.phiit'i'P'***1' J u.. \.J- I.-.- u^ / < i Li 15,;.. AUG-7 !£„.; THE l- —bAl.L. BOSTON MEDICAL AND SURGICAL JOURNAL. Vol. LIV. Thursday, March 20, 1856. No. 7. TRIAL FOR MAL-PRACTICE. LComraunicated for the Boston Medical and Surgical Journal.] Messrs. Editors,—The folloAving is a report of the trial of Gusta- vus H. Loomis, M.D., of Putney, Vt., for mal-practice. The me- dical testimony is given in full, prepared by Mr. W. Wesley Wil- kins, one of my students, from notes taken by himself and compared Avith those of Mr. Marsh, the junior counsel for the defence. To this I have prefixed a summary of the facts in the case, derived from the testimony of the other (non-medical) witnesses, and from several depositions which Avere presented to the court; not deem- ing it worth Avhile 1o occupy your pages with details of no profes- sional interest. I have closed the report with remarks on the most important points in the case. Very truly yours, Woodstock, VI., Feb. 22d, 1856. Wm. Henry Thayer. On the 25th of October, 1852, in the evening, Mrs. Nancy Clos- son, widow, aged 57, fell down the cellar stairs of Mr. Stoddard's house in Putney, Vt. Mrs. Closson's home was in Walpole, N. H., seven or eight miles from Mr. Stoddard's house. She had been a resident of Westminster, the town north of Putney, for the greater part of the forty years previous to her injury. Dr. Campbell, of Putney, had, during all that time, been her physician, and he was immediately sent for Avhen she Avas hurt. His house is three miles south of Mr. Stoddard's. He Avas unable to go, but sent her word he Avould see her in the morning. She, hoAvever, being in great pain, sent for Dr. Loomis, of Putney, who came. Dr. Campbell called the next morning, but learning that Dr. Loomis had taken charge of her, left her and saw her no more. Dr. Loomis found swelling of one wrist, and serious contusion of one leg just below the knee, with so great sAvelling of the leg that it AvouTd have been impossible to ascertain, Avith certainty, the ex- istence of fracture of the tibia, had he considered it proper to make a thorough examination. But, finding neither unnatural mobility nor any apparent displacement, he Availed for subsidence of the inflammation before handling the part—in the meantime supporting the le<* and foot and making applications to reduce inflammation. 2 Trial for Mal-praciice. The wrist gave no evidence of fracture or dislocation, and when the swelling about it had subsided, Dr. L. gave it no furl her attention. On the eleventh day, the patient was removed to Westminster by her friends, three miles further (six miles in all) from Dr. Loomis's house—without the knowledge or consent of the physician. She rode in a wagon, silting on the seat, with her foot resting on its side on bedclothing piled up before her. Dr. Loomis did not see her again. For seventeen days she remained without medical attend- ance, and then called in Dr. Kiltredge, of Walpole—having in the meantime removed again, to Walpole. Dr. Kiltredge made a deposition which Avas read to the Court. He deposes that he found deformity of the radius, from a fracture within an inch and a half of its lower extremity, with dislocation of the ulna ; and deformity of the tibia from a transverse fracture three inches below its head, and displacement of the lower frag- ment towards the fibula—the upper fragment remaining in place. He deposes that union of the tibia was not then complete, and that the limb could not support her weight. He deposes that he applied pasteboard splints and bandages. He did not attempt to reduce the fracture. Hoav long the splints Avere continued, Ave have no evidence. The limb has been tightly rolled to the present time, and the patient has never attempted to use it, but has constantly gone on crutches. This is the case, as presented by Avitnesses at the trial. Between one and tAvo years after the injury Avas received, Mrs. Closson removed from Walpole, N. H., lo Woodstock, Windsor Co.,^ Vt. After remaining there long enough to acquire a legal residence, she entered actions for mal-practice against Drs. Camp- bell and Loomis in the Windsor County Court. She then returned to Walpole to reside. When the case of Dr. Campbell was to come to trial, she Aviihdrew the suit against him in Woodstock, and commenced one in Keene, N. H. Dr. Campbell was tried in Keene in October, 1855, and acquitted. The suit against Dr. Loomis Avas tried at Woodstock, Vt., in the December term of 1855, before Judge Underwood. Messrs. Tra- cy of Woodstock, and Marcy of Royalton, Avere counsel for the plaintiff; Messrs. Washburn and Marsh, of Woodstock, for the defendant. The jury brought in a verdict for the defendant. The grounds of accusation were, mal-trealrnent of the case and unjustifiable desertion of the patient. The counsel for the plaintiff attempted to show that the displacement of the tibia could not have taken place during her removal ; as it would have been attended with so much pain that it. must have been evident to the patient " that something extraordinary had taken place." Whereas she testified that there Avas no particular increase of pain at that time, as she was already suffering nearly all she could bear. Her coun- sel therefore contended that the displacement must have existed * Putney, where sh$ was hurt, is in Windham County, Vt. Trial for Mai-practice. 