THE 
WESTERN JOURNAL 
o r 
MEDICINE AND SURGERY. 
FEBRUARY, 1848. 
Art. I.-Notes on Medical Matters and Medical Men in Paris.- 
By David W. Yandell, M.D., of Louisville, Ky. 
Having spent nearly four months in a tour through Eu- 
rope, in which I have seen the principal cities of the Conti- 
nent, I find myself at the beginning of the lecture term once 
more in beautiful Paris. At some future day, when I have 
more leisure, I may give you some account of the things 
medical seen on my journey-of the noted medical men of 
Berlin, Vienna, Venice, Florence, and Rome-and of the 
medical institutions of Germany and Italy; but at present, 
amid the pressing calls upon my time made by studies which 
must not be neglected, I can do nothing more than send you 
a few of the practical details gathered in my attendance at 
the hospitals. 94 
Foreign Correspondence. 
Velpeau on Fractures of the Femur.-M. Velpeau, in his 
last annual summary of the cases that had been treated in 
his wards during the scholastic year, 1846-'47, among other 
things, spoke as follows of Fractures of the Femur: 
You have had opportunities for observing twelve cases of 
fracture of the femur, among which were fractures of the 
body, of the neck, and of the extremity or condyles of this 
bone. We have had only one example of this latter variety; 
this was in an exceedingly intractable little boy, who, in a 
fall had broken the external condyle very obliquely. This 
single case, however, has sufficed to show you the difficulty 
of precise diagnosis, as well as of the coaptation of the parts, 
and how important it is not to confound this variety with 
fracture of the body, the treatment and prognosis of which 
are essentially different. 
The danger of fractures of the inferior extremity of the 
femur are of two kinds, and relate-1st, to the possibility of 
inflammation of the knee; 2d, to the production of a more 
or less considerable deformity. This last accident may itself 
be grave in two ways; the joint, deformed either by the fact of 
the fracture alone, or by the irregularity of the consolidation, 
will present inequalities that will produce stiffness in the 
movements, perhaps a demi-anchylosis; or, the extremity of 
the femur, badly consolidated, as nearly always happens, will 
offer projections which, pressing on the surrounding tissues, 
will give rise to a more or less severe and more or less con- 
stant pain, and lead to ulceration of the vessels, nerves, skin, 
etc. As I have hinted, the treatment of fractures of the 
condyles and of fractures of the body of the femur is entirely 
different, the former offering difficulties that you do not en- 
counter in the latter case. This is owing to the fact that 
fractures of the condyles are ordinarily unequal, irregular, 
angular; and, as in this region the bones are naturally irregu- 
lar, covered with projections or points, it is very difficult to 
distinguish, in the midst of the tumefaction of the soft parts, 
what are the connections, extent, and form of the fragments. 
These difficulties which you experience in establishing a pre- Foreign Correspondence. 
95 
cise diagnosis imply that there are no fixed rules of treat- 
ment; for how can you deal with fragments of which you 
know neither the form nor direction? How effect an exact 
coaptation? Especially, how can you maintain these frag- 
ments on which you have no hold? Thus it is we are 
obliged to grope our way; here you have the reasons which 
induce us to place by turns the leg in the various degrees of 
flexion, extension, and rotation, until we succeed in bringing 
the fragments in a favorable position. But even here, the mus- 
cular force acts against the efforts of the surgeon; the muscles 
in drawing upon the leg tend to elevate the tibia, and place it 
upon the fragments, which it slips between, separates, and 
produces a transverse displacement of greater or less ex- 
tent. 
You w'ere able to observe all these accidents in the case of 
our little patient whose indocility added to and increased the dif- 
ficulties just enumerated. You saw the irritation caused by 
the irregularity of the fragments produce an abscess, which 
gave me for an instant much uneasiness for the joint; though 
this abscess, once opened, improved very rapidly and the 
patient left the hospital cured. You have had an opportuni- 
ty of seeing him since, as he returned and passed some days 
in our ward for a light contusion situated on the right leg. 
