-No. 5.] LONDON, SATURDAY, . FEB. 5, 1825.

SURGICAL LECTURES,DELIVERED BY

MR. ABERNETHY.

Theatre, St. Bartholomew’s Hospital.

LECTURE 17.

GENTLEMEN,I said that I should consider, to-

night, some of the causes which pre-vent the union of fractures.

Non-union of Fractures.

If a fracture take place in a bone,and if all other circumstances be fa-

vourable, yet if any motion be allowedfrom day to day between the ends ofthe fractured bones, they will not

unite by an ossific medium. Rest is

necessary for the restoration of the

parts. Union of a fractured bone isaccomplished in the same sort of way i

as a wound of the soft parts ; lymphis effused ; this becomes organised byvessels shooting into it from the

broken surfaces, and then earthy orbony matter is deposited, and the

part acquires the strength and den-

sity of the surrounding part.It is evident then, that if the least

degree of motion be allowed betweenthe broken extremities of the bone,that an ossific union cannot take place.Finding that that degree of repara-

tion cannot be made that she wishes,Nature sets about procuring a flexibleunion. The ends of the bones become

smoothed over, the ragged particlesare absorbed, and the motion allowedbetween the bones, perhaps, assists

in this smoothing process. There is a

sort of joint formed, and the union iseffected by ligament, just as we seethe fractures of the patella, and some.times of the olecranon, become united.

Sometimes, however, bones will notunite, although you may keep the

broken surfaces in perfect apposition,and preclude the least degree of mo-tion. And I am satisfied, that thecause of this is a certain state of the

constitution which renders the vascu-

lar system of the injured part incom-

petent to secrete the ossific matter.

I can relate to you a notable instance

of this :-A man came into this Hos-

pital with a fracture of the os brachii,about its middle; he was a stout man,a labouring man, a muscular man,not that sort of person to whom you

might impute any physical defect, orany deficiency of the vital energy.

The fracture was secured in the usual

way, and very well secured, as I was

given to understand; the arm was

kept in splints rather beyond the

time usually considered necessary for

such a fracture; but when the splintswere taken off, there was a move-

ment perceptible between the broken

130

extremities of the bone. The arm was

done up again very carefully, and al-lowed to remain so a longer time thanat first. But when examined the se-

cond time, the fracture was found notto have united. There was nothingparticularly wrong in the man’s health ;his stomach, bowels, and so on, ap-peared just as they should be. ’Vell, ,,

he remained in the house a long time,and every attention was paid him, butstill the fracture would not unite, andhe was obliged to leave. He went to

his work again, but he found very

great inconvenience from the loss ofpower which the limb bad sustained,and, after a certain time, he cameinto the Hospital again, and said thathe wished we would do something for

him, that he was willing to have donewhatever was considered necessary,and so on. It was really very cu-rious to see this man attempt to lift

any thing from the ground; he benthis elbow well enough, but there was

another flexion in the middle of the

upper arm, by which he lost consider-able power.

Mr. LONG proposed cutting downupon the ends of the bone, and re- Bducing it, as near as could be, to thestate of a recent fracture ; he madean incision on the outer edge of thedeltoid muscle down upon the ends

of the bone, and he turned them out

through the wound. He chipped andrasped off all the smooth surfaces

from each, and then returned them totheir proper places. The arm was

very properly secured, but the bonesdid not unite in any other way than

they did before. It might have been

supposed, that an operation of this

kind would have been attended with

very considerable constitutional irri-

tation, fever, and high local inflam-mation, but there were no such reo

sults ; it appeared only like a flea-biteto him, as they say; such was the

torpor and non-excitability of his sys-tem.

A gentleman in America proposed,that in these cases where union did

not take place, instead of cuttingdown upon the bone, and removinga portion of it, to pass a seton betweenthe surfaces, and in this way to excitea sufficient degree of irritation in the

parts that might lead to the depositof adhesive, and afterwards ossific

matter. It is a mode which I believe

has been frequently practised, but sel.dom found to succeed. I have known

several instances in which it has been

tried, but the degree of disturbancein the part and in the constitution hasbeen so great, that they were veryglad to lay the practice aside.

