dislocation of the wrist

2
509 possible" for a wound to be made into the bladder during parturition, in any other way than by the improper or unskilful ap- plication of instruments, has been met from without as might be expected. That opi- nion is opposed to known facts : in proof of which, in addition to my own, I am now able to quote from the experience of many surgeons, some of whom have been in ex- tensive midwifery practice for nearly half a I century. Take the following: it is an ex- tract from a letter which I have received on the subject from a gentleman at a distance, and which I select on this occasion, not only because the facts therein stated are valuable, but also because I had no previous knowledge of the writer. 11 Dolgelly, May 10, 1841. " Sir,-I yesterday found in THE LANCET, April 10, 18,11, an account of an inquest on a patient of yours, where I think Messrs. Cooper and Batty gave their evidence in a very suspicious way, particularly with re- spect to the wound in the bladder. I have myself been engaged in the practice of midwifery in this town and county for a period of thirty-five years, and I can assure you that I have known two cases of au opening into the bladder where no instru- ments were used ; nor, iudeed, had I any reason to suppose that the midwives em- ployed before I was called in had used any violence or improper interference. In both of these cases it is my opinion that the opening into the bladder was caused by the head of the child pressing for about three days on the pubis, the liquor amnii having previously been discharged. One of the women survived the mischief; and although she is unable to retain her urine, nor has she since menstruated, and the passage through the coats of the vagina and perito- neum into the abdominal cavity remains open, she enjoys good general health up to the present time. * * I am, Sir, yours truly, " LEWIS EVANS, Surgeon." To Dr. Weatherill." In bringing this matter again before the public, it is particularly requested that the reader will be generous : I am looking after truth, at principles, and not individuals.* Your obedient servant, THOMAS WEATHERILL, M.D. 13, Hunter-street, Liverpool, June 6, 1841. * We omit the remainder of this para- graph, since all that was added may be com- prehended from what is given.—ED. L. THOMAS WEATHERILL,M.D. 13, Hunter-street, Liverpool, DISLOCATION OF THE WRIST. To the Editor of THE LANCET. SIR:—Under the head of 11 Univer3ity Hospital," in last week’s number of your valuable Journat, is detailed a case of dis- location of the left wrist-joint with fracture of the opposite radius in 1’1 boy, aged nine. The possibility of dislocation of the wrist- joint from falls being so problematical, and no tcell-aretlrenticated case of this accident having as yet been published, makes me regret that the details of the above case were not more precise, so that all doubts on the subject might have been removed. Since Dupuytren announced his disbelief in the possibility of dislocation of the wrist result- ing from falls, this question has been the subject of much discussion ; but I believe that, at present, most of our learned neigh.. bours, the French surgeons, deny its possi- bility, and consider all the cases that have been published as dislocations, to have been simply fractures of the inferior or carpal ex- tremity of the radius, which, according to them, present all the signs of dislocation of the wrist. The reasons on which the re- porter of the case in question decides that dislocation existed are, first, that "the car- pus formed a considerable projection on the back of the articulation, while the styloid processes of the ulna and radius were dis- tinctly felt in the palm of the hand." By no means wishing to call into question the exactness of the gentleman’s examination, it strikes mp, however, that, viewing the con- siderable swelling that always supervenes on accidents of the wrist-joint, particularly anteriorly, it would be almost, if not en- tirely, impossible for any surgeon, however practised in manipulating, to decide for cer- tain whether the projecting extremities, felt in the palm of the hand, were not rather the fractured ends of the bones than their arti- cular extremities, especiaily when it is known that in these cases the fracture takts place at about five or six lines from the arti- culation. Secondly, " that the radius and ulna could be traced through their whole course, and were found to be entire." As we have said, the fracture generally takes place at but a few lines from the articula- tion-thus the bones might apparently be traced through their entire course, and no evident shortening exist. Thirdly, 11 on ex- teuding the parts, and at the same time moulding the wrist into shape, the bones returned into their situation suddenly, and with a snap : the patient immediately re- gaining the use of the joint." The sudden return of the bones into their natural posi. tion might as well occur in fracture as in dislocation; and the possibility of the pa- tient’s-immediately using the joint, although at first sight strongly in favour of the suppo- sition of dislocation, still sometimes, as I

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509

possible" for a wound to be made into thebladder during parturition, in any other

way than by the improper or unskilful ap-plication of instruments, has been met fromwithout as might be expected. That opi-nion is opposed to known facts : in proof ofwhich, in addition to my own, I am nowable to quote from the experience of manysurgeons, some of whom have been in ex-tensive midwifery practice for nearly half a Icentury. Take the following: it is an ex-tract from a letter which I have received onthe subject from a gentleman at a distance,and which I select on this occasion, notonly because the facts therein stated are

valuable, but also because I had no previousknowledge of the writer.

11 Dolgelly, May 10, 1841." Sir,-I yesterday found in THE LANCET,

April 10, 18,11, an account of an inquest ona patient of yours, where I think Messrs.Cooper and Batty gave their evidence in avery suspicious way, particularly with re-spect to the wound in the bladder. I have

myself been engaged in the practice of

midwifery in this town and county for aperiod of thirty-five years, and I can assureyou that I have known two cases of au

opening into the bladder where no instru-ments were used ; nor, iudeed, had I anyreason to suppose that the midwives em-

ployed before I was called in had used anyviolence or improper interference. In both

of these cases it is my opinion that the

opening into the bladder was caused by thehead of the child pressing for about threedays on the pubis, the liquor amnii havingpreviously been discharged. One of thewomen survived the mischief; and althoughshe is unable to retain her urine, nor hasshe since menstruated, and the passage

through the coats of the vagina and perito-neum into the abdominal cavity remainsopen, she enjoys good general health up tothe present time. * * I am,Sir, yours truly,

" LEWIS EVANS, Surgeon."To Dr. Weatherill."In bringing this matter again before the

public, it is particularly requested that thereader will be generous : I am looking aftertruth, at principles, and not individuals.*Your obedient servant,

THOMAS WEATHERILL, M.D.13, Hunter-street, Liverpool,

June 6, 1841.