3 from (he first, and ought 1o have been discovered by the physician. And, in their argument, these learned gentlemen ridiculed the idea that a blow severe enough to produce a transverse fracture of the tibia, would not displace the fragments, while such displacement might take place gradually and even without producing any pecu- har sensations, in the course of a ride of three miles, eleven days later ; a singular instance of ignorance and Aveakness of mind, that substitutes partizan presumption for the evidence of experi- ment and experience. It is well for the ends of justice and truth that there are many lawyers whose mental cullure' extends beyond mere legal technicalities. Law and common sense are said to be synonymous. We have no doubt they are—but such men are not true exponents of the law. Medical Evidence. Witnesses summoned by Defendant. Gustavus II. Loomis* called.—I am defendant in this suit. Have practised medicine and surgery for nine years. I was first called to visit the plaintiff on the night of the 25th of October, 1852, be- tween the hours of 10 and 11 o'clock. I saw her at John H. Stod- dard's house in Putney, Vt., between the hours of 11 and 12 o'clock. I found her lying on a sofa. Her friends said she had fallen down cellar. She appeared in a very nervous and excited state. I made a very slight examination of the leg when she was lying on ihe sofa. Assisted in carrying her to the bed. I think I examined the arm before moving her. After she was placed on the bed, I passed my hand over the limb ; it was very much sAvollen—more than I ever saAv in such a case before in so short a time. I examined her by passing my hand over I he bone and by looking at the limb. She was quite fleshy. I deemed the best course to pursue was to place the limb in an easy position, and try to reduce the inflammation and SAvelling.f I placed a pillow under the knee, and supported the limb so as to make it as easy as possible. I treated it as though it had been a fracture. I thought it might be a fracture. Gave an anodyne, and applied a cooling lotion. I rotated the Avrist, bent the fingers, flexed the Avrist and extended it. She could adduct and abduct it. She complained of some pain, but I could not de- tect any displacement. I treated the wrist Avith a flannel roller and applied cooling lotions. Used flannel, as this Avould retain mois- ture longer. I left her comfortable. I gave her no opinion—I mean no direct one. I said to one of the attendants, if the small bone of the leg was broken and high up, it Avould take care of itself, and Avould not need a very extensive examination. Should think I Avas there three or four hours. Accident occurred on Monday, and this Avas early Tuesday morning. I saw her again near the mid- * Both plaintiff and defendant were on the stand in this ease. By Vermont law, all parties may he witnesses in a suit. f Inflammation and swelling are repeatedly spoken of in the evidence, .because understood by Che counsel as distinct in meaning. 4 Trial for Mai-practice. die of the day. Was as comfortable as could be expected. Treat- ment continued. Leg more swollen ; more discoloration. Wrist much the same. Too much swelling to make a correct diagnosis. Did not see her on Wednesday, because my own health was poor, and I thought she would get along as well. I saw her again on Thursday. There Avere blisters on the leg; more inflammation ; skin shining. Blisters Avere from the size of a fourpence-half-penny to that of a pin's head. The foot Avas somewhat swelled. Inflam- mation Avas more extensive. I directed a yeasl-poullice to be ap- plied to the part. I did not advise this before. I put this on, as there Avere symptoms denoting a tendency to mortification. There Avas no poultice on Avhen I came. I did not examine the limb to ascertain Avhether there Avas fracture, as it would have been necessary to press the limb hard enough to have felt the edges of the bones, and move the limb so as to produce crepitus ; and this, in the already excited state of the parts, might have pro- duced gangrene. I felt confident that if there Avas fracture, the bones were in apposition. I applied liniment to the Avrist. I saw her again on Friday. She Avas better. Her whole condilion bet- ter. Her leg had not increased in size. Blisters were no worse. Did not make an examination, for the same reasons that I did not yesterday. Examined the wrist; could detect no fracture. I again saAv her on Saturday ; the swelling had gone down a very little on the leg ; not any on the knee. Discontinued the yeast-pouliice. The blisters had disappeared, and the general appearance was better. I made no examination, because I did not think it safe. The limb did not shoAv any departure from the proper direction and natural position. There Avas no apparent deformity. What force was used in my examinations of the fracture had not shown that there was any motion in the bones. She said on Saturday that I need not trouble myself any more about her wrist, as that Avas well enough. She had all the motions free in it, and after this day 1 did