It has been often requested by pa-tients who have had fractures, whosecases have terminated thus unfortu.

nately, to have the extremity reo

moved. Formerly it was very much

the practice with surgeons to do so,but I do not think it commendable.

You may ask, What is to be done insuch cases ? To which I should answer,that I believe that, by keeping those

fractures, in which flexible union hastaken place, perfectly quiet for a

longer time than is usually done,many such cases will unite. I have

known many examples of this kind,but I will only tell you two. A sailor

came into this Hospital, who had frac-tured his arm, by a fall from the main.

131

yard on the deck it had been treatedin the usual way, and been kept quietfor the usual time, but yet a flexibleunion bad taken place. The man was

so annoyed at having this joint in hisarm, that he came here for the pur- Ipose of having it removed. I told

him that if it were my case, I should

not have my arm so treated, but ad-vised him to have the limb kept per-fectly still for some length of time,and that there was a probability ofthe part uniting by bone. - I explainedto him what the object was, and howit was to be accomplished, and youmust in such cases explain to the pa-tients the necessity of strictly pre-

venting any motion between the frac-tured portions. The patient was keptOil what is called a generous diet, hisbowels regulated, and his digestiveorgans improved. Now this man had

his attention rewarded by a firm unionof the fractured arm ; he was very at-

tentive in keeping the splints suffi-

dentIy tight, and would not allow ofthe least motion.

The other case which I said I

should mention, is that of a gentlemanof fortune, who broke his thigh in twoplaces. It was a very bad fracture; it

was secured in the usual way, as I

understood from him, and kept theusual time in the splints ; but it wasfound that neither fracture had united

by bone. It was really distressing tosee him attempt to walk : he totteredon one side, his thigh bending underhim, as if he would fall to the ground.Consultations were held with some of

the leading men of the profession,about the propriety of removing the

limb, and they appeared to think that

it was necessary. I dissented, how-ever ; I told him what I have before

told you, that I should not be dis-

posed to have the limb removed be-

fore I had tried what could be done

by strictly preventing motion betweenthe fractures for a longer time than isusually considered necessary. I said,if it were my own thigh, that Ishould be disposed to treat it in thatway. The gentleman consented, thethigh was placed between splints, thelimb was properly attended to, andbony union took place.* * I am in-

duced then to think, that if fractureswill not unite by the method which Ihave mentioned, they will not uniteeither by sawing off their surfaces, or

by exciting irritation in them bysetons.I have told you what I know respectingthe non-union of fractures, and of the

probability which exists of causingeven old fractures to unite, by ob-serving perfect quietude between theirsurfaces for a considerable time. I

shall now say something about

Compound Fractures.

There is merely this difference be-tween a simple and a compound frac-ture ; the one unites by adhesion, theother by granulation. In a simplefracture there is blood first effused

between the ends of the bone, which

becomes, in a great measure, absorbed;the coagulable lymph of the blood re-mains, and perhaps there is additionmade to it; this becomes organised,and thus a vascular medium is esta-

Mr. ABERNETHY omitted, in thisand in the former case, to mention avery important point,-the time whichthe fractures required to unite bybone.

132

blished between the broken surfaces.