* We omit the remainder of this para-graph, since all that was added may be com-prehended from what is given.—ED. L.

THOMAS WEATHERILL,M.D.13, Hunter-street, Liverpool,

DISLOCATION OF THE WRIST.

To the Editor of THE LANCET.SIR:—Under the head of 11 Univer3ity

Hospital," in last week’s number of yourvaluable Journat, is detailed a case of dis-location of the left wrist-joint with fractureof the opposite radius in 1’1 boy, aged nine.The possibility of dislocation of the wrist-joint from falls being so problematical, andno tcell-aretlrenticated case of this accidenthaving as yet been published, makes meregret that the details of the above case werenot more precise, so that all doubts on thesubject might have been removed. SinceDupuytren announced his disbelief in the

possibility of dislocation of the wrist result-ing from falls, this question has been thesubject of much discussion ; but I believethat, at present, most of our learned neigh..bours, the French surgeons, deny its possi-bility, and consider all the cases that havebeen published as dislocations, to have beensimply fractures of the inferior or carpal ex-tremity of the radius, which, according tothem, present all the signs of dislocation ofthe wrist. The reasons on which the re-

porter of the case in question decides thatdislocation existed are, first, that "the car-pus formed a considerable projection on theback of the articulation, while the styloidprocesses of the ulna and radius were dis-tinctly felt in the palm of the hand." Byno means wishing to call into question theexactness of the gentleman’s examination, itstrikes mp, however, that, viewing the con-siderable swelling that always superveneson accidents of the wrist-joint, particularlyanteriorly, it would be almost, if not en-tirely, impossible for any surgeon, howeverpractised in manipulating, to decide for cer-tain whether the projecting extremities, feltin the palm of the hand, were not rather thefractured ends of the bones than their arti-cular extremities, especiaily when it is

known that in these cases the fracture taktsplace at about five or six lines from the arti-culation. Secondly, " that the radius andulna could be traced through their wholecourse, and were found to be entire." Aswe have said, the fracture generally takesplace at but a few lines from the articula-tion-thus the bones might apparently betraced through their entire course, and noevident shortening exist. Thirdly, 11 on ex-teuding the parts, and at the same timemoulding the wrist into shape, the bonesreturned into their situation suddenly, andwith a snap : the patient immediately re-gaining the use of the joint." The suddenreturn of the bones into their natural posi.tion might as well occur in fracture as indislocation; and the possibility of the pa-tient’s-immediately using the joint, althoughat first sight strongly in favour of the suppo-sition of dislocation, still sometimes, as I

510

have seen in two cases, occurs after reducinga fracture ; and this can be easily explainedby the breadth of the fractured surfaces.

Besides, the fact of the accident requiringa similar apparatus to the one applied to theopposite arm would tend to strengthen myopinion. Trusting you will excuse thesehasty remarks on a subject so interesting tosurgeons, I remain, Sir, your obedient ser-vant, E. S.

GRUBER’S EAR SPECULUM.—LAPISDIVINUS IN OTORRHŒA.

To the Editor of THE LANCET. ’

SIR :-In examining the meatus auditoriusexternus in cases of otorrhoea, I have foundgreat advantage from the use of Gruber’sspeculum, which I first saw when in consul-tation with him last autumn at Vienna, andof which I send you a drawing. You will

perceive that it differs from the so-calledKramer’s speculum, and from that of Itard,inasmuch as the shield does not form onesolid piece with the remaining portion of theinstrument, but can be detached from it, andleft behind in the meatus, to protect itsparietes, while caustic or other applicationsare made to the diseased parts. By themeans of an adapting screw, connecting thehandles, they may be kept more or lessapart, at the will of the operator, and ac-cording to the exigencies of the case : I con-sider both these differences to be markedimprovements, and I have no doubt that theywill be found such in practice. The sur-

geon is better enabled to attend to the case,and to do whatever is requisite, when bothhis hands are at liberty, as they are whenthe shield can be detached from the handlesand left in the meatus, than if one of thehands was employed grasping an unwieldyinstrument, to say nothing of the danger ofan unforeseen movement of the patientthrowing the speculum out of its place, and,perhaps, doing other mischief.* When Iam desirous of ascertaining the exact condi-tion of the membrana tympani, after I havepassed the speculum, I am in the habit ofusing Gruber’s lamp, which has a strong re-llecting lens attached, by which the light ispowerfully thrown into the meatus, and onthe membrane, in such a manner that its pa-thological condition can be readily ascer-tained. I have found it of material servicein making those investigations into the stateof the meatus, which are requisite in all

* As the shield is composed of two halfpieces, one or both may be retained in situ,according to whether it is required to makethe applications to the membrane of the tym-pauum, or to the lining membrane of themeatus itself.

,, cases of otorrhoea. The other engraving re-t presents a pair of forceps which I broughtwith me from Berlin, and which I find of

; great use in applying a ligature roundpolypi ; a task often of considerable diffi., culty. The eyes in the grasping part of theforceps carry the thread, which is morereadily passed round the neck of the poly.pus than by any other instrument I am ac.quainted with.