A Treatise on Fractures, Luxations, and Other Affections of the Bones

by P.-J. Desault

“On examining the arm, I found that the humerus had been fractured about two inches and a half above the elbow joint, and that the ends of the bone had passed each other, about an inch: the lower fragment, or that nearest the elbow, was situated over, and on the outside of the upper portion of the bone. The connexion that existed between the ends of the humerus was so flexible, as to allow of motion in every direction, and by forcible extension, the lower end might be pulled down considerably, but never so low as to be on a line with the end of the upper extremity. He was admitted into the Pennsylvania hospital, the latter end of May; but the weather becoming very hot, it was judged best to defer any operation that might be necessary, until the fall of the year. Unfortunately he then contracted a bilious fever, of which he was so ill, that his life was despaired of for some days. From this fever his recovery was so slow, that it was not thought proper to perform any operation until December. It still remained to decide, by what means a bony union of the humerus, might most probably be effected. In the year 1785, when a student, I had seen a case in our hospital, similar to this in every essential circumstance, in which an incision was made down to the extremities of the fractured bone, which were then sawed off, thereby putting the parts into the condition of a recent compound fracture. No benefit, however, was derived from this painful operation, and some months afterward the arm was amputated. This case had made a strong impression on my mind, and rendered me unwilling to perform a similar operation. I therefore proposed to some of the medical gentlemen of the hospital, who attended in consultation, that a seton-needle, armed with a skein of silk, should be passed through the arm, and between the fractured extremities of the bone, and that the seton should be left in this situation, until by exciting inflammation and suppuration, granulations should rise on the ends of the bone, which uniting and afterwards ossifying, would form the bony union that was wanting. This operation being agreed to, it was performed on the 18th of December, 1802, twenty months after the accident happened. Before passing the needle, I desired the assistants to make some extension of the arm, in order that the seton might be introduced as much as possible between the ends of the bone. Some lint and a pledget were applied to the orifices made by the seton-needle, and secured by a roller. The patient suffered very little pain from the operation. After a few days the inflammation (which was not greater than what is commonly excited by a similar operation through the flesh, in any other part) was succeeded by a moderate suppuration. The arm was now again extended, and splints applied. The dressings were renewed daily for twelve weeks, during which time no amendment was perceived; but soon afterwards the bending of the arm at the fracture was observed to be not so easy as it had been, and the patient complained of much more pain than usual whenever an attempt was made to bend it at that place. From this time, the formation of the new bony union went on rapidly, and, on the fourth of May, 1803, was so perfectly completed, that the patient could move his arm, in all directions, as well as before the accident happened. The seton was now removed, and the small sores occasioned by it, healed up entirely in a few days. On the 28th May, 1803, he was discharged from the hospital; perfectly well, and he has since repeatedly told me that his arm is as strong as it ever was.”

To the preceding paper it is unnecessary to add, that the mode of treatment there stated might be adopted in similar fractures of other bones, provided a seton-needle could be passed near to the ends of the fragments, without any risque of wounding blood-vessels, nerves, or other parts of importance. It is thus that solitary facts minutely detailed and well substantiated, oftentimes grow into principles of extensive application.

ARTICLE II.

An account of Dr. Physick’s improvement of Desault’s apparatus for making permanent extension in oblique fractures of the os femoris.

Dr. Physick having observed that in the application of Desault’s apparatus, the patient was sometimes injured by the pressure of the strap or roller g g ([plate 2]) which passes under the tuberosity of the ischium for the purpose of making counter-extension, devised the following method of remedying this inconvenience, in which he succeeded to his wishes.

He directed the upper end of the long external splint to be formed like the head of a crutch, and the splint itself to be lengthened so as to reach and bear against the axilla of the affected side, which must be well defended from pressure by a bolster of flannel or some other soft material. By this expedient the Dr. evidently formed two points of counter-extension, instead of one, as is the case in the apparatus of Desault. Between these two points, namely, the axilla and the perineum, the same quantity and force of pressure is, by Dr. Physick’s improvement, divided, which, in the original apparatus of Desault, is borne by the perineum alone. The risque of excoriation and injury to the patient, then, in the former case, is to that which he runs in the latter, only as one to two, or nearly so. As it is no less the duty of the surgeon to prevent suffering than it is to remove deformity or to save life, Dr. Physick has certainly in this respect made an important step in the advancement of his profession.

But there is still another advantage derived from the lengthening of the external splint. In the original apparatus of Desault, the strap gg intended for counter-extension, by passing no higher up than the spine of the ilium, runs too much across, and therefore acts too much on, the upper part of the thigh. By this it not only irritates the muscles of the part, and induces them to contract, but also tends to draw the upper fragment of the os femoris a little outward, and thus to render the thigh in some measure deformed. But, in the improvement of Dr. Physick, the strap gg is secured in a mortise cut in the external splint, about midway between the spine of the ilium and the axilla. This strap, by being thus carried higher up on the body, does not run across the thigh at all. It consequently presses on and irritates the muscles much less, acts more in the direction of the os femoris, and has no tendency to draw the superior fragment outward.

Hence this improvement not only diminishes the patient’s sufferings, but gives him, perhaps, the best possible chance of having his limb preserved free from deformity.

Another improvement made on the lower end of the external splint by Dr. James Hutchinson deserves also to be mentioned. It was found that in the original apparatus of Desault, the strap or roller L ([plate 2]) used for the purpose of extension, had a tendency to draw the foot too much outward. This fault Dr. Hutchinson very ingeniously remedied, by attaching to the lower part of the external splint, a little above the mortise, a small block extending inwardly, at a right angle with the splint, so far as to be on a line with the middle of the sole of the foot. Over the end of this block, in which a notch is cut to receive them, the ends of the strap L are carried, previously to their being secured to the external splint. By means of this expedient extension is made precisely in the direction of the limb, and the inconvenience of drawing the foot outward is completely obviated.

Thus improved by Drs. Physick and Hutchinson, the apparatus of Desault for oblique fractures of the os femoris, leaves, perhaps, scarcely a remaining desideratum on the subject.