WAIT V. COLLIS.

Oamaru Mail, Volume IV, Issue 1319, 26 October 1880, Page 2

WAIT V. COLLIS.

The hearing of this case, in which Dr. . Wait sought to recover from Mr. E. Collis L 9 18s 6d for professional services and medicine, was further continued at the Resident Magistrate's Court to-day, before T. W. Parker, Esq., R.M. Dr. de Lautour was placed in the witness box and further examined by Mr. Hislop. The witness stated that in measuring Collis he did so from the ankle to the upper line of the pelvis. An unskilled person might have some difficulty in finding the point, but when a patient had been measured he should be able to point out. the starting point. The bone was more easily ascertained and felt in thin people. Collis was in thin condition at the time. To make the measurement the patient might be lying on his back or standing ; lying on his back was the best. A layman might get the measurement roughly, but he would not place much reliance himself upon such a measurement. An unskilled man might make a mistake of half-an-inch or more. There was no difference in the points on either side of a person. Having ascertained the point on one side there would be no difficulty in finding the point on the other side. The point at the hip was prominent and easily ascertained. The point at the hip was very easily ascertained. Still an unskilled person might make a mistake of half an inch ; but not of an inch and a half. Cross-examined by Mr. Newton: Witness said that his qualification as a member of the College of Surgeons enabled him to practice medicine. The examination that.hu had to pass in the College of Surgeons required that he should also pass in medicine, He had been practicing in Oamaru about six or seven months when he was called in to attend Collis. He obtained his deploma in May, 1874 He had studied surgery between five and six years before being admitted to practice. He had previously treated similar cases to that of Collis, and had had at least half a dozen such cases while acting as house surgeon. Coliis was a perfect stranger to him when he was called in, and had nut heard of the accident. In the event of a second surgeon being called in to consult with him in regard to a patient, and they did not agree, and the treatment of the second doctor was called in, he would, if he were the surgeon first called in, consider that his further attendance was not requited. In the event of two medical men agreeing to try a new course of treatment suggested by the doctor last called in, the treatment would be under the supervision of the doctor who suggested it, and who would be responsible for its results. The patient would no doubt expect that he should get the benefit of the new advice. The second doctor would control the treatment carried out at his suggestion, but not control the first medical attendant. Dr. Wait had never agreed with him that there was shortening ; but he still agreed to try extension, and he (the witness) supposed that Dr. Wait agreed to his treatment because it would give the patient rest. His agreement to try the treatment did not imply that he accepted the correctness of witness' statement that there was shortening of the injured limb. He was under the impression that when they parted on the occasion of their first consultation that Dr. Wait agreed to meet to apply the extension, and when he did not keep the appointment he thought he might have been detained, or that he was annoyed at his suggesting the new treatment. He was decidedly of opinion that Dr. Wait agreed to meet and try the treatment. He was prepared to state positively Dr. Wait did not say he would not meet, and was under the impression that he assented. In consequence of Collis telling him that Dr. Wait would not attend him any more, he (witness) attended him regularly after having put on the weights. He was not aware that Di\ Wait was continuing his attendanoe. He had met Dr. Wait several times, and had asked him to visit Collis with him and see how he was getting on. He had only once been informed that Dr. Wait had afterwards visited Collis. Collis told him that Dr. Wait looked in on the evening upon which the weights were applied, and expressed his regret that he had been prevented from being present. At this point some argument took place as to the advisability of certain evidence, and afterwards there was a short adjournment for lunch. On resuming, the cross-examination of Dr. de Lautour was continued. He brought the whole of the extending apparatus with him to put it on. He intended to put it on himself, or assist Dr. Wait to do so. The extending of a litnb that had been fractured was advised. It would depend upon how extension was applied whether it had the effect of rupturing the ligament ; but he did not think the extension used in. Collis' ;ase would have such an effect. His opinion was what took place in Pollis' case was fracture of the neck of ;he fermur, but it was difficult :o diagnose whether the fracture ivas intra or extra-capsular. It was lot impacted when he saw it. Ah intracapsular fracture was not very common, it any rate in this country. It was very jncommoh in subjects under 50 years of ige. Even in cases of impacted fracture shortening may be reduced at once, but it vas not advisable to apply force. It was juite possible, and very probable, that in JSO cases of intra-capsular fracture of the eg there might be only two instances in >eople. under 50 years of age. The only lymptoms of fracture he discovered at the ime of his examination were shortening, ' iversion of the foot and knee, and deormity in the altered condition of the ' rochanter-major, and possibly greater nobility of the limb than there should be. i L'he altered condition of the trochanter- ] najor only tended to strengthen his < ipinions as/to shortening and: fracture, i in all cases of shortening of the neck of I he thigh bone there would be an altered i icisition of the greater trochanter/ varying 1 ccording to the circumstances which < aused the shortening. He did say ) hat' which he observed ' I a the position of the greater i fhen examining Gollis only tended to, i onfirm the results of his measurement i

