Part 7

Thirteenth day, the patient is in her ordinary state; the apparatus is renewed. Twenty-fourth day, the reunion is evidently advancing. Thirty-second day, the consolidation is complete.

The patient now began to perform gentle motions with the limb, which she gradually increased, till about the fortieth day, when she was perfectly well, and free in all her motions.

25. I will here repeat an observation, already made, on the subject of the bandage for the clavicle, of which this is nothing else than a modification. In a short time the bolster sinking downward, the bandage becoming relaxed, and the splints less tight, do not effectually oppose a displacement, unless the bandage be daily examined, and reapplied, when it seems to act too feebly. There are many surgeons, who have not been fortunate in retaining the fragments with exactness, because, trusting too far to the action of the bandage, they have for a long time neglected to examine it; this remark is applicable to every apparatus composed of rollers.

26. Here, much more than in other cases, it is all-important that the limb be accustomed to motion, after the process of consolidation. Situated near to the joint, the fracture always leaves some stiffness in it, which time no doubt wears away, but which will sooner disappear under the above treatment.

§ VIII.

REMARKS ON COMPLICATED FRACTURES.

27. Complicated fractures of the neck of the humerus are to be classed with all other accidents of a similar nature, and it would be difficult here to lay down such general rules as would be applicable to every case. The practitioner must be always governed by circumstances. The necessity of the case sometimes urges him to the adoption of daring measures, which, in developing the resources of the art, do honour to the talents of him who exercises it. Of this the following case is a proof.

CASE III. Pierre Lena, aged fifteen, as he was at work on a scaffold, forty feet from the ground, fell from that height on the corner of a stone. He experienced instantly such severe pains, that he was unable to rise. He was carried to the house of a surgeon, who, believing that he had suffered a luxation, made fruitless attempts to reduce it, produced in the part an enormous swelling, augmented his pains, and all to no purpose.

The patient was carried to the Hospital of Charity, where Desault at the time was surgeon in chief. A fracture of the neck of the humerus was discovered, through the tumefaction and echymosis, which had overspread the whole shoulder. A suitable bandage was applied.

A few days afterwards, a manifest fluctuation, an evidence of an effusion of blood, disclosed the necessity of making an opening. This was accordingly done, and the fingers being introduced into the part, several large splinters were discovered, and a sharp-pointed bone, the end of the lower fragment, pricking the deltoid muscle, and occasioning, no doubt, the pains which had hitherto continued without intermission.

The indication was evident. To give vent to all the splinters, and cut off the point of the bone, or to amputate the limb, was the only alternative that was left. Most of the practitioners that were consulted were in favour of the last measure. But Desault ventured to repose a hope in the first, the successful issue of which would be the certain preservation of the limb. He performed the operation as follows.

A large incision made in the posterior, and one still larger in the anterior part of the arm, enabled him to remove with ease all the splinters. Then taking hold of the pointed extremity of the inferior fragment, he drew it through the anterior opening, and cut it off with a saw and a pair of cutting forceps. He then replaced it with his fingers, and fixing the head of the bone in its proper position, applied an apparatus somewhat similar to that intended for the retention of fractures.

A suppuration taking place, the patient was dressed every day. Several abscesses were formed during the course of the treatment; each time the pus was discharged by means of an incision.

At the end of four months, the bone was perceived to be in a state of necrosis. The dressings were regularly continued; but the patient, becoming tired of his residence in the hospital, left it, being able to move without difficulty, and having, in the upper part of his arm, a deep fistula, from whence there was a constant escape of ichorous matter, and through which several splinters were discharged, in the space of six months which he passed at his own house.

About the expiration of this period he returned to the Hospital of Charity. Desault had, in the mean time, left this institution to take charge of the Hotel-Dieu. Amputation was proposed to the patient as his only resource. He refused to comply, and went to Desault, who, examining the state of the parts, found an irregular callus formed, which he removed, together with a portion of the soft parts corresponding to the fracture. At the end of two months and a half, the patient was discharged perfectly cured, except a weakness in the limb, which disqualified him for hard labour.

28. This case may throw considerable light on the difficult question relative to amputations at the joint. But this is not the place to state the ideas of Desault on that point of practice.

I will only observe, that in many cases of gun-shot wounds, a similar treatment would probably save life, without exposing the wounded to the dangers of an operation, in which so considerable a portion of the system cannot be removed with impunity, and would secure to them a limb, for the preservation of which they ought not to shrink from the pains and hazards of a tedious treatment. To sacrifice a part for the preservation of the whole, is the last resource of the art. It is necessary, before resolving on this, to exhaust those previous ones that might restore the whole of our organs to life and their proper functions.

MEMOIR VI.

ON THE FRACTURE OF THE LOWER EXTREMITY OF THE HUMERUS, WITH A SEPARATION OF THE CONDYLS.