It has been youi' good fortune to have had opportunities in 
the course of this year for observing the three varieties of 
fracture of the neck of the femur. We have had, you will 
remember, patients in whom the fracture was seated within 
the articular capsule, (intra capsular fracture); in others the 
solution of continuity was external to the capsule, (ex/ra-co/wu- 
lar fracture); finally, some have offered the modification 
called fracture by penetration, in which the neck of the femur 
was buried in the head of the bone. Two patients have pre- 
sented us the characters of this last species of fracture; that 
is, with them, there was notable shortening of the limb, rota- 
tion of the-foot outwards, absence of crepitation, and the leg 
could be lifted up. If the member did not lose its functions, 
if there was not immobility, it was owing to the fact that the 96 
Foreign Correspondence. 
neck having entered the head of the femur, the penetrated 
fragment maintained the fragment penetrating it. 
In the extra-capsular fractures, there is projection at the 
hip; the pain is seated beneath the articulation; there is 
shortening, mobility; possibility of giving to the member its 
length; the leg cannot be raised; the point of the foot is 
turned outwards. 
In intra-capsular fracture, the fold of the groin is effaced; 
the pain exists on a level with the articulation; the rotation 
outwards is more marked than in the former case; shortening; 
loss of functions of the member. 
You have been able to see that if these fractures have a 
certain gravity, it is much more by reason of the advanced 
age of the patients, of the necessity of confining them to bed, 
than to the solution of continuity itself. There are no im- 
portant organs or viscera in this neighborhood to be wound- 
ed. This class of fractures occurs mostly in old people, 
and one is hardly at a loss to comprehend that a casualty 
which requires two or three months of confinement, is serious. 
Nevertheless, it should be remarked that certain old persons 
support the immobility without any great inconvenience. 
You may remember the woman, 83 years old, who kept 
her bed for more than two months without accident, without 
her health appearing affected. But I must insist that the 
contrary is most often the case, and one can easily conceive 
that there are very few healthy persons who after keeping 
their beds for a certain length of time, would fail to become 
diseased, for exercise and motion are necessary to the integ- 
rity of the functions; the circulation languishes, the digestive 
organs grow sluggish, no longer act with their accustomed 
energy, and finally become covered with a muddy coat, 
which alters the mucous membrane. Nothing is more cer- 
tain than that if you place an old person in these conditions 
he runs the greatest risk; he loses his appetite, then comes 
diarrhea, marasmus, and often death. 1 hope you will re- 
member this; many old persons who are treated for fracture 
of the neck of the femur die in this way. Foreign Correspondence. 
97 
Another danger attendant upon fracture of the neck is 
owing to the prolonged compression experienced by certain 
projecting regions; such as the eschars of the sacrum, grand 
trochanter, etc.; eschars which may penetrate to the bones 
and change them; which produce an abundant suppuration, 
and react upon the whole economy in an unpleasant manner. 
It is in virtue of these various circumstances that the frac- 
tures of the neck of the femur possess gravity. 
The question of the consolidation of intra-capsular frac- 
tures has been differently resolved. Sir Astley Cooper re- 
jected the possibility of consolidation, because the head of 
the bone, receiving fewer vessels, no longer preserved the 
same vital energy, and could not furnish the elements of the 
reparatory work. This opinion, however strange it may 
appear at first glance, found numerous partisans, among 
whom was a celebrated surgeon of Montpellier, Delpech, 
who went so far as to offer a prize of two thousand francs 
to the person who would show him a consolidated fracture of 
the neck of the femur. It is also true that he afterwards 
awarded the prize to himself. 
One of the first who examined the other side of the ques- 
tion was Smith, who published a memoir accompanied by 
plates, and endeavored to prove that these fractures could be 
consolidated. But it is apparent from the difficulty which 
he had in collecting examples that this consolidation, if it is 
possible, is also extremely rare, It is clear, that in the ob- 
servations he cites, the consolidation is real; but these facts 
appear to belong to the category of fractures by penetration. 
Now, for my own part, I no longer consider the consolida- 
tion of fractures of this kind to be an open question. It was 
not of those that Sir Astley Cooper meant to speak, because 
they had attracted very little attention up to that time. The 
memoir of Smith, then, does not demonstrate the possibility 
of the consolidation of intra-capsular fractures, without pen- 
etration of the fragments. 
Even in the mass of facts collected by M. Chassaignac. 98 
Foreign Correspondence. 
and borrowed especially from Amesbury, Stanley, Vanhonte, 
Brulatour, etc., one sees that if these fractures do consoli- 
date, such instances must be rare; and that in no case is the 
consolidation ever complete as in the body of the bone. 
