Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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* Malgaigne, op. cit, p. 85.

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toid to near the condyles, extending through the entire thickness of
the bone, and the edges of the fissure so much separated toward its
lower extremity as to adroit the blade of a knife.^ Ghaussier has
related a case in which a criminal, who died soon after having sub-
mitted to the torture, was found to have a nearly longitudinal fissure
of the radius in its upper fourth, and which penetrated half-way
through the thickness of the bone.* Gulliver saw a fissure in the
pelvis of an infant.' Malgaigne has seen two specimens of this frac-
ture in the iliac bones, both of which belonged, as he thinks, to adults;
in one, the fissure was limited to the internal table;* and in the case
of the lad reported by Gariel, as having a fissure of the inferior
maxilla, there was also found a fissure of the left ilium, but which
was limited to the outer table.*

M. J. Cloquet has mentioned a case of fissure of the shaft of the
femur passing through the condyles and extending upward to near
the miadle of the bone. The fissure was produced by a bullet, which
had completely traversed the bone from behind forward, a little above
the condyles.^ M. Malgaigne has also represented, in one of his plates,
a fissure of the femur extending along the front of the bone, some-
what irregularly, from a point a little below the trochanter minor to
near the condyles.^ The bone was presented to the Museum of Val-
de-Grfice, by M. Fleury ; but it is to be regretted that we have no
farther account of this remarkable specimen. Certainly, in the com-
plete absence of any farther history of the case, one might be justified
in expressing a doubt whether it was not a fissure occasioned by the
contraction consequent upon exposure and drying after death.

The following account of a fissure of the neck of the femur, of the
same character with those which now occupy our attention, is copied
from the proceedings of the " Boston Soc. for Med. Improvement," at
its regular meeting in September, 1856 : —

" Partial Fracture of the Neck of the Femur in a man set. 44 years.
Specimen shown by Dr. Jackson. — The fracture, which appears as a
mere crack in the bone, commences anteriorly just above, but very
near to, the insertion of the capsular ligament, runs along this inser-
tion for about an inch, and then extends directly upward to the mar-
gin of the. head of the bone. From this last point it crosses the upper
surface of the neck almost in a straight line, and at a little distance
from the margin of the head, but afterward approaches very closely
to this margin posteriorly; it then turns downward and obliquely
forward, and stops at a point about halfway between the small tro-
chanter and the head of the femur, and two-thirds of an inch or more
anteriorly to the line of this trochanter. The fracture then involves
about three-fourths of the neck of the bone ; the inner-anterior portion
only being spared. There is considerable motion between the neck

* Campaignac, Des Fract Incomplet, &c., p. 24.

> M6d. Legale, p. 447 et seq. > Gazette M^d., 1885, p. 472.

« Op. cit., p. 84. « Bulletins de la Soc. Anat., 1885, p. 24.

• These du Concours de Pathol. Exteme, 1881, pi. xli., flg. 7. Also, Des Frac,
etc., par Campaignac, 1829, p. 19.

y Op. cit. p. 87, pi. 1, flg. 1.

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and the shaft, and the fracture could, undoubtedly, be completed with-
out the application of any extraordinary force. Dr. J. referred to
other cases of partial fracture; but a fracture of this sort, as occurring
in this situation, and in a fully adult subject, he believed had never
before been described. There was, also, in this case, a transverse frac-
ture of the same femur midway, with a split extending upward nearly
to the neck of the bone ; and still further, a fracture of the spine. The
patient, a laboring man, fell through two stories of a building and
down upon a hard floor. On the same day he entered the Massachu-
setts General Hospital, and on the 18th day from the time of the acci-
dent he died. The femur is perfectly healthy in structure, and no
changes are observable in the bone about the fracture."*

Whatever doubts may have been thrown upon the possibility of this
accident) as applied to the neck of the femur, by the ingenious ^argu-
ments of Robert Smith, of Dublin,' the question is now at least deter-
mined by an incontestable fact. Dr. Smith had rendered it quite pro-
bable that both Colles and Adams were mistaken, and that the cases
described by them were examples of impacted fracture, and not of
partial fracture ; but, in arguing the improbability of its occurrence,
from the infrequency of fractures of the neck of the femur in early
life, he overlooked the fact that there were two forms of incomplete
fractures, and that it was only the "green stick" fracture which be-
longed mostly to childhood ; " fissures" being found most often in the
bones of adults. Indeed, I think the example recorded by Tournel
in the Archives de ifidecine, had already, so early as the year 1837,
established the possibility of a " fissure" in the neck of the femur ; al-
though by Malgaigne this case has been mentioned as an example of
that other variety of partial fractures which is almost peculiar to
childhood, and in which the bones yield quite as much by bending as
by breaking. But the man was eighty-five years old, and, having
died three months and a half after the accident, a long crevice was
found, extending nearly through the neck of the femur, partly within
and partly without the capsule.