not examine it. I next saw her on Monday. The leg was improv- ing ; the swelling had gone doAvn a very little ; but I did not make any examination, for the same reason as before. I again saw her on Thursday. I did not make any examination. Her leg was in the same position as at the previous visits ; the inflammation was less. There Avas something said about her being moved. I declined giving my consent, on this occasion, and at all times. I told them I would be there on Friday or Saturday and make a thorough examination, and determine about her moving; and Avhen she was moved, I Avanted to be there myself, and see to it, and fix it up. They said " yes, she must be bandaged, of course." I said to them that that would not do ; I must see to it myself. I went there again on Sat- urday, and was then informed that she had been moved. I had not been informed that she Avas going to be moved. I had never given my consent to her being moved at any lime. 1 did not knoAv where she was going. I was told, after she was gone, that she was at Mr. Floyd's, a distance of six miles from my house. I never saAv her Trial for Mal-praclice. 5 afterwards professionally. I was never asked to attend her after she Avas moved, nor did I suppose that I was expected to do so. I supposed she was in the hands of her oavii physician. I never put any bandages or splints to her leg. The use of splints is to keep broken bones in apposition. In this case I think bandaging might produce mortification. Bones begin to unite in from nine to Uvelve days, as a general thing; but this Avould be affected by the health and age of the patient, and other circumstances. In the plaintiff's case, with her health, I should expect in a common simple fracture that union Avould commence in from twelve to tA\Tenty days—say fourteen or sixteen days. In such a case as this, I think the in- flammation should somewhat subside before reducing the fracture. The size of the broken ends at the point of fracture Avould tend to keep the bones in place ; or it Avould not be so liable to displace- ment as if they Avere smaller. Where there are two bones in a part, as in the forearm and leg, the unbroken bone operates as a splint. There Avas no displacement of the fibula. If bones are in place and the direction of the limb is right, no further examination is necessary. It would make a great difference from Avhat part of the Avrist-joint Dr. Kiltredge measured.^ The nearer to the wrist- joint the fracture Avas in the radius, the more difficult Avould it be to diagnosticate, and the less Avould be the danger of displacement.! If a patient Avas moved that had such a fracture as the plaintiff, Avithout preparation, I should expect displacement. By preparation I mean splints. If the reasons for moving Avere very urgent, I Avould have her limb splinted, and have her moved as easily as pos- sible. If the patient must be moved, in a case of simple fracture Avhere there is no great inflammation, the sooner she is moved the better. After reparation had begun, it ought not to be allowed. If bones are in apposition, and they can be kept there Avithout, it is as A\rell not to use splints as to use them. A simple fracture is where there is no communication Avith the external air through the soft parts. Cross-Examination.—I have testified in this case once before. I cannot say that I then stated anything about gangrene. I think I then said there was not much deformity or swelling at the Avrist. I made no thorough examination, because I deemed it to be impru- dent, on account of the inflammation ; and if there was a fracture, it might produce displacement or extreme irritation and inflamma- tion. She might or might not have any great amount of pain in moving. This might depend on the amount of nervous sensi- bility. I thought it would not be safe to move the limb. Moving of the limb A\rould be apt to produce irritation under any cir- cumstances. I did not know Avhere the house Avas where Mr. Floyd lived. I did not know Mr. Floyd. They Avere stran- gers to me entirely. I had practised in that neighborhood. I had, * Referring to Dr. K.'s deposition that there was fracture of the radius an inch or an inch and a half from the joint. i The testimony was in reference to transverse fracture. 6 Trial for Mal-practice. I suppose, attended a patient in Mr! Floyd's house. How long be- fore, I do not know. I universally refused to give my consent to her being removed. I called on Mrs. Closson once at Walpole. I did not call professionally, but because I heard a rumor about there being broken bones. I found them fractured ; the tibia of the leg, and the radius of the arm. There was a decided deformity. Direct Examination resumed.—I went to see the plaimiff, and slaid there some tAventy minutes. There was not much swelling. I could see there Avas a crook where it ought to be straight. When I last saw her there was no such crook. If there had been such a crook, I should have seen it Avhen she Avas at Putney. If I Avere going to move her, I should prefer a litter. John Campbell called.—I reside in Putney. I am a practising physician and surgeon. I Avas called on the night of October 25th, 1852, to see Mrs. Nancy Closson, the plaintiff in this suit. I saw her the next morning. 