1. Fractures of the humerus, accompanied with a separation of the condyls, appear to have escaped the notice of most authors who have written on diseases of the bones. The ancients have transmitted nothing to us on this point. Petit, Duverney, and Bell, among the moderns, have made no mention of it. Heister adverts to this fracture of the bone, only to express an unfavourable prognostic respecting it, without determining the mode in which it is to be remedied. Yet it is by no means rare to meet with examples of it in practice. Desault, in particular, has had frequent occasions to observe it.

§ I.

OF ITS VARIETIES AND SIGNS.

2. These fractures, like those of the condyls of the os femoris, are rarely the effect of a counter-stroke. They are almost always produced by the immediate action of external bodies; such, for instance, as a fall on the joint of the arm; the wheel of a carriage passing over this part, &c. &c.

3. Whatever may be their cause, they generally occur in such a manner, that a longitudinal division separates the condyls from each other, and, extending upwards to a greater or less distance, is terminated by another transverse or oblique division, which passes through the whole thickness of the body of the bone, so that there are three fragments, and two fractures.

4. Sometimes the division is simple; in which case, being directed outwards or inwards, it crosses the lower end of the humerus, obliquely from above downwards, and terminating at the joint, separates but one of the condyls from the body of the bone, leaving the other adhering to it.

5. In the first case (3), there is more deformity at the broken extremity of the humerus; and the mobility is also greater. If the fingers, placed before or behind, press on the limb in the direction of the longitudinal fracture, the two condyls will be separated from each other, the one yielding in an outward, and the other in an inward direction, leaving a fissure or opening between them. The part at the same time expands in breadth. Thus, the two condyls of the os femoris, are seen to separate from each other when in a similar fracture, pressure is made on the rotula. The fore-arm is almost constantly in a state of pronation. When we take hold of one of the condyls in each hand, and endeavour to make them move in opposite directions, they can be brought alternately forward or backward: and, if their surfaces touch, a manifest crepitation is heard.

6. In the second case (4), the condyls cannot be so easily separated from each other; but it is always practicable by taking hold of that one which is divided from the body of the bone, and moving it from before backward, to produce a crepitation, which is a sufficient proof that a fracture exists. In a case where the external condyl was alone separated, Desault found the limb in a constant state of supination, a position to be attributed, without doubt, to the muscles attached to this condyl.

7. An acute pain, the almost inevitable effect of the flexion or extension of the fore-arm, the habitual semi-flexion of the limb, a tumefaction of it sometimes supervening, and a swelling more or less considerable, around the joint, are symptoms which accompany both modes of division (3 and 4). The fracture may further be rendered complicated by means of wounds, splinters, &c. when the blow has been very severe, or when a pointed fragment has made its way through the surrounding soft parts, &c.

§ II.

OF THE PROGNOSIS.

8. The preceding assemblage of signs, leaves in general but little doubt on the subject of the diagnosis; but is the establishment of a solid prognosis attended with the same facility?

If authors be consulted, they will be all found to agree, in considering the communication of fractures with a joint as a complication of a very serious nature. A swelling of the adjacent parts, their inflammation, a continuance of the pains after the reduction, extensive abscesses, a gangrene even of the soft parts, and a caries of the bones; such, according to these authors, are the almost inevitable consequences of these kinds of fractures, of which an anchylosis is the most favourable termination that can be expected. Petit, Heister, and Duverney, do not describe the evils that accompany these accidents. Pare, in speaking of them, says, “In such cases, the violence done to the tendons generally gives rise to great inflammation.”

9. From whence can arise these exaggerated fears? Can it be, as is pretended, the mere communication of the fracture with a joint, that is productive of such serious affections? What relation, then, can reason discover between the cause and the effect? Does not experience answer in other cases, in a manner that admits of no reply, when it furnishes us with the analogy of fractures of the rotula, the olecranon, &c.?

Modern researches have entirely abolished the ancient theory of an effusion of callus into the joint, and with it one of the principal causes assigned by writers for the accidents and evils which they so much dreaded.

The admission of air into an articular cavity, would be, without doubt, in such cases, a consideration of more weight; but this does not occur except in fractures accompanied with wounds, and yet all those in the vicinity of joints, whether compound of not, are regarded as extremely dangerous. Besides, observation has oftentimes proven to Desault, that even the contact of air is not so dangerous as it has been commonly supposed, and many instances occurred to him in his practice, where, notwithstanding such a complication, a perfect cure was obtained.

10. It is, then, to the want of a skilful mode of treatment, and to the irritation experienced in the parts, in consequence of an ill-constructed apparatus being applied to them, that the accidents formerly mentioned (8) ought to be attributed. Such accidents never occurred to Desault, in any of the numerous cases that fell under his care. It is thus that in the fracture of the neck of the os femoris, the insufficiency of the means, is oftentimes productive of unfavourable results.