.showing the shortening of the limb. Collis was lying on his bed when he measured him. He believed he gave instructions to have Collis placed in a firm bed. It was the proper thing to do, and he always did so. Otherwise there might be deformity when least expected. He was of opinion that he ordered a change of bed at first, but it was possible that Collis was on a suitable bed when he first saw him, and that there was no necessity for a change. He measured Collis in the presence of Dr. Wait on the bed upon which he was lying at the time. It was not absolutely necessary to place a patient on- a board in order to measure him. It was not always necessary to make a patient stand when measuring him ; sometimes it was advisable, and sometimes it would be dangerous. He did not know that it would have been dangerous in Collis' case, bat he did not think it was necessary. There would have been considerable motion, which would have been inadvisable. There would have been about the same amount of motion as that of rotating the limb. It often occurred that curiosity on the part of a surgeon led him to rotate the limb violently in order to find crepitus, but he thought it very inadvisable. In the generality of cases a patient would be in a better position to obtain a correct diagnosis standing than lying down, but it was not necessary in many cases. One wouldhaveabetteropportunityof taking an observation standing than lying down- Apparent shortening was of little value unless confirmed by actual measurement. It was dangerous to accept conclusions arrived at taking a patient and placing both legs together and putting a hand across .the knees to discover shortening—that is dangerous to rely Upon an opinion formed in such a manner. - Apparent shortening must be verified .by some process. He thought he would be able to notice by observation only shortening if it was to the extent of an inch and a half, but he would still not place any reliance upon his cpinion without verifying it. Eversion of the foot was partly caused by the action of the external rotative muscles and partly by the natural tendency of the limbs to fall into that position when supported. Eversion of the foot was the natural position assumed ly the limb in sleep, the muscles not being in play. The symptoms of intra-capsular fracture there would be, immediately after an accident, eversion of the foot, sometimes inversion, possibly crepitas, frequently alitjle shortening, occasionally considerable shortening, there would be more or less pain according to the cause of the accident, inability to movethe limb, greater natural mobilitiy, and more or les3 deformity. In rotatingthe limb the arc described by the greater' trochanter when rotated was apparently less than in its normal condition. Shortening in intra-capsular fracture after the lapse of some time would perhaps extend to two inches or more. It was not likely to be so great in eight weeks, but he could quite conceive that it might become great, especially in old persons who had received no attention, or where the bones had not united. The usual thing was that shortening should not be more than an inch and a half or thereabouts in six weeks, because, as a rule, steps would be taken to prevent shortening. In simple extra-capsular fracture there might be less than an inch shortening at first, but it was not visual., He conceived it to be quite possible that in a case of simple extra-capsular fracture occurring from slight violence, which it very seldom does, and that the patient were immediately examined before the muscles have time to contract and before the patient is allowed to place the weight of his body on the injured part, and if the measurement could be taken at the time, the shortening might not exceed a quarter of an inch. If, as was assuredly the case, the fracture resulted from a severe shock, the shortening would be considerably more. In a case of impacted intra-capsular fracture there would be less shortening, less eversion, less preternatural mobility, and no crepitus. It. was generally very difficult, and sometimes absolutely impossible to distinguish the difference between the classes of fracture. Shortening of a limb was caused by displacement of the fragments. In intra-capsular fracture shortening is generally delayed, and when it does occur it is generally sudden. In a case of extra-capsular fracture of the hip shortening would take place at once; it might be gradual. Frequently similar symptoms resulted from contusion as from fractures. In all cases of fracture there was contusion. It took less violence to cause contusion than fracture. Professor Sayre, of New York, ascribed 250 cases of hip joint diseases out of 370 to the result of contusions of the hip without fracture. lutra-capsularfracture sometimes occurred from very slight causes, but these cases only occurred to very old people, and in these cases, unless the displacement was severe, there would not perhaps be contusion, unless the line was drawn very tine. There might be cases of fracture of the neck of the thigh bone without contusion in very old people or young people with disease of bone. There might have been cases of contusion that were mistaken for fracture. (Mr. Newton here read from a number of authorities, and asked the witness if lie-agreed with.them, and Dr. de Lautour replied in the affirmative). The fact of a patient who had met with an accident having previously suffered from any form of chronic articular rheumatism would not increase the difficulty of making a diagnose of the injury. The fact of a patient having suffered from rheumatism might, under certain circumstances, add to the difficulty of diagnosing. When a patient had suffered from rheumatic arthitis the difficulty of making a diagnosis would be increased. Impacted fracture of the neck of the thigh bone was very difficult to distinguish from contusion, arid in some cases it might be impossible,to do so. If crepitus were obtained immediately after an accident it would be conclusive proof of a fracture, and crepitus was generally present in a case of 'fracture, unless it were impacted. Other things being equal, the surgeon who first examined a patient after an accident would be better able to ascertain the nature of the injuries ' than one who was called in six we§ks afterwards. No other case of fracture being mistaken for contusion had come under his own notice, but it was quite possible that a patient might be taken into a hospital where there were four surgeons, and that two would declare .it to be contusion and the other two a fracture. Union by bone was very rare in cases of intra-capsular fracture. He believed there had been bony union in Collis' case. The first process of union would commence almost immediately after the accident, but it might take nine or twelve months to complete the process. He would not say positively that there was intra-capsular fracture in Collis' case. There was fracture, and he thought it was probably intra-capsular. At such a remote period after the accident it was impossible for him to say positively whether or not the fracture was intra or extra-capsular. To the best of his knowledge and ability he believed there had been union of the bone in Collis' case. He had no opinion as to whether" the fracture was intra br extra-capsular. Ha still thought the fracture was, not invpiicetd when he ; ejyuwined Collis! Crepitus wis probably . repdered impossible of detection by the separation of the fragn\e^ta x and that at the expiry of 315 wayksi after-the accident there would t>.&. a deposit ; of lymph. Jjound the edges if the bones, which would prevent them nibbing, together and'getting the orepita;ioQ. }n ordinary cases of extra-i-capsular ■racture orepitus easily detected. Bony rarely oc<ywed ;ea£oept whop the : besa.Jtep't in apposition.