I said, when speaking of the union oithe soft parts, that the newly organisedstructure gradually acquired the struc-ture of the surrounding part, so it

happens in the reparation of injuriesof the bone, (for you will recollect thatI am now speaking of such as are

produced by mechanical violence) ;the uniting medium having been ren-dered vascular, gradually receives thedeposit of ossific matter till the chasmbetween the two surfaces is com-

pletely filled up. Now what happensin simple fracture by the adhesive,takes place in compound fracture bythe suppurative inflammation, or bygranulation. When you consider that

bone, in a healthy condition, is an in-sensible part, possessing a low degreeof vitality, and therefore not being ivery readily excited to action ; when,at the same time, you recollect thatthe filling up of the chasm, even in the.soft parts, by granulation, is a verytedious process compared to the ad-

hesive union; you need be at no lossto discover why a compound fractureshould be a more important injurythan one which is simple.The mischief does not result from

the exposure of the broken surfaces to

the air, but to the removal of the bloodwhich was poured out between the

surfaces of the fracture. In a com-

pound fracture, the layer of coagulatedblood putrifies and passes away by the iwound of the soft parts, consequently ithere is a chasm formed, and how canit be filled up but by granulation ?Vessels cannot shoot from one surface

to another when separated, but theremust be some medium; you cannot

. glue parts not lying in contact. The

f hollow then is filled up by granula-1 tion, just as a hollow in the soft parts,- with this difference, that bone is de-

t posited in the granulations. Here

again we may see another cause whyt an injury of bone should be much

longer repairing than a proportionate; injury of the soft parts. The vessels

of a bone are extremely minute, theycannot therefore secrete so readilypus, or the adhesive matter that is to

form the substance of the granulations.Again, we know that there is a greaterdegree of constitutional disturbance

attending the suppurative than the

adhesive inflammation, and that gra-nulations which, for a time, looked

healthy and vigorous, all of a sudden

become changed in their character,and even absorbed; we notice these

transitions in the states of ulcers,where the granulating process is im-

mediately brought into view, and wecannot but suppose that the same

causes will produce similar deviations

from the healthy action in granula-tions between the extremities of bones.

The consideration of the different

methods in which simple and com-pound fractures united, and of the

dangers and difficulties frequentlyattendant on compound fractures, in-duced Mr. MUDGE, of Plymouth, to

adopt that treatment which appearedto him to render the compound frac-ture, as nearly as possible, in the samecircumstances as the simple, aud he

accordingly closed very carefully theexternal wound, he brought its edgestogether by sticking plaster, and thenhe varnished the plaster, so that thebroken bones were covered almost as

133

effectually as by the integuments. He

has recorded many cases in which his

practice was successful. It is un-

doubtedly right to protect the fracturefrom the danger which would attendthe suppurative process, you should

therefore, after you have reduced thebones as neatly as you can, bring,’ theedges of the wound together, and youmay varnish the dressings, for if youcan prevent the escape of the coagu-lated blood, the fracture may unite

by the adhesive process. In addition

to this, you should recollect that thesoft parts in the immediate neighbour-hood of the fracture are frequentlyvery much injured, and the result of

injury is an inflammatory process.Now you may very much lessen the

subsequent inflammation, and preventthe suppurative inflammation by di-

minishing the temperature of the partThere is no measure so useful in thE

treatment of inflammation, as that oj

the regulation of temperature. Laythin cloths, wetted with Goulard’s

lotion or spirit and water, over the

part, to diminish any excessive heatthat may accumulate there, and youwill do a great deal toward prevent-ing the evils frequently attendant ona compound fracture. Keep the partsat the same time on a splint, and per-fectly quiet. It is a point of very

great importance in the treatment offractures, to place the limb, and to

place the patient in that position fromwhich there may be no necessity toremove him for a considerable time.

Compound Fruclure, with Haemorrlwge.

It sometimes happens that there is

considerable bleeding from a com-

e pound fracture ; the sharp end of thes bone has pierced a vessel, and hsemor-- rhage follows. It has been recom-

mended immediately to enlarge the

1 wound, if you cannot get at the ves-Isel without, and by tenaculum to pullit forth and secure it. I cannot saythat I should approve of such a prac-

tice; one wound is bad enough, youneed not make two. And as to stuff-

ing foreign bodies into a wound to

stop haemorrhage, oh ! that is a verybad practice. I can only tell youthat I have known large arteries,’ aye,even the principal arteries of a limb

wounded, and yet the haemorrhagewas stopped by a different method.I remember two cases of compound

fracture of the leg, in each of which I

had every reason to believe, that theanterior tibial artery was wounded.There was a considerable flow of

blood from the wound, the cellular

membrane was distended with ef-

fused blood, even down to the foot.