1 went into the room. 1 did not move the limb. Her leg was swollen and a good deal discolored. It was in a good position and well supported. I Avas about to run my hand up on the leg, and she objected. I judged that the leg was not out of place. It had none of the appearances that it had at Walpole some ten or twelve Aveeks afterwards. I think I should have noticed it, if it had been out of place as at Walpole. There appeared to be a good deal of nervous sensi- bility. I should not have thought it good practice to have made a thorough examination. I have known Mrs. Closson for tAventy years. She is of a nervous temperament and a scrofulous habit. I have attended her during several severe fits of sickness ; one of epidemic erysipelas. She at one time had a functional heart-diffi- culty. Union between broken bones takes place in from ten to twenty or twenty-five days. In this case I don't think nature A\-ould have done much in less than fifteen days. The time would increase with age, and be modified by constitution and habit. Splints are for keeping bones in apposition. They are a necessary evil. Where there is great inflammation, splints and bandages may produce gangrene. We should do without them when we can—that is, when the bones will remain in place without them. I have had to take off splints and bandages after I have put them on. From the breadth of surface of the broken bone, the fracture would not be easily dis- placed. The fibula in this case would serve as an excellent splint. I Avould delay examination in such extensive inflammation until the inflammation had in a great measure subsided. The position was a good one ; the limb Avas flexed just enough to relax the muscles. If the patient was put into a wagon, placed on the seat, and moved in this way, 1 should expect displacement of the bones. The nearer a fracture is to the end of a bone, the less likely it is to be displac- ed, and the more difficult Avill it be to make a correct diagnosis. A fracture of the radius Avithin an inch or an inch and a half of the wrist-joint, may not affect the motions of the hand as much as a se- vere sprain. In case of transverse fracture of the radius, the ulna Trial for Mal-practice. 7 would not necessarily be dislocated, and if it was dislocated there must, be displacement of the radius. Cross-Examination.—I made no particular examination. In an ordinary case, the practice is to reduce the limb as soon as the sur- geon is called. It depends on the constitution of the patient, the condition of the limb, &c. I usually prefer doing it at once, Avhen it can be done. When the fracture is oblique, there is more danger from spasms of muscles. If such a patient was to be moved, splints should be put on the limb. If the bone Avas displaced during the journey, the pain caused by it Avould be discernible. Direct Examination resumed.—I did not examine the bone very critically at Walpole. The visit Avas a short one. It is my impres- sion that Dr. Loomis invited me there. There is very little danger of displacement in a fracture like this, Avhen the patient is asleep. If I rotated the hand, flexed and extended it, and felt the bones Avith my fingers, I should think it Avas a sufficient examination. Wm. Henry Thayer called.—I am a practising physician and sur- geon. Have been in practice tAvelve years. Am professor of pathology and the practice of medicine in the college in this place. I teach anatomy during the Avinter term. When a surgeon is called in a case of injury, it is his first duty to make as thorough an ex- amination as the circumstances of the case Avill alloAv : and ascer- tain, if possible, whether there is a fracture, and, if so, its nature and extent. The ordinary symptoms of fracture are displacement and unnatural mobility of the bone. There may be fracture Avith- out displacement. There Avould be more difficulty in determining whether there Avas or Avas not fracture, in such a case. The liability to displacement would be affected in this case by there being an- other bone in immediate relation with the fractured one. The two bones of the leg are bound together by strong ligaments, Avhich make them like one bone. There is not so much tendency to dis- placement, Avhere the tibia is fractured near its upper extremity, from the greater size of the broken ends at that point. If the frac- ture Avas occasioned by a direct Uoav, I should expect SAvelling of the soft parts to follow at once. In a case like the plaintiff's, I should expect considerable SAvelling, and that it Avould commence immedi- ately after the injury; and if the surgeon Avas called in three or four hours after the injury, it might be impossible to determine wilh accuracy Avhether there Avas a fracture or not. In such a case as the plaintiff's, the surgeon ought not to handle the soft parts; he should disturb them as little as possible—that is, in a case like this, Avhere there is no material displacement. There being no apparent displacement, and much sAA^elling in the surrounding tissues, the sur- geon's duty is to place the limb in as easy a position as possible for the patient, and make such applications as will tend to alleviate the pain and reduce the