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January 18th. Experiences a sensation of giddiness on sitting op, tongue still coated, slight pain in the stomach, aching pain in the back part of the head, pulse 106, (this is the 6th day) three lenticular rosecoloured spots are visible on the upper part of the chest, they disappear completely on pressure and return when pressure is removed, slight pain on pressure on the right iliac fossa, temperature 1033, ordered a drachm of oleum ricini.
January 19th. Took medicine last night, her bowels remained unmoved, tongue cleaner than at last visit, slight pain in the bowels, and tympanitis, pulse 112, temperature 102, about twenty typhoid spots, sparsely scattered over the surface of the back, face considerably flushed.
On January 20th. Ordered oleum ricini 3j, bowels have not yet been moved, says she feels better, has slight headache, pulse 100, temperature 1011, additional spots visible on the anterior parts of the chestthe number also increased on the posterior region ; pupils much dilated.
January 21st. Looks much better, and says she feels well; is anxious to sit up, had one evacuation of an ochrey yellow colour, and offensive; feels no pain in the head or bowels, tongue cleaning off at the edges, slightly fissured in the centre, and papillæ somewhat enlarged; pulse 94, temperature 98; no fresh spots visible, and those which were well developed are fading; pupils remain dilated.
January 22nd. No important changes to note since last visit, had one natural evacuation this morning, she is very much improved, tongue cleaning off, and no fresh spots visible, pulse 86, temperature 98; wishes to be allowed to sit up.
January 23rd. Tongue clean, no pain, is convalescing rapidly, pulse 84, temperature 98, ordered full diet and clothes, and is permitted to sit up in the ward.
January 24th. Is restored to perfect health.
Surgery. TREATMENT OF FRACTURE OF THE RADIUS AT THE STYLOID PROCESS BY MEANS OF GORDON'S SPLINT.
By Mr. Rawson Tait. Few fractures have had so many painfully ingenious splints devised for their treatment as that common injury to the radius, which generally
goes by the name of Colles's fracture, if we exccept fracture of the patella with the awe-inspiring hooks of the late M. Malgaigne. The French pistol splint for twisting the hand to either side, the American splint for twisting the hand down, and some other kind of splint for twisting it up, have all been used, and nearly all given up as insufficient, besides being, for the most part, perfectly intolerable to the patient. Thus it is that we find Sir William Fergusson recommending the ordinary palmar and dorsal straight splints for the treatment of this fracture, and these, I believe, are used by most British practitioners with the addition of various supplementary pads as required by the exigencies of each case.
In spite of the utmost care most cases of this fracture turn out unsatisfactorily, and many are the actions of damages that have been raised on its account. The reason of this non-success is, I think, very plain; and let any one examine his own wrist, and the following explanation will be clear. Holding the hand straight out in a plane with the forearm, it will be seen that, while the dorsal aspect is almost a straight line, there is a considerable concavity at the wrist on the palmar aspect; indeed, that a line drawn from the elbow to the ball of the thumb would be, so to speak, the chord of a segment of a circle. Thus it is that when an arm, with the radius broken as it is in Colles's fracture, is pressed by two straight splints, one of either aspect, extending from the elbow to the fingers, the upper fragment must necessarily be pressed towards the palmar aspect of the limb; while the lower fragment, which is practically the same in this condition as the ball of the thumb, is pressed in the opposite direction—in fact, that the distortion is only increased by the splints as they press the fragments in the very direction in which they are already displaced. If this be correct, then it is easy to understand the success which has attended the use of Dr. Gordon's splint in the treatment of this fracture, and to believe that it is devised on sound anatomical and mechanical principles—that it really is what all splints ought to be, viz., a dermal skeleton.
This instrument was originally invented and described by Dr. Gordon, of Belfast; the only notice, however, which I am aware that it has subsequently received is in a paper by Mr. Stokes in the Dublin Medical Journal. It is composed of two pieces of wood, the one for the palmar aspect of the forearm being about nine inches long, two and a quarter inches wide at the elbow; the surface to be in contact with the skin is slightly hollowed out to fit the arm, and along its radial border it has screwed to it a wooden bar or pad, which is rounded off at the distal extremity to fit the concavity of the radius ; this latter, of course, necessitates that, to fulfil this condition, separate splints are required for the right and left arms.
The pad, in addition to its being rounded off at the extremity, is rounded all along its inner surface so as to press accurately against the radius throughout nearly its whole length, and it is of sufficient height to embrace rather more than half the thickness of the forearm. The other portion of the apparatus consists of a plain piece of three-eighth inch board, two inches and a quarter broad, and two inches longer than its fellow; it is for application to the dorsal aspect of the forearm, and has the surface to be in contact with the skin slightly hollowed, and it likewise has its distal extremity transversely rounded. Its application is effected as follows:- The fracture having been reduced, the limb is retained in position by an assistant, the lower part of the apparatus is then applied, padded with spongio piline or lint, to the radial portion of the forearm alone, and not to the hand. Then the upper splint is to be applied, likewise padded, in such a manner that the proximal ends of the two parts of the apparatus are maintained at the same level, while the distal end of the upper one projects about two inches beyond the end of the radius. For a more particular description and a drawing, see Dublin Medical Journal, for February, 1865. The whole apparatus is firmly secured, by two small straps with buckles. In this manner no pressure is exerted on either of the fragments but what is calculated to keep them in their correct position. The arm, during the after progress of the case, is recommended to be kept in the position most agreeable to the patient, which will be found to be that of almost complete pronation. In the employment of this apparatus the wrist will be found to be confined only to a limited extent, while the movements of the fingers and carpo-metacarpal articulations are quite unimpeded; thus entirely doing away with the most objectionable condition of stiff joints, which is such an annoyance both to surgeon and patient for weeks after the common splints have been removed from the forearm.