How can we comprehend, in fact, that intra-capsular frac- 
ture can be completely consolidated, when we remember 
that the head is no longer held by any thing but the round 
ligament, which contains only a few capillary vessels? How 
hope, under such circumstances, that a complete callus will 
be developed, especially when it is impossible to maintain the 
two fragments in perfect coaptation? A priori, then, the 
consolidation appears difficult; and since the facts collected 
and the observations published, are not of a nature to re- 
move all doubt, one is right in still doubting. 
Here, now, is probably what passes: there is not a com- 
plete callus, but a considerable work is established, which 
leads to the formation, within the capsule, of osseous plates- 
of stalactites. These osseous plates, at first small, gradual- 
ly extend, join to one another, and form an imperfect mass 
which encases the neck of the bone, re-establishes its solidi- 
ty, and thus causes the thigh to recover its movements. But 
in certain cases, the capsule becomes itself encrusted with 
calcareous matter, the movements remain, embarrassed, dif- 
ficult, and the lameness persists. 
From all this, one may deduce a therapeutic consequence. 
Why treat these fractures, since, as I have shown you, the 
treatment may be attended with serious inconveniences and 
the consolidation would be irregular ? 
This is the starting point of the doctrine of Cooper. 
I will not speak of the various bandages invented for the 
treatment of fractures of the neck of the femur. For twen- 
ty years I have in some degree left the patients to them- 
selves. If the fracture is extra-capsular, mobile, in an old 
person, I place the member in demi-flexion, put a cushion 
under the popliteal region; then at the end of fifteen or 
twenty days, I make the patient get up and walk with 
crutches. The weight of the member makes extension in the Foi 'eign Correspondence. 
99 
walk; the movements do not hinder the formation of stalac- 
tites, of the osseous vegetations which establish the consolida- 
tion. From this mode of treatment it results that the pa- 
tients are able to walk about at the end of the third week, 
first with crutches, then with a cane; whereby, consequent- 
ly, they do not incur all the dangers attached to a long con- 
finement in bed; the movements of the limb are established 
in part, and sometimes the lameness at length disappears. At 
the end of six weeks upon this plan the patients are at the same 
point as after three, four, and five months of treatment by im- 
mobility, and they have not been exposed to the same dangers. 
Further, they have not had to support the pains caused by a 
bandage keeping up continued extension, nor all the acci- 
dents that it induces, eschars, oedema, etc. Certain surgeons 
reject this treatment from fear of shortening; but this is en- 
tirely chimerical; for the patient does not rest upon the weak 
member, he walks upon the other foot, and, as I have just 
now told you, the weight of the member exercises a continu- 
ed extension which one must court. The fragments are not 
agitated by the movements, for these do not go on at the ar- 
ticulation of the hip where they would produce a lively pain. 
Of the twelve patients whom we have treated this year, one 
alone has died, and that occurred because we were not able 
make him get up. 
Cyst, of the Liver.-Repeated punctures.-Consecutive In- 
flammation.-Influence of the air in accidental cavities.-I 
propose calling your attention this morning, said M. Velpeau, 
to the patient, the history of whose disease since his entry 
into the hospital, which was many months ago, until this mo- 
ment, when I intend performing a sort of operation upon him, 
offers us useful instruction in a practical point of view. 
This man has in the right hypochondriac region a tumor 
belonging to the liver; I believe that this tumor was primari- 
ly hydatic, though I could in no wise detect that particular 
fremissement which has been called bruit hydatique. 100 
Foreign Correspondence. 
The first time that I punctured it a transparent, citrine, 
limpid liquid came away; the patient was relieved, and it 
was sometime before the tumor filled anew. I then practiced 
puncture for the second time, when the liquid had another as- 
pect; it was reddish; the tumor now refilled itself with greater 
promptitude. A third puncture was made which gave issue to a 
liquid again modified in its aspect; it was redder and thicker. A 
fourth puncture became necessary. It is now some weeks that 
well characterized pus has come away from the tumor. You 
see this was a cyst, at first almost inert; in consequence of 
the first puncture there was an irritation established which 
was not very intense; alter the second it was more marked, 
and after the third, the irritation was sufficient to determine 
locally a very violent pain, and an inflammatory action which 
gave rise to a general febrile reaction to such a point, that 
pus was formed in the tumor and the fourth puncture gave 
issue to it. 