inflammation. The surgeon may make an exami- nation Avhen the inflammation has in a great degree subsided, and he should not do so before that time. No union of the bones can 8 Trial for Mal-praclice. take place while there is great SAvelling and inflammation^ in the parts, and these should be first reduced. The object of splints is lo keep bones in apposition. In regard to the proper position for the leg, there might be a difference of opinion. I think the position was a good one. It is good practice in some cases to dispense Avith splints. It would be bad practice to use splints where there Avas great swelling and inflammation around the fracture. Splints can- not be used Avithout bandages. It would not have been proper to apply splints in such a case as was testified to by the defendant. To have used them in the condition in which the plaintiff then was, would have endangered the safely of the limb. The use of splints would not. have been indicated until the inflammation had in a great measure subsided. No displacement could well take place in a fracture such as this is shown to have been, Avhile the limb is at rest. There is no force in the limb itself to draw the fragments from their proper relations, Avith the exception of one muscle (the popliteus) ; and that could only affect the upper fragment, as it is inserted into the upper fifth of the tibia. The upper fragment Avould not. be likely to be displaced, from the fact, that it is held in position by strong muscles. The other musclesf run parallel Avith the shaft of the bone, and consequently could not affect its fragments in a man- ner to produce displacement. I Avould account for the displace- ment in this case, by the removal of the plaintiff without the limb being sufficiently supported. The plaintiff might have been remov- ed carefully after putting on splints and bandages, Avithout produc- ing displacement. In a case such as the plaintiff's, I should expect such removal as Avas testified to, might produce displacement. I should not expect any dislocation of the fibula from the removal. I heard the defendant's testimony in regard to his treatment of the leg. I think his treatment Avas good, as he has stated the facts. A fracture of the radius near the wrist joint is not so easily disco- vered as one farther up. Such an one is sometimes very difficult to detect. On being called to see a wrist that had received an injury, I should first examine it Avith the eye to see if the bones Avere in place. If I could not satisfy myself by this, I should pass my hands along the edges of the bones, and observe the motions of the joints. If there Avas no apparent deformity, and I could detect no evidence of a fracture, by passing my hands over the bones, and the mo- tions of the Avrist were free, I should keep the part quiet, and make such applications as would tend to reduce the inflammation. The highest medical authority says that a fracture of the radius occur- ring as near the wrist-joint as it appears to have been in this case, is sometimes very difficult to detect, and will sometimes exist Avithout displacement of the fragments. If the ulna had been dislocated, it would have been most probably throAvn either backward or for- Avard, producing so great a deformity either on the back or in the * Inflammation is not understood by lawyers to include swelling; hence the phraseology of tes' tiinony here and elsewhere. t Meaning, all but the popliteus. Trial for Mal-practice. 9 palm of the hand as could not be overlooked by a surgeon. Sub- sequent displacement of the fractured ends of the radius Avould not. of itself dislocate the ulna. It would require some neAV injury to occasion it. The surgeon having made up his mind that there was no fracture, the inflammation having subsided, and no complaint being made by the patient, I do not think there Avas any necessity of his making another examination. Spasmodic contractions of the muscles Avill occur from the effects of displaced bone on the surrounding tissues. They may occur at any time, according to the circumstances of the case. I do not consider it probable that the tibia could have been displaced by the spasmodic action of the muscles. Displacement is very unlikely to occur when the pa- tient is quiet in bed. She is not likely to move her limb when it is in the state described. She might, if she were delirious or in a slate approaching to delirium. Cross-Examination.—Displacement of the tibia, as it exists in the plaintiff's case, Avould not be likely to occasion spasmodic muscular contractions. Such displacement will not necessarily produce pain. Pain does usually attend the displacement of the fragments occur- ring at the time of fracture. It is possible for displacement of the fragments to take place at a subsequent period, Avithout pain—par- ticularly if gradual. I presume pain always occurs Avhen a bone is broken. I think severe pain will be felt Avhen a broken bone is pro- jected into the flesh. A displacement might have taken place dur- ing the removal of the plaintiff, Avithout her experiencing any addi- tional pain. I think she Avould know that something extraordina- ry had taken place—from the motion of her limb in its inflamed state, whether