In cases of bn union might I 'take place long afterward even if the bones had not been kent ■' apposition, provided the fragments w 15 brought into apposition proper treating! applied. _lt was almost impossible i cases of intra-capsular fracture to h union of bone unless the fragments been kept in apposition. Under very , ceptional circumstances bony union mi be obtained six weeks after the fraetu If broken fragments could be kept in r6 ' position for a sufficient length of tin?" even though they had been separated f' some weeks, the fragments would in t! meantime have been passing out lymnb aftewards to be used in the form tion of bone and in the process union unless the bone became dead n might at any time, if not dead, bo excited to recommence its operations. The head f ; the neck of the femur, even if the fo ments were not kept in apposition, miiiht continue in a fit state to throw out lymph and be capable of union long as it maintained its vitality 0 ° so long as the patient lived, and might be made to renew its operations If left entirely at rest the bone would continue to pour out after about three or four weeks, but if irritated it would continue to do so much lon«er The time would also vary according to°tha amount of inflammation at the time of tho injury. In a case where a patient had walked abont daily on crutches after the fracture of the head of the neck of the femur would continue to throw out lymph for six weeks, but it would be absorbed by a similar process and would not turn into bone. If the fragments had not been brought into apposition and had not commenced union six weeks after the fracture, bony union might still bo obtained. If the fragments, had commenced to unite by bone, and six weeks after the accident were disunited there might still be union by bone. Collis' case the bones were not in apposition, and were not united when he first: examined him. If the fracture in Collis" case was intra-capsular and the bones had. united, they had done so in an irregular manner, a little above one another and & little to one side, hence • the difficulty. At the time when he examined the defendant both the fragments were each undergoing a process of repair, but they had riot united ; there was not even parj tial union between the two parts. Tho parts not being in apposition they could not very well form bony union. He had reduced the shortening of Collis' leg by fully half an inch. The leg was still an inch and a half shorter than tho. other. The fragments were not got into, perfect apposition, but sufficiently so. to obtain a union. They were certainly not in anything like proper The periosteum must have torn through in Collis' case, or had given way. He still maintained that notwithstanding all this that the fragments, if brought into anything like proper . apposition, might unite. The fragments in Collis' caso were not in anything like proper, apposition. Both in intra and extracapsular fracture lameness in some degreewas inevitable, to a greater or lesser degree. Bony union was less likely in a, person of weak than in a person of strong; constitution. Prom the inquiries ha hadi made, he was of opinion that Collis,. although not absolutely of a weak constitution, was certainly not robust. His: constitution had been affected by the accident. It was possible that he might maka a mistake of half an inch, but he did not think a non-professional man would make a much greater mistake, but lie would not accept the result as absolutely corroot. In a case of either intra or oxtra-capsnlar fracture he would get a patient up in a few days. It would be absolutely necessary to do so, for instancej iu the case of an old woman. In re-examination by Mr. Hislop, tbo, witness said that the positions he occupied in King's College—assistant demon-, strator of anatomy, prosector of anatomy, and resident house surgeon—were considered such high honors as to ontitlo their holders to have their names placed in the medical directory. As a matter of fact, Dr. Wait had not made any exeuso to him for not having kept his appointment. When Dr. Wait told witness that there was no shortening, he (Dr. Wait)* did not, witness thought, make a measurement, but looked at Collis' legs. A slight, apposition only was necessary to enablo. fragments to unite. And what was necessary was that the bones should be. brought close enough together for theprocesses going on in the two fragments-, to meet. Collis possessed good repairingpower. The case was then ■ adjourned unfciK Friday.