I directed the limb to be put in a pro-per position so as to replace, as nearas could be done, the ends of the

bone, and directed cold rags to be

applied to the part so as to allow of

evaporation, the temperature of the

part was lowered, and the haemor-

rhage ceased. The other case was

under the management of one of our

dressers here, I think Mr. GEORGE,now settled at Bath ; he very pro-

perly laid the limb on a splint, so thatthere might be no motion allowed inthe fracture, and then he fitted ano-ther splint over the limb, in this man-ner : he removed a piece of the mid-dle of the splint, so as to leave the

part uncovered, but he connected the

134

two pieces together by a bracket oi

iron, so that the splint acted as effec-tually as if it bad a continuous surface.On the part he applied his cold lotion,and the bleeding was effectually stop-ped. From these, and many other

similar cases, 1 imagine that you maygeilcrally command the bleeding fromarteries in compound fractures evenof some impottancet by the use of

cold.

O6lique Compound Fractures, with con-siderable projection of Bone.

A fracture may not only be coi-n-

puund, but there may be considerableprojection of bone through the ex-

ternal wound. In a very oblique frac-ture the bone may protrude very

much through a small opening in the

integuments. A person may, in jump-ing from a carriage, or from a height,fracture his leg, and fracture it so

obliquely as even to push it throughhis boot. What are you to do in that

case ? The bone is protruding con-

siderably through a small opening inthe integuments, from the obliquityof the fracture. I remember a time

when this used to be a frequent ques-tion put to those who presented them-selves at Surgeons’ Hall, by the lead-ing men there, and especially by Mr.PoTT, who was one of the first men

of his time as a surgeon. What would

you do, sir, in such a case-wonld youenlarge the wound or saw off the

bone ? I know that the answer ex-

pected was, I would rather enlargethe wound than saw off the bone." Mr.

PoTT had a great objection, and thisobjection was general at that time, tothe removal of any part of the bone,

if it could possibly be avoided. If any

spiculn’ of bone should make the sur.face of the fracture appear ragged,

then it is a different thing, they niaybe removed, because in attempting to

return them you might irritate very Imuch the neighbouring soft parts.They objected very much to the re,move of any considerable portion of

the fractured boue, and so do I object .

to itt Whatever portions of bone Iyou may remove leave of necessity

’

a chasm to be filled up, which must

be greater or less iu proportion to thesize of the pieces of hone which youmay remove. The only way in which

I it can be filled up is by granulation, ’,and the demands made upon the consti-tution, under the suppurative process,are- very great, producing that de-

gree of irritability called hectic fever. :

I say, then, that I would rather eit- ,large the wound than saw off any

.

considerable portion of the bone.

Comminuted Compound Fracture.

You may have a compouud frac.

ture, in which the bone is very much

smashed, broken into a great manypieces, which might cause you someperplexity. It has been said, that

you should take away the loose and

detached portions, but I do not see

what advantage can be derived from

picking away the smaller pieces of

bone. The only mode in which thefracture can unite is by the separatepieces of bone becoming vascular, andthe probability appears to me, that

they will become more so when the I

pieces are small than when they arevery large. If there should be any

projecting detached pieces of bone,

135

’ which appear very much to disturb

the proper position of the fracture, I’,you should take them away ; but it is i

impossible to lay down any such pre-cise rules in surgery that will direct

one in all cases, unaided by the con-viction of a man’s own judgment.You must, therefore, be very muchguided by circumstances ; if you couldreplace the different pieces of bone, iand by giving the part a moderate

degree of support, retain them there,I think you had better not take any

away. It is of no use to strap andbandage a fracture to make it uniteby main force-that will never do.