displacement of the broken bone occurred or not. The immediate result of such a displacement would very likely be to increase the inflammation of the limb, and affect her comfort. This effect would probably continue several days. There is sometimes great difficulty in detecting a fracture' of the radius near the Avrist-joint. I have never seen a transverse fracture of the radius within an inch and a half of its knver extremity, and Avith- out displacement of the fragments. There is no medical writer, except one, as far as I know, Avho mentions such a case. But Ave have his authority, which is great, for the occurrence of such frac- tures and the great difficulty^ of their detection. In a case like this, it is the surgeon's duty to Avatch the limb, and make an exa- mination Avhen the proper time comes. Nothing the patient may say in regard to the injured part, can excuse him from making an examination, if he thinks it necessary to do so. Dislocation of the fibula is less likely to occur than fracture of it; any force applied lo it Avould sooner break than dislocate it. Direct Examination resumed.—Had a dislocation of the upper extremity of the fibula existed at the time Dr. Loomis saw her, it might not have been discoverable on account of the swelling. It * Th« difficulty depends upon the absence of displacement of the fragments, and the rarity re- fers to the same point. 2 10 Trial for Mat-practice. is not the duty of a physician to continue in attendance on a pa- tient Avho removes her place of residence, unless he is requested to do so. A displacement like that now existing in the tibia did not necessarily occur all at once, by any sudden action. It is more likely to have been gradual, and probably took place in that man- ner during her removal. 2d Cross-Examination.—If a physician is in attendance on a pa- tient, and is informed that she is to be removed, it is his duly to fol- low her, or give notice that he will not do so. Ptolemy Edson called.—I am a practitioner of medicine and sur- gery. I have been in practice forty-five years. The duty of the surgeon Avhen called to see a patient Avhere there may or may not be fracture, is to make an examination at once. If not called un- til after SAvelling and inflammation have taken place, he must make a slight examination only. If ihere has been injury of the soft parts, more swelling lakes place. If there is much SAvelling, he should put the limb in as quiet a condition as possible and apply cooling lotions. Fracture Avithout displacement is very common in transverse fractures, and especially in parts where there is another bone. If the fracture is near a joint, it is very difficult to detect; and if there be much swelling, it may not be determined Avithout using such force as would be an injury to the patient. The exami- nation should not be made until the swelling and inflammation have subsided in a great measure ; for the reason that union Avill not take place Avhile the parts are in such a highly inflamed state. Splints are used to keep bones in place. When there is another bone in the part, it furnishes one of the best splints Ave can have. Splints may often be dispensed with. When splintsare used, bandages must also be applied. I think Dr. Loomis treated the limb in this case right. I think a patient, in such a case as this, ought not to be moA'ed for the first eleven days. If it Avas absolutely necessary, she should be moved on a litter. If moved in the manner shown by the testimony, I should fear displacement. I never saAv a case in practice, of fracture of the radius within an inch and a half of the wrist-joint, without dislocation of ihe ulna. We have very few accounts of such in medical books. It is very difficult to discover fractures of the radius at this point. The usual Avay to detect it, is to observe the motions of the Avrist ambhand, and this is not always sure. In a case like this, as testified by the defendant, if I could discover no displacement, I should place the arm in as quiet a po- sition as possible and apply cooling lotions. After I had examined it once, I should not probably examine it a second time, if 1 heard no complaint. Cross-Examined.—When there is a dislocation of one bone and a fracture of another, I should reduce the dislocation and apply splints. I use splints more than is usually done iioav. If there is dislocation, the eye will detect it at once ; as the joint will bethroAvn out of shape. Should think if the displacement of the tibia took place all at once, the patient would think something extraordinary Trial for Mal-praclice. 11 had taken place. It might be displaced gradually. If displacement took place some lime alter the fracture, it might occasion only slight swelling. The pain would subside soon after the displacement— in an hour or two. Edwin Hazen called.—I am a physician and surgeon. I have practised medicine thirteen years. I have seen the plaintiff, and examined her Avrist and leg. I found indications of a transverse fracture at the wrist. There is no apparent dislocation of the ulna, and no evidence of any dislocation ever having taken place there. The ulna is a little more prominent than usual, from the hand being carried more to ihe radial side of the arm. 1 found evidence of a transverse fracture of the tibia about three inches below the knee- joint. I measured both limbs. There is no evidence noAV that there has ever been any dislocation of the fibula. I think it would have broken rather than its ligaments have given away. I heard Dr. Loomis testify. I think his treatment of this case Avas correct. Cross-Examined.