Thus, this cyst, at first perfectly inactive, gradually be- 
came irritated and inflamed, and has become something more 
serious than it was previously. What is the cause of this 
change? It is most certainly not the introduction of air that 
we can accuse; the canula was extremely small, and all ne- 
cessary precautions were taken in introducing it to prevent 
the introduction of air into the cavity. I repeat, that punc- 
ture practiced in the deep-seated tissues may often give rise 
to inflammation without the air having penetrated, without 
the air having any hand in it. 
There are persons who think that subcutaneous punctures 
cannot produce inflammation; this is an error. These punc 
tures are not always unattended by danger; they are not as 
innocent as they are represented to be. 
Our patient had a cyst for many years; it gave him almost 
no trouble; all the functions of his system were well executed; 
he was in almost perfect health, and now behold him in an 
entirely different state. Before, it was possible to leave him 
in the state in which we found him; now, it is impossible to 
leave him without treatment. Foi 'eign Correspondence. 
101 
For a long time I have hesitated about treating him; for 
the means which we possess against his disease are not to 
be depended on, and may even be of dangerous tendency. 
In surgery, we often have cases comparable to this, as, for 
example, tumors of the ovaries, fibrous bodies, which are, in 
a great number of circumstances, compatible with long life. 
For these tumors, persons have dared to open the abdomen 
and thus extirpate them; and it is especially in England and 
America, that these rash endeavors have been made. As 
for me, I blame them very severely; these are unreasonable 
attempts which are unworthy of surgery. In the beginning, 
I recoiled before an operation, and I had engaged our patient 
to quit the hospital, but he afterwards refused; he wished 
that I should cure him. I decided with pain to make a se- 
cond puncture, and this little operation has determined an in- 
flammation which may result fatally if I leave the patient 
without treatment. For thirty years his affection has been 
beyond the resources of art; to-day it may be combatted. 
A first procedure consists in incising the walls of the abdomen 
upon the tumor, to lay it open to its bottom and put in a 
pledget of lint. This is the most prompt, but also the most 
dangerous procedure, for the peritoneum is opened, and the 
matter may escape into its cavity; a double chance of peri- 
tonitis. Unless one be assured that the peritoneum is adhe- 
rent, he must reject this operation. Dr. Graves, of Dublin, 
acts in another way. He incises the abdominal walls layer 
by layer; then, arrived at a few lines distance from the perito- 
neum, if there be adhesion, he punctures on the spot, if not, he 
stops and waits, hoping that a local inflammation will cause the 
peritoneum to adhere to the tumor and the walls of the ab- 
domen. 
This procedure is not sure; first, because it is impossible 
to go with certainty just to the peritoneum, without wound- 
ing or opening it, and afterwards because the inflammation, 
instead of being adhesive, may be purulent, and the pus, if it 
escapes into the abdominal cavity, will produce a peritonitis, Foreign Correspondence. 
102 
Further, the tissues in cicatrizing, thickening, may prevent 
the tumor from opening externally. 
M. Begin does better. He incises in the same way to the 
peritoneum; then he incises the peritoneum as respects the 
tumor. This last naturally becoming engaged in this spe- 
cies of button-hole, contracts adhesions upon its sides; later, 
the tumor is punctured. This procedure has, to my knowl- 
edge, been employed two or three times by M. Begin; I 
have myself used it twice with success; but it is only appli- 
cable when the tumor is globular; if it be flat as this is, it 
does not engage itself in the button-hole, and its gliding 
upon the borders of the wound may produce an inflammato- 
ry irritation. 
A fourth procedure is that of M. Recamier, and it is this 
that I am going to adopt in the case of our patient, because 
it is the best. It consists in the application of caustics to 
that portion of the abdomen corresponding to the tumor. It 
is necessary to have a deep eschar and as large as a five 
franc piece. Three or four grains of caustic must be ap- 
plied. Then wait for or endeavor to hasten the fall of the 
eschar. Apply the caustic four or five times, until you have 
destroyed the entire thickness of the abdominal wall. You 
thus forcibly produce an eliminatory inflammation without, 
and an adhesive one within. When you arrive at the cyst, 
introduce the instrument. These means are then, so to 
speak, but preparatory. They have for their end to bring 
the tumor to the exterior. This obtained, you act upon this 
tumor as you would act upon an external one. As far as 
the operation goes nothing is more simple; but is this all? 
