Part 16

§ 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.”