—I think Ihe examination Avould not be so satis- factory as one made six or eight weeks after ihe accident. If the fibula had been dislocated, there Avould have been more deformity than there is. Direct Ecrimination resumed.—If the fibula was dislocated, and not reduced within a few Aveeks from the time of injury, it Avould present the same appearance now. She had her leg bandaged from the fool to the knee, with a book cover under the bandage. She said it was to reduce the pain. I think the bandages have had a bad effect on the limb. The muscles have grown smaller—are atro- phied. Witness summoned by Plaintiff. Thomas E. Powers called.—I Avas called about ten days ago to go and see the plaintiff. I examined both her leg and arm. 1 dis- covered that there had been a fracture of the upper part of the tibia, and there Avas a lateral displacement of about one quarter of an inch. The upper end of the lower fragment had been carried tOAvard the fibula—it may be from a quarter to a half an inch. It has united in the situation 1 have described. I have practised medi- cine and surgery for tAventy-eight or tAventy-nine years. I Avas not able to make up my mind that there was any dislocation of the fibu- la. I examined the wrist, and found the radius had been broken about an inch and a half from the joint, and the upper fragment carried towards the ulna. There is a deformity there now. At the first examination I made, I thought there had been no disloca- tion of the ulna ; I have since examined it and I think there has been a dislocation of the ulna. I don't see how this deformity could exist, unless there had been such a dislocation. I think there is nothing unusual in a fracture at this point. If there was not much SAvelling, there Avould not be much difficulty in detecting fracture at this point. When no bone is broken, but only a bruise, I should suppose a removal could be made Avithout difficulty. If 12 Trial for Mal-practice. the leg was fractured, a removal Avould tend to produce inflamma- tion and s\A7elling. Cross-Examined.— I think a sudden displacement would produce more immediate pain than if it was gradual. The broken ends project in toAvards the ulna. I think the deforrmly is too much for a simple fracture. It is difficult lo tell whether there Avas any dislocation of the ulna or not. A fracture might exist in the radius, and the ulna be dislocated, and still the patient might be able to give a rotary motion to the hand. The mere fact of pain in rotating the hand, Avould not of itself indicate Avhelher it Avas a fracture or a sprain. There might be difficulty in determin- ing Avhere the fracture now is; and a difference of opinion as to Avhere it is. The tAvo main points at issue in this case, Avere the correctness of the surgical treatment by Dr. Loomis, and the propriety of his dis- continuing his attendance after the patient's removal. In regard to the second point, no opinion Avas given by the medical Avitnesses— the questions put to them by the plaintiff's counsel having reference to circumstances which did not exist, namely, Avhat would be a sur- geon's duty in relation to continued attendance on his patient Avho had removed her place of residence, having" previously informed him of her intention to do so ? It had been testified by Dr. Loomis him- self, and deposed by the nurse, that Avhen Dr. Loomis became ac- quainted with the general desire of the patient to be removed as soon as she Avas able, he had uniformly discouraged it, and had said, that, should it become unavoidable, he must come and apply splints and rollers to the limb. He had never been called upon to do so, and when, therefore, on one occasion he came and found the patient gone, he was fully justified in considering the contract be- tAveen them to have been annulled by the act of the patient herself. If bound to follow her to the next town, why not further ? Where is to be the limit ? And this was the view taken by the counsel for the defence. The other point—the correctness of the treatment—included the propriety of omitting such an examination of the leg as Avould de- termine absolutely the existence of fracture of the tibia, the pro- priety of omitting the application of splints to the limb, and the jus- tification of the surgeon in not discovering the fracture of the radius. On these three points, the testimony of the physicians Avho were called upon the stand had reference to the case "in hand. As lo the time for learning exactly the state of a fractured bone and re- ducing it, every surgeon knoAvs that to put the fragments in place is the readiest mode of reducing inflammation. But in the trans- verse fracture of one bone of the leg, Avhere there appeared to be no displacement, and it was hardly possible, from the anatomical arrangement of the parts, that any should exist, there is no reason Trial for Mal-practice. 