We have here parietes of a thickness more or less great, 
but slightly retractile; the tumor may always remain open, 
as nothing tends to obstruct the cavity. 
There remains a large cavern which may secrete a patho- 
logical liquid; and as it is almost impossible to make the open- 
ing in the most depending portion, the liquid stagnates and is 
decomposed by the air; this air is not at all an excitant, as 
has been said, but merely a chemical menstruum necessary Foreign Correspondence. 
103 
by virtue of its oxygen to all fermentation-to all decom- 
position. 
Do you believe that the tissues will remain indifferent to 
the presence of these putrid products? No. The dead na- 
ture in chemical reaction will be at war wilh the living tis- 
sues. It has been counselled, the tumor being open, to ex- 
ercise no pressure upon it, to leave it to empty itself by the 
organic retraction of the tissues. 
It is an error to believe as many do, that the air may enter 
every open cavity. The air by no means enters with facili- 
ty the cavities whose walls are soft; the atmospheric column 
may often approach and apply these walls one against the 
other, instead of being introduced between them. But if 
the walls are inextensible, the atmosphere is incapable, by 
its weight, of effecting the occlusion of the cavity by the 
mechanism that I have just mentioned. 
In our patient, the fear of the introduction of the air into 
the cavity is well founded; the central parietes as well as 
the parietes of the liver are but slightly flexible; this inevi- 
table introduction will not, however, produce a direct exci- 
tation of the tissues, but will simply afford a chemical men- 
struum to the morbid liquids which they will secrete. In 
what manner shall we oppose the decomposition? In these 
cavities, it is the practice to make detergent antiseptic injec- 
tions, that are made to lodge there for a certain length of 
time by closing the opening, which may be done by various 
means. 
Some days after, the inflammation assumed a bad charac- 
ter, pus was effused, and, escaping into the abdomen, a peri- 
tonitis was developed, from the effects of which the patient 
died. 
Continuation and conclusion of M. Hugier's lectures on 
Catarrh of the Uterus. Diagnosis.-We have already seen 
what are the characters proper to the discharges in catarrh of 
the uterus, but we should not, although these afford the prin- 
cipal and essential elements of the diagnosis, omit to inquire Foreign Correspondence. 
104 
whether the disease be simple; whether due to a local or gen- 
eral cause; whether dependent or not on an affection of the 
tunic, of the neck, or of the body of the uterus; whether it 
is the consequence either of a lymphatic temperament, an 
anemic, or a scrofulous taint. These, you will at once 
perceive, are all very useful in furnishing the essential thera- 
peutic indications, which we now proceed to speak of. 
Treatment.- Our anato mico-pathological researches on 
catarrh of the uterus, rather than any purely therapeutical 
or speculative views, have led us to adopt a new medication 
which alone often proves efficacious after all the ordinary 
therapeutic means have failed. But we must repeat that it is 
important, nay, we should say indispensable, to examine into the 
causes to which the diseaseisowing-whether it be produced 
by excessive coition, onanism, syphilitic virus, etc. These 
circumstances, in fact, being known, certain therapeutical in- 
dications naturally present themselves to the mind. When 
the affection assumes an acute form and is accompanied by 
considerable reaction, local and general antiphlogistics are at 
once suggested; but it is not with this form that we usually 
have to do. It is rather with the chronic, and in such cases 
local antiphlogistics from the commencement are indicated. 
If the catarrh is of an atonic nature, general and local 
tonic medicaments are to be insisted on. Along with these 
allow substantial and invigorating food; make use of aroma- 
tic and sulphur baths, seabathing; conjointly with these, free 
exercise in the open air, change of scene, moral stimuli, and 
the hundred et ceteras that will suggest themselves to the 
mind of the intelligent physician, may be made of very great 
assistance in the cure of his patient. Locally, tonic and as- 
tringent injections, with oak bark, quinine, rhatany, alum, 
etc., etc. 
It has been thought, when these different means have fail- 
ed to produce the desired result, that it would be useful to 
throw medicated injections into the cavity of the body of 
the uterus itself. This method, by no means new, was form- 
erly somewhat in vogue, but had fallen entirely into oblivion, p. 105-110 missing