modified by the degree of laceration of the soft parts " at the site of fracture; the situation of the fracture; its direction, &c.”

When the thigh is amputated high up, the flexors often act so powerfully as to place the stump, for a time, nearly at right angles with the pelvis, hence it must be evident, that when there is a solution of continuity in the bone, the muscles which tend most to displace the upper fragment, are the iliacus internus and psoas magnus; and the effect of their contraction is more or less powerful in raising the upper part, in proportion to the distance of the fracture from the point of their insertion; or the length of the lever by which they are resisted. But what muscles act most upon the lower portion, so as to produce displacement in the transverse direction? It will be recollected, that the fixed points for the action of the gastrocnemius and popliteus are, in the natural state, principally the condyles of the femur; and that their contraction assists in the extension of the foot and flexion of the leg. But fixed points, in anatomical language, are considered as those which oppose the greatest resistance to the action of muscles, hence it will appear that those points, which in the natural state are the most fixed, may after the accident become the most moveable. If a muscle were attached to two bodies, which oppose an equal degree of resistance to a contraction of its fibres, these two bodies must move with an equal degree of velocity towards its centre; but if one of these bodies be more fixed, either by weight or length of lever, than the other, the lighter body must move towards the heavier, or more resisting, in whatever manner the resistance may be produced. From this it will appear, that when a fractured thigh is placed in the extended position upon the heel, the fixed points for the action of the gastrocnemius and popliteus are, pro tempore, no longer in the condyles, but at the points of their insertion; therefore, the contraction of these muscles tends to carry the lower fragment in a direction directly opposite to that of the upper; and this with a degree of force proportionate to the distance of the fracture from the lower end of the bone. If the solution of continuity be across the upper third, the transverse displacement, as far as the muscles are concerned, is principally produced by the action of the iliacus internus and psoas magnus; and if near or through the condyles, by that of the gastrocnemius and popliteus:--the former muscles move tho part to which they are attached upward and forward; and the latter, Vol. III. No. 12.

6 B

[ocr errors]

downward and backward; thus, the upper portion is bent upon the pelvis; and the lower is bent upon the leg. The straight position puts these muscles into a state of tension, and consequently increases their power over the unresisting fragments. The transverse displacement being once produced, the extensors and long flexors of the leg are goaded into action; and, assisted by the triceps adductor femoris and, if the fracture is high up, by the pectinæus, they contract forcibly and draw up the lower portion, which glides beneath the upper -sometimes the distance of several inches, and, at last, comes in contact with it at a considerable angle. From these causes arise pain, spasm, inflammation, abscess, deformity and lameness."

“ Other muscles tend to produce displacement, according to the situation of the fracture, but these I need not mention, as my object was merely to shew those muscles whick principally produce displace ment in the transverse direction, a displacement which must necessarily precede shortening of the limb."

We are not told in what way the action of the muscles affect the fracture, when the soft parts are much torn; or when the bone is broken in any particular direction. The cause of this omission may be looked for in the onset, where the author states it is not his intention to enter into detail at present; we must, therefore, wait the complete development of his notions upon this subject, before we venture to make our own observations upon them.

“ Mr. Pott had the honor of pointing out the advantages we gain by bending the limb, and consequently

relaxing the muscles, which tend most to disturb the fracture; and to forward his views upon this subject, he laid the limb upon the side in the half bent position. In this posture, the limb may be placed at any angle the case may require; and forms, from the trochanter to the foot, a line straight enough to lie sufficiently smooth upon a plane; provided the trunk, also, is placed upon the side; and, if the patient could maintain this position during the period of cure, the limb may be straight and perfect; but he soon becomes tired and turns upon his back. By this rotatory motion, the trunk carries with it the upper fragment of the fracture, while the lower fragment and the leg continue as they were placed; and hence arises eversion of the foot:-a species of deformity which, in this kind of treatment, is with difficulty avoided, and is every day occurring."

From what we have here extracted we perceive, that the author approves of Mr. Potts' plan of relaxing the muscles, though he does not agree with him in the practice of placing the limb upon the side, according to the manner Mr. Pott advised. But it does not appear that the author wishes to argue against the practice of placing the limb either on the heel or on the side, but against confining it to either of those positions; for he says, (p. 442)

“ But whoever attends strictly to the treatment of these injuries will find, that any one position long-continued is extremely irksome to the patient, and in the young and irritable can scarcely be main

« PreviousContinue »