The support you should give a frac- iture should be gentle and equable, ijust such as it would derive from the

healthy state of the parts. ’

I remember being told the historyof a case of compound fracture byMr. POTT, which shows what naturealone will do in such injuries. Mr.

Porr was a man on whose veracity Icould rely, and when I told the storyat the College of Surgeons, some ofthe old codgers there (a laugh) saidthey recollected the case; that was

confirmation strong enough, if anyhad been required.A lunatic, in attempting to get over

a wall, fell, and produced a compoundfracture of his right leg; the bone pro-jected a little through the skin ; the t

opening was enlarged, and the bonereduced. The fracture was secured,first by a many-tailed bandage, thenby splints, the wound carefully closedby plasters, and the surgeons who

had the management of the case went

away consoling themselves with thenice apposition of the bones. The i

man paid particular attention to the

manner in which they applied the ap-paratus, and as soon as they were

gone, he took it into his head to re-

move the bandage and splints from theinjured leg and set them on the other.He discovered a hole in the feather-

bed on which he was lying, and hethrust his fractured leg into the middleof it. (A laugh.) When the sur-

geons arrived on the following day,they were much pleased with the lookof the limb ; they said, how straight

it lies’ it appears not to have shifted

in the least from the position in whichwe placed it; what little swelliug

there is ! indeed there is scarcelyany, and so on. They thought it wouldturn out a very excellent case. Theycame, from time to time, to see the

patient, and finding every thing goingon so favourably they did not disturbthe limb. After the usual period had

elapsed in which such a fracture issupposed to unite, they took off thesplints to examine it. They werequite surprised to see how straightthe leg was ; and as to the wound inthe integuments, it had closed so

nicely, that they could not even findthe scar. Well, this is very extraor-

dinary ! But, said a person present, isthis the leg that was broken ? Broken !

yes, certainly. Could it be supposedthat the splints were put on the wrongleg? (Another laugh.) However, it

was thought they might as well lookat the other, but it was not to be

found. After some search it was dis-

covered buried in the feathers, and

when they had it out, egad! it was

crooked enough, with a large bunch

j of feathers sticking into the leg, like

136

a cockatoo (loud laughter) ; yet the

wound had healed and the bone

united.

Fractures may not only be com-

pound and comminuted, but they maybe produced in such a way as to causeextensive injury of the neighbouringsoft parts; for instance, the wheel ofa heavy carriage passing over thelimb, or gun-shot wounds, may do so

much violence as to render it proba-ble that the parts will slough; undersuch circumstances, it has been a ques-tion of some consideration whether an

operation for the removal of the partshould be immediately performed ornot. Mr. GUTHRIE, who has writtenon this subject, recommends imme-diate operation ; but you must takethis into account, that his conclu.

sions are drawn from peculiar circum-stances. Mr. GUTHRIE, as a militarysurgeon, has perhaps seen the neces-sity of amputating sur le champ, be-cause the wounded can only be takenaway in heavy, rough-going carriages,which would, to a certainty, injure theparts materially, and very much pre-clude that chance of success that

might otherwise be gained by delay.Other persons have advocated the

same opinion ; but I should rather de-fer operating, if possible, until the

next day, if 1 could, or the next even-ing. The constitution has sustained

a very serious shock by the injury,and the additional shock of the ope-

ration, before the first was recovered

from, would, in many cases, extinguishlife. I know that the practice of im-mediate operation would not succeedamong Londoners, for there are veryfew of them capable of sustaining such

a two-fold injury. I should say, wait;tell the patient that you will leave it

until the next day; let him recover

a little, aid prepare his mind for it.

r If you find, that the circumstances ofthe case are not more urgent on the

; second ,day, say you will put it off a

little longer. It is astonishing to seewhat little impression a large wound,such as that formed in amputation,

will make upon the system, when ithas been for some time previously suf-fering from considerable irritation.