13 for handling a limb—already very much SAvollen by serious contu- sion—as roughly as would be necessary to discover such a fracture as existed in this case. It would be the worst practice to do so. John Bell is very strong on this point. The » Principles of Sur- gery, by that acute surgeon, contains a paragraph which I shall quote entire, as it refers to several poinls at issue in this case. " In fractures of the lower extremities there is no occasion for bandages for the patient lying in bed, the part is in no danger of being moved. Unless you could invent a machine which could enable a patient to walk or stand upon his leg, you need none. In all fractures of the leg, then, simple as well as compound, you merely lay the limb out upon its pilloAv or splint; nothing but convulsions, delirium or ma- nia, can endanger the fracture or require bandaging. In laying a fractured leg, where but one bone is broken, you need be at no pains about the posture; if the leg lie easy, and the patient com- plain of no pain, all must be right; but when both bones are bro- ken, you must be at pains to trace the sharp line of the tibia with your finger—for that regulates the posture of the leg. This you cannot do at first, because the general swelling hides the bone, but you have no fear of altering the posture of the limb, and you knoAv that the subsiding of the swelling marks the proper period for as- certaining the posture of the limb."* So Sir Charles Bell says, " Avhen SAvelling has arisen, an exami- nation of the position of the bones will be found impracticable." I shall be pardoned, I trust, for referring to several good authorities on this point and the question of the use of splints, although it is Avell known that there is no difference in the practice of surgeons in this respect. John Hunter says, " splints should not be applied till after inflam- mation has subsided." Nathan Smith warns his reader against the application of splints in such a Avay as to produce injury by their pressure. Dr. Hayward, in his volume of Surgical Reports, page 82, speaks of pressure as liable to cause ulceration or sloughing. Mr. Fergusson says that in certain cases (Avhere there is great injury of the soft parts) it is necessary to do without splints. Mr. Cooper, in his Surgical Dictionary (p. 378), says, " when the fragments are not out of their relative position, the surgeon must strictly refrain from all avoidable disturbance of the limb." In South's translation of Chelius (Vol. I. p. 556), Ave have the following remarks. " No fracture (coilar-bone and oblique fracture excepted) should ever be set, that is, put in splints and bandaged, till after three or more days, or, more properly speaking, till the swelling has ceased, and nearly or completely subsided. * * # # Therefore, all that should be done at first, is, to lay the limb upon a pilloAv, in a position Avhich gives the patient the greatest ease and soothes the irritability of the muscles." We have thus discussed the first and second points—upon which * Principles of Surgery, by John Bell, New York Edition, 1810, p. 128. 14 Trial for Mal-practice. the daily practice of all good surgeons is sustained by the highest authorities among surgical writers.* The third point relates to the fracture of the radius. A trans- verse fracture of the radius within an inch and a half of the lower extremity, without displacement of Ike fragments, and without dislo- cation of the ulna, is a very rare occurrence. So much so, that 1 am not aware of any author except Chelius who makes any men- tion of it. But Ave have his authority for saying that it does occur, and that it is extremely difficult, of recognition. Had the fracture been oblique, as it usually is, there would, in most instances, have been displacement of the fragments at once, and the nature of the accident could not have escaped the observa- tion of the surgeon ; but the fragments were probably so intimately engaged at their surfaces, that, in the absence of any physiological force to draAv them asunder, they gave no crepitus nor indication of mobility. They became gradually displaced after the limb had passed from the observation of the surgeon and the patient began to use her hand. It was then that the nurse first noticed that the Avrist was " growing out." I have referred to Chelius. The folloAving remarks are taken from South's translation of Chelius, Vol. I., p. 611, American Ed. " Fracture of the radius is mostly consequent to a fall on the hand, Avhen the arm is outstretched ; in Avhich case it usually happens in the middle of the bone. More rarely it is produced by direct ' violence. " The diagnosis is not difficult; the seat of fracture is felt, and, during pronation and supination, crepitation also. The frac- tured ends turn toAvards the cubit. Only when the fracture is near the lower end of the bone is the diagnosis difficult, and its confound- ing with sprain so much the more possible, as frequently at the first there is scarcely any or no distortion of the hand, nor is its motion in- terfered withy Whereas, Avhen displacement has occurred, he says " pronation and supination, bending and violent straightening of the hand, are very painful and restricted,