§ III.

OF THE REDUCTION, AND THE MEANS OF MAINTAINING IT.

11. The displacement here is, in general, inconsiderable, because, being drawn in contrary directions, by the muscles of the arm and fore-arm, the condyls separated from the bone remain stationary between these two forces. A fall, a percussion, or some other external cause, can alone produce a displacement, by communicating some degree of motion to the fragments. Now, from what was formerly said (5 & 6), the condyls may, under such an impulse, move either forward or backward, or else may separate from each other, leaving between them an intermediate void. Hence the apparatus ought to oppose to them a resistance in these four directions, namely, inward, outward, forward, and backward; a resistance which it will be easy to make, by means of four splints, placed in these directions, and properly retained by a roller. The two lateral splints, are particularly necessary, when the condyls are both separated from the body of the bone, and divided from each other (3). If one of them be still attached to the humerus (4), a splint on that side becomes less useful.

12. It is needless for the apparatus to extend as high up as in a fracture of the arm. What effect, in sustaining the fragments, would casts of a roller have, when applied to the body of the bone, above the place of division? Their only advantage would consist in compressing the brachial and triceps muscles, and in that way preventing their action.

On the other hand, the roller must be continued along the fore-arm, in order that the elbow joint may correspond, according to the judicious precept of Paul of Egina, to the middle of the bandage, which is in general more compact and solid, in the middle than in any other part, and also, that a slight compression may be thus made on the muscles attached to the condyls.

13. The pieces which compose the apparatus, are 1st, A roller five or six yards long, and three inches broad, made of soft linen or muslin, and rolled up in a ball. 2dly, Four splints (11), two of them flexible in the middle, in order that they may bend to fit the fold of the arm, and the elbow, and the other two very strong and inflexible, intended to be applied at the two sides.

14. Every thing being arranged, the reduction is effected in the following manner. One assistant is directed to make extension at the upper part of the arm, which he grasps with both his hands; another makes extension on the fore-arm half-bent, which he uses as a lever of the second kind,[12] where one of his hands, being placed under the wrist, forms a fulcrum, while the other applied towards the fold of the arm, represents the power. The surgeon, in the mean time brings the condyls together, adjusts their level and apposition, both between themselves, and with the body of the bone, and then proceeds to the application of the apparatus, the limb being still kept in a half-bent position, as was long since recommended in such cases by Paul of Egina. “_Si in vicinia cubiti brachium fractum est, etiam ipse cubitus deligandus, angulari figura servata._”

[12] In this form of lever, the power is applied between the fulcrum and the weight to be moved, or the resistance to be overcome. TRANS.

15. The roller (13), wet with vegeto-mineral water, which facilitates its application, and prevents the swelling of the part, is fastened by one of its ends, about two-thirds down the fore-arm, and continued upwards by oblique and reverse casts, to the joint. The surgeon then passes a cast of the roller from the anterior and superior part of the fore-arm, to the posterior and inferior part of the arm (humerus), redescends by an oblique cast from the other side, over the fore-arm, and returning along the first track, makes a number of casts in the form of the figure of 8, round the joint, which he next covers by circular casts, applied so close to each other, as to leave no opening between them; he then proceeds upwards by oblique casts, as at the first, to the middle part of the arm (humerus), when the roller is given into the hand of an assistant.

The first of the splints (13) is now placed anteriorly on the fore-arm and arm, and, if it does not bend, in such a manner, as to accommodate itself to the fold of the arm, the vacant space beneath it is filled up with compresses, laid on top of each other, so as to make its compression uniform throughout. The second, being applied on the posterior side part of the arm, moulds itself to the projection of the elbow, while the other two occupy the sides. These are secured below by an assistant, while the surgeon resuming the roller, which he had just given out of his hand, fixes them firmly by circular casts descending along the arm and fore-arm.

The limb is then laid on a pillow, so disposed that the hand may be raised higher than the elbow, in order to prevent the subsequent swelling, which is oftentimes produced by the fracture, as has been already mentioned (7).

16. The effect of this bandage is simple, and has a particular relation to those directions and causes, in and by which, displacements might occur. The two lateral splints prevent the separation of the condyls from each other; the anterior and posterior ones prevent them from moving backward or forward; the muscles are compressed; the motion of the joint is prevented; and, in common, no great length of time is necessary for the reunion of the bone.

As soon as this is accomplished, it is of importance to move the limb in every direction, to prevent that stiffness, which is so commonly the consequence of fractures situated in the neighbourhood of joints. The following case, drawn up by Le-geulle, will furnish the reader with a detailed account of the treatment pursued, in such accidents, by Desault.