Amputation of a limb from a man infull health is known, by experience,to be a very dangerous thing, and

therefore I should recommend you to

wait a little after the receipt of a

violent injury before you perform it.

Rule for Amputation.It does not follow, as a matter of

necessity, that because a hone is com-minuted and the soft parts contused,that you must operate. There are

many such cases that do well. What

then are the principles which oughtto guide you in determining on the

operation. It is quite impossible to

lay down any precise rtlle, founded

on this or that appearance of the

parts ; or to say, that because this

artery is torn, or that part is injured,or that the bone is broken in this or

that manner, that you must operate.But if there appears to you to be such

mechanical injury done to the livingstructure as could not ultimately he

repaired by nature’s processes, or,

that if reparable would, from the

state of the person’s general health,make such demands on the vital

powers as they could badly support,

137

then you might be justified in ampu-tating. Rules! there is but one rule

in surgery, or there ought only to beone rule-Do unto others us you would

have done to yourself. If you can say,

after asking yourself, if your limb

were in the condition of that man’s,you would have it removed, then I

say, you can with great propriety re-commend it.

Operations, generally speaking, domuch better in the country than in

town; and injuries requiring ampu-tation in town will often be recovered

from in the country. Of amputations,I have found that those of the thighdo better in London than those of the

leg, especially about the calf of theleg; and those of the upper arm dobetter than the fore-arm. The ques-tion which we have been discussing isone of great importance, and deservesyour most serious attention. I did

intend to have said something more ,,

on the subject to-night, but the time !,will not allow me, and I must postponeit until another evening.

LECTURES

ON THE

PRINCIPLES AND PRACTICE

OF PHYSIC,

BY DR. ARMSTRONG.

Theatre of Anatomy, Webb Street.

LECTURE 14.

IN this Lecture I shall speak of

Inflammation of the Lungs, Pleura,and Pericardium.

I have already made many observa-tions on the predisposing and exciting

causes of inflammation, and I nowmerely enumerate some, by way ofcalling your attention to this subject,which is very important in a preven-tive view. The tendency to inflamma-tion of the lungs, pleura, or pericar-dium, is sometimes hereditary, some-times acquired. It is a very remark-able circumstance, in regard to in-flammation of the pericardium, that itis very apt to occur in those families,the members of which are liable torheumatic affections, and such indivi-duals are also apt to have enlargementsof the heart. If the lungs, pleura, orpericardium have been once inflamed,there is generally a liability left to thesame disorder.

The most common exciting causeof inflammation of the lungs, pleura,and pericardium, is a low, or a varia-ble temperature. The inflammationsprevail most in cold dry weather, butsometimes in cold moist -weather. Anattack of inflammation in the lungs orpleura may be excited by a currentof cold air. If an individual chanceto be chilled by exposure to rain, orthe like or if cold be applied par-tially, especially to the chest and feet,it often happens that the whole sur-face becomes cold, re-action takesplace, and, if predisposed, inflamma-tion of the lungs or pleura takesplace. If any one be wet while he iswalking, he should keep in motion, byway of maintaining the animal heat,and thus preventing a chill, and sub-sequent inflammation; but in such astate he should always change hisclothes as soon as possible ; where thesurface has become cool, the soonerhe uses a tepid salt bath the better ;it is an excellent preventive of inflam-mation. Persons may contract in-flammation of the pleura, lungs, or

pericardium, by sleeping in dampsheets, so commonly used in some

inns ; and therefore it is a good rule,in travelling, always to sleep betweenblankets. Sometimes a sudden plungeinto a cold bath produces inflamma-tion of the lungs or pleura. The rea-son why these inflammations occur sofrequently, when the surface is chilled,appears to be this: that there is a

much freer anastomosis between thevessels on the external and internalparts of the chest than in any otherparts of the body, so that when the