I have seen, in Dr. Mutter^s valuable collection of bones at Phila-
delphia, a specimen of fissure of the trochanter major, which, it is
believed, occasioned the death of the patient by hemorrhage.

Gulliver says there is an example of a fissure in a patella belonging
to the museum of the Edinburgh College of Surgeons ; the fissure tra-
versing its articular face only.'

The first example of a fissure of the tibia is recorded by Corn. Stal-
part Vander-Wiel, in 1687 ; and indeed this is, according to Cam-
paignac, the first exact observation of this species of fracture which
our science possesses, although its existence had been recognized by
the most ancient authors. A servant had been kicked by a horse, and
after a time, pain continuing in the limb, his surgeon, Dufoix, suspected

■ BoBt. Med. and Surg. Joum., vol. Iv. p. 851. Bee, also, Amer. Journ. Med.
Scl. for 1857, p. 806, with engraving ; and Bigelow on Hip Joint, p. 187.

* Treatise on Fractures in the Vicinity of Joints, etc., by Robert Wm. Smith,
Dublin, 1854, p. 44 et seq.

3 Malgaigne, op. cit, page 85.

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a fissure of the tibia, and having cut down to the bone, a cure wa9
soon eQected.^

In the Dupuytren Museum, at Paris, there are two tibise with linear
fractures ; one without history, and the other presented by MM. Mar-
jolin and EuUier, " and which had been broken by a ball."* In the
example related by Campaignac, a woman, having leaped from a
second-story window, died immediately, and upon examination she
was found to have three fissures in the upper portion of the left tibia,
one only of which entered the articulation.^

Many examples of fissure from '' perforating" gunshot wounds of
the bone have been observed during tHe late war in this country;
but as these examples belong peculiarly to military surgery, they
will be discussed more at length in the chapter on gunshot fractures.

Duverney saw a priest who had fallen and bruised the middle of his
left leg ; the swelling and pain consequent upon which were subdued
after a few days. The patient believed himself cured, and acted ac-
cordingly. Suddenly, in the night, he was seized with an acute pain
in the limb ; and on cutting down to the bone, a bloody serum escaped
from between it and the periosteum, and the bone was discovered to
be fissured longitudinally. Subsequently the tibia was trephined, but
the fissure did not reach the marrow. He recovered completely in
less than two months.

The same writer mentions another case, in which a soldier received
the kick of a horse in the middle of his left leg, which was followed
immediately by great pain, and subsequently by much inflammation,
and even gangrene of the skin. The wound, however, cicatrized
kindly, but after three months he was seized suddenly with a severe
pain in the limb; and, after the trial of many remedies, resort was
finally had to the knife, when the tibia was seen to be discolored, and
cracked longitudinally. On the following day the bone was opened
over the course of the fissure with a chisel and mallet, and the patient
was at once relieved by the escape of a yellowish and very ofi'ensive
matter. At the next dressing, the bone was opened more freely by
several applications of the trephine, and an abscess was exposed in
the centre of the bone. The patient finally recovered after about four
months.^ M. Campaignac saw, also, at the hospital La Charity the
tibia of a woman, mt, 88 years, upon which were found four fissures;
the report of which case is accompanied with a wood-cut illustration.'

Fissures may occur probably at all periods of life, but they are more
frequently found in the bones of adults. Campaignac, however, men-
tions a fissure of the humerus in a child ten or twelve years old, and
Gulliver has seen a fissure in the pelvis of an infant.

Etiology. — They may be occasioned by most of those causes which
produce fractures in general, such as direct or indirect shocks; but
they are occasioned much more often by direct blows, especially when
inflicted upon bones imperfectly covered by soft parts, such as the

1 Campaignac, op. cit., p. 17. ' Malgaigne, op. cit., p. 86.

* Campaignac, op. cit., p. 21. ^ Malgaigne, op. cit., p. 39 et seq.

s Campaignac, op. cit., pp. 21-22.

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tibia. Bullets, having violently struck or penetrated the bone, have
frequently occasioned fissures.

Their course may be parallel with the axis of the bone, oblique,
or transverse ; they are often multiple ; some merely enter the outer
laminae, others open into the cellular tissue, and others still divide both
surfaces of the bone through and through; and, according as they
penetrate more or less deeply the bone, their lips will be found to be
more or less separated. They frequently extend into the joint surfaces.