CASE I. Joseph Kisler, an ostler, aged forty-one, fell from a height of thirty feet, on the left side, his arm being undermost, and fractured the lower end of the humerus. A surgeon gave him immediate assistance, and, at the expiration of two days, he was carried to the Hotel-Dieu.

From the signs formerly mentioned (5 and 7), Desault discovered a fracture, consisting in a separation of the condyls from each other, by a longitudinal division, and from the body of the bone, by a transverse one. The usual apparatus (16) was applied, and, from a state of extreme anguish, which he had till now suffered, the patient experienced immediate relief.

In the mean time, a considerable swelling around the joint, pointed out the necessity of blood-letting, a low diet, and other antiphlogistic remedies. These were immediately had recourse to, and the limb was placed in the proper position (16).

Notwithstanding these precautions, the tumefaction and redness were increased on the following day. The bandage was applied anew, and wet from time to time with vegeto-mineral water.

On the following days, pain less severe, the bandage kept constantly wet with the same fluid.

Eighth day, the swelling almost gone; the apparatus, being loosened, was again reapplied.

Fifteenth day, the fragments, being examined, were found in regular contact, and already united by a substance of considerable firmness; the strictness of regimen gradually relaxed; solid food taken in small quantity.

Nothing new till the twenty-second day, when the splints were laid aside, having become useless, in consequence of the rapid progress of reunion: from this time till the completion of the cure, nothing was used but the simple roller.

On the twenty-fourth day, gentle flexion and extension of the arm and fore-arm were for a short time performed; these movements were attended with acute pain, notwithstanding which, the fortitude of the patient enabled him to persevere in them.

Thirtieth day, no pain accompanies the movements of the arm: the range of these movements visibly increased; the roller laid aside; from this time the range of motion increases rapidly.

On the thirty-seventh day, the patient was discharged perfectly cured, and free from every vestige of his disease, except a trifling stiffness, which was doubtless soon removed by the motions of the joint.

17. When wounds, splinters, or severe contusions, render these kinds of fractures more complicated, an inflammation occurring on the articular surfaces, may cause them to unite together, and by that means give rise to an anchylosis. But this accident, inevitable in such a case, according to writers, does not always occur, provided nature be assisted, by a judicious mode of treatment, in her attempt to reunite the broken bone. Desault has established this truth, in many instances. Here, as in other joints, he has oftentimes obtained a complete cure, without the loss of motion, although the part had sustained the greatest violence. Incisions, easily made, the extraction of splinters, a frequent renewal of dressings, a most vigilant care to prevent all jarring of the limb, and consequently all derangement of the contact of the fragments, an assemblage or combination of those minute attentions, which art cannot teach, which genius suggests, and which characterize the true surgeon; a precaution (not to be dispensed with) to make the limb perform motions, gentle at first, but gradually increased afterwards, when the adhesion of the parts has acquired sufficient solidity to admit of it; such are, in general, the steps and circumstances constituting the bases of that treatment, requisite in these complicated fractures, which, like all others, appear, in each case, to assume a new aspect, and to present different indications.

CASE II. A person, carrying a heavy burden, fell with his elbow on a sharp corner of a bar of iron. The external condyl was broken, being separated from the body of the bone, by an oblique division running into the joint. Anteriorly, a large contusion; posteriorly, a transverse wound; on the outside, the end of the condyl projecting through the soft parts, which it had lacerated: such were the complications of a fracture, for which the patient was admitted into the Hotel-Dieu, on the seventh day of January, 1794.

On examining the state of the parts, Desault discovered, in the transverse wound, two splinters which when extracted, gave vent to an effusion of blood. He reduced, instead of cutting it off, as authors have advised, the end of the separated condyl, applied a bandage of strips,[13] and, to prevent accidents, ordered a strict diet, copious blood-letting, and diluting drinks.

[13] (_Bandage a bandalettes._) This is a most convenient form of bandage, in fractures of the upper or lower extremities. It is composed of strips of soft linen or muslin, from two to three inches wide, and of a length accommodated to the size of the limb, on which they are to be applied. These strips are not sewed together, but merely laid along side of each other, or rather spread in such a way that their adjoining edges may overlap a little. Being thus arranged, on the bed or mattress, where the patient is to lie, the broken limb is placed on them, when the surgeon, taking them, one by one, folds them round it, so as to form a very perfect and neat covering. The number of these strips must be regulated by the extent of the limb, or, at least, of that portion of the limb, which they are intended to cover. TRANS.

Compresses wet with vegeto-mineral water, kept the apparatus constantly moist.

On the day following, the dressing was renewed superficially; severe pains in the part; abated towards evening; almost gone next day; low diet continued.

Fourth day, pains returned; an incipient swelling around the joint; more blood drawn.

Sixth day, considerably better; all the apparatus renewed; suppuration beginning to appear.