Shortly before I became acquainted with this splint, I met with two cases of Colles's fracture, in which, in spite of the greatest care I could possibly bestow on them, there still resulted a considerable degree of the deformity peculiar to this particular injury. The first case occurred in an old lady, and the other in a young collier lad; in both the injury resulted from a fall on the palm of the hand. The unsatisfactory results of the ordinary methods of treatment of this fracture having been thus prominently brougnt under my notice, I was induced to pay special attention to what had been suggested by surgical authors as to the cause of the displacement and as to the best means of overcoming the resulting deformity. Much has been written on the action of those muscles which some have supposed to be the cause of this peculiar deformity; but I think
that this is one of the many instances where muscular action is blamed for ill effects of which it is blameless. The deformity seems to me to be caused solely by the direction of the violence which is the cause of the injury, this being almost invariably a fall on the palm of the hand. The mechanism of the fracture seems to be that when the patient falls on the hand, and that by its being forced outwards it drags with it the epiphysis of the radius, the ligaments breaking the bone rather than yielding themselves. Much the same, indeed, as in the very analogous fracture of the fibula at its lower fourth, where the internal lateral ligaments of the tarsus much more frequently drag away with them the tip of the malleolus externus than are ruptured themselves. Again, the idea that the displacement depends merely on the violence is borne out by the occasional occurrence of a case where the patient falls on the back of the hand, and when the ball of the thumb and lower fragment of the radius are driven upwards and towards the palmar aspect of the forearm. Bearing these things in mind, and looking at the great improbability of fragments so displaced returning spontaneously to their normal position, it seems to me that, in this instance at least, the theories which would attribute to particular muscles the power of drawing particular fragments this or that way, thus
, producing and maintaining the displacement, are quite needless. What is required in the treatment of this fracture, if we wish to obtain a perfect result, is not mere repose of the parts, which alone is secured by the ordinary straight splints, but such special adjustment of the normal curve of the shaft of the broken radius with its apophysis as will restore their normal relation to each other, and to the corresponding extremity of the ulna. This result, theory satisfied me was obtainable by the use of Dr. Gordon's apparatus, and the result in the following cases will, I think, satisfy any one of its utility and success.
Since reading Mr. Stokes's paper on this splint, I have met with two cases of the fracture, both of which were treated by means of it with remarkably pleasing results. The first occurred in the left arm of a boy, about eight years old, who fell from a height and lighted on the palms of his hands. In this case, the deformity was excessive, putting me in mind at the moment of that mysterious symbol connected with our early faith, known to antiquarians as the zig-zag sceptre ornament. He had his arm in the Gordon splint scarcely three weeks ; and now, from careful examination of both wrists, it could not be told in which arm the fracture had occurred. The other case occurred in a gentleman, aged 63, whose carriage was upset, and who likewise lighted on his palms. In this instance the deformity was well marked, but not nearly to so great a degree as in the former example. After their original adjustment, the
splints were not touched for six weeks, and there now exists not the least deformity. In fact, I had an opportunity of examining this gentleman's wrist within the last few days, and am quite as well satisfied with it as with the other.
Recently Dr. Heron Watson mentioned to me a case of this fracture which he had treated by Dr. Gordon's apparatus with the most satisfactory results. The patient was an adult male, and had met with the accident in the usual way. “ The injured limb," writes Dr. Watson, " had been put up in the first instance in Gooch's splints by my House-Surgeon; but when I saw him next day, as he was uneasy, I took
I them off and applied Dr. Gordon's. They were adjusted two or three times while they were required, which was only four weeks. The original displacement was well marked, and the result was eminently satisfactory, the position of the ulna with reference to the carpus being natural, and the movements of the wrist quite unimpaired; while the rotation back: wards and outwards of the styloid process and articular surface of the radius was, if present, imperceptible.”
In none of the cases did the patients complain of the slightest pain or inconvenience arising from the apparatus.- Medical Times and Gazette, February 17th, 1866.
HYSTERICAL SPEECHLESSNESS-SPEECH RESTORED BY THE INTI.
MIDATING EFFECT OF GALVANISM.
Under the care of Dr. Pavy at Guy's Hospital.
S. C., aged 17, having been occupied as a domestic servant at Tottenham, was admitted into Mary Ward, under the care of Dr. Pavy. Her history,which she gave in writing, is as follows:--About seven months ago, whilst out on an errand in the evening, a man laid hold of her arm and demanded money of her. He tore her jacket, but inflicted no personal injury upon her. She was so frightened that she could neither speak por move for some time. She, however, at length reached home, although she does not remember how. On her arrival home she had a hysterical fit, which lasted for two hours and a-half, and from that time up to her admission--a period of nearly seven months—she has been perfectly speechless and partially deprived of the use of her lower extremities.
She is healthy in appearance. When spoken to she does not attempt to answer, but shakes or nods her head. The movements of her tongue and lips are free enough for other purposes besides speaking. She can