Diagnosis, — The signs which indicate the existence of a fissure must,
in a large majority of case^ be insufficient to determine fully the
diagnosis during the life of the patient. It is not probable that such
fissures could ever be clearly made out by the touch alone, where the
skin is not broken, since the pain, swelling, suppuration, etc., are only
characteristic of inflammation of the bone or of its coverings, and
might be equally present whether a fracture existed or not. In those
rare cases only in which the flesh is torn oft^ and the surface of the
bone is brought directly under the observation of the eye, will the
diagnosis become certain.

Treatment. — Fortunately, an error in judgment in this matter will
not materially, if at all, prejudice the interests of the patient; since,
whatever may be the fact in other respects, if the bone, or its perios-
teum, or its medullary tissue, is inflamed, and rest, with antiphlogis-
tics, does not accomplish its speedy resolution, incisions and perfora*
tions become inevitaole, if we would give either safety or relief to the
sufferer. Accordingly, in the inflammation and suppuration conse-
quent upon these fractures, we have seen that it has been occasionally
found necessary to lay open the soft tissues freelj^ and even to trephine
the bone at one or more points.

Fissures in Cartilage, — I have once met with a fissure in the thyroid
cartilage, which constitutes, so far as I know, the only example upon
record of a fissure in cartilage.^



§ 1. OssA Nasi.

Of twenty-five cases of fracture of the ossa nasi recorded by me,
only fourteen were seen by a surgeon in time to afibrd relief. It
seemed to me necessary, therefore, that the student should be in-
structed how frequently the nature of this accident is overlooked
by the friends, and even by the surgeon himself, to the end that he
might be thus admonished of the necessity of always instituting, in

» See Buffiilo Med. Joura., vol. xiii. Article entitled Fracture of the Thyroid

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sucb cases, careful and thorough examiBations. In some of the cases
recorded in my notes, where surgeons were called in time, and a de-
formity remains, it is not improbable that the accident was not recog-
nized. The rapidity with which swelling ensues after severe blows
upon the nose, concealing at once the bones, and lifting the skin eveii
above its natural level, explains these mistakes. The nose, also, is
remarkably sensitive, and tne patient is often exceedingly reluctant
to submit to a thorough examination. It ought, however, not to be
forgotten that the omission on the part of the surgeon to do his daty
will not always be excused, even though the patient himself has pro-
tested against his interference, especially where an organ so prominent,
and so iroportaut to the harmony of the face, is the subject of his
neglect or mal-adjustment; since the most trivial deviation from its
original form or position, even to the extent of one or two lines,
becomes a serious deformity.

When the ossa nasi are struck with considerable force, from before
and from above, a transverse fracture occurs usually within fjom three
to six lines of their lower and free margins, and the fragments are
simply displaced backwards; or if the blow is received partially upon
one side, they are displaced more or less laterally. This is what will
happen in a great majority of cases, as I have proven by examinations
of the noses of those persons who have been the subjects of this acci-
dent, and by repeated experiments upon the recent subject.

These fragments are generally loose, and easily pressed back into
place by the use of a proper instrument, A silver female catheter,
which we have seen recommended by surgeons, may answer well
enough in a few instsyices, but it will more often fail. The diameter
of the meatus at the point where the instrument must touch in order
to make effective pressure upon the ossa nasi, is on the average not
more than two lines; and when the membrane which lines it is injured,
it becomes quickly swollen, and reduces the breadth of the channel to
a line or less. Under these circumstances, any instrument of the size
of a female catheter could only be made to reach and press against
the nasal process of the superior maxilla, which is too firm and .un-
yielding to allow it to pass without the employment of unwarrantable
force. In this way it happens that the operator is occasionally sur-
prised to find how much resistance is opposed to his efforts to lift the
bones, and, after repeated unsuccessful attempts, the case is not unfre-
quently given over. If, however, he had used a smaller instrument,
he would have found almost no resistance whatever. A straight steel
director, or sound, or sometimes even a much smaller instrument, if
possessing sufficient firmness, is more suitable than the catheter. For
the same reason, also, one ought never to wrap the end of the instru-
ment with a piece of cotton cloth, as some have, I suspect, without
much consideration, recommended.

What I have said of the facility with which these bones may be
replaced, when a proper instrument is employed, is true only when
the treatment is aaopted immediately, or at most within a few days
after the accident.

Boyer, Malgaigne, and others have noticed the fact that these frac*

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tores are repaired with great rapidity. Hippocrates tbought the union
was generally complete in six days ; and in a case which has come
under my own observation, the fragments were quite firmly united
on the seventh day.

Nor has Malgaigne, whose observations are always very accurate,
overlooked the fact, also, that their repair is effected without the in-
terposition of provisional callus, but, as it were, " par jyremiire tnten-
tionJ^ My own observation confirms this statement. Among all the
specimens which I have seen in the various college and private col-
lections illustrating fractures^ of the ossa nasi, and amounting in all to
over forty, in no instance has there been detected, after a careful ex-
amination, the slightest trace of provisional callus.

I am not certain that it will always be found so easy to retain these
loose fragments in place, as it is to replace them. The very swelling
which takes place so promptly under the skin tends to depress the
fragments, unsupported as they are by any counter-force ; a tendency
which, possibly, is in some instances increased by attempts on the
part of the patient to clear his nostrils by snuffing and hawking. I
have, in one instance, noticed very plainly a motion in the fragments
when such efforts were made. How we are to remedy this, I am not
prepared to say. None^of the plans which I have seen suggested
possess, in my estimation, very much practical value. JB'ew patients
will consent to the introduction of pledgets of lint, or of stuffed bags,
or, indeed, of anything else, sufficiently far up into the nostrils to
answer any useful purpose. The membrane is too sensitive and too
intolerant of irritants to enable us to have recourse generally to such
methods. Then, too, it would require, on the part of the surgeon,
more than ordinary tact to accomplish so nice and delicate an adjust-
ment of the supports from below as these cases demand, where the
slightest excess of pressure, or the least fault in the position of the
compress, must defeat the purpose of the operator.

Yet, if one were disposed to make the attempt in certain cases
where the comminution was very greats or where, for any other rea-
son, the fragments would not remain in place, I think there could be
no better plan than to push up in succession a number of small pledgets
of patent lint^ smeared with simple cerate, to each one of which there
has been attached, a separate string, so arranged as that their relative
position may be recognized, and that they may at a suitable time be
removed in the order of their introduction.

The employment of canulas, as recommended by Boyer, B. Bell,
and others, allows of the nostrils being stuffed without interfering
materially with the breathing ; a provision, however, which is quite
unnecessary with a majority of persons, so long as there exists no
impediment to the free admission of air through the fauces.

With nicely adjusted compresses made of soft cotton or lint, and
secured upon the outside of the nose with delicate strips of adhesive
plaster or rollers, we shall be better able to prevent the fragments
from becoming displaced outwards than by moulds of wax, of lead, or
of gutta percha, under which it is impossible to see from hour to hour
what is transpiring.

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The coraplioated apparatus devised by Dubois and recommended
by Malgaigne, to lift the bones and retain ibem in place, seems to me
indeed very ingenious, but destitute of a single practical advantage.

A more considerable force than that which I have first supposed
will break, generally, the ossa nasi transversely and a little above
their middle, while, at the same time, the nasal processes of the supe-
rior maxillary bones may suifer slightly.

With neither of these accidents is the cribriform plate of the eth-
moid likely to be broken or disturbed. Indeed, in numerous experi-
ments made upon the recent subject, and in which the force of the
blow was directed backwards and upwards, breaking and commi-
nuting the nasal bones above and below their middle, with also the
nasal processes of the superior maxillary bones, and the septum nasi,
the cribriform plate of the ethmoid was, without an exception, unin-
jured. The exceeding tenuity and flexibility of the septum nasi at
certain points prevents effectually the concussion from being commu-
nicated through it to the base of the brain. If, therefore, after these
accidents, cerebral symptoms are occasionally present, as I have
myself twice seen,^ they must be due rather to the concussive effects
of the blow upon the very summit of the nasal bones, where they rest
immediately upon the nasal spine of the os frontis, or to some direct
impression upon the skull itself.

The amount of force requisite to break in the nasal bones, at their
upper third, is very great; no less, indeed, than is requisite to fracture
the OS frontis. If they do finally yield at this point, then no doubt
the base of the skull must yield also. Nor do I think patients could
often be expected to recover from an accident so severe. To this class
of fractures belongs the specimen contained in my museum, in which
not only both of the nasal bones are sent in — the nasal spine being
broken at its base — but also the os frontis is depressed ; the nasal pro-
cesses of the upper maxillary bones are broken and greatly displaced,
^nd the anterior half of the cribriform plate of the ethmoid is forced
lip into the base of the brain. If it is meant that in these cases the
patient is in danger from injury done to the base of the skull through
the fracture and depression of the ossa nasi, we can appreciate the
value of the opinion ; but we do not understand how this danger can
exist when the nasal spine of the os frontis is not broken, and the
upper ends of the nasal bones are not displaced backwards. But, ad-
mitting that it were possible in this way to force up the base of the
skull, it does not seem to me that we ought to attach any value to the
advice occasional! v given, to attempt to restore the broken ethmoid
by seizing upon tne septum and pulling downwards. A force suffi-
cient to break the base of the skull never fails to comminute and
detach almost completely the septum nasi. We are to proceed in
such a case as we would in a case of broken skull. We must lay
open the skin freely, and with appropriate instruments seek to elevate
and remove, if necessary, the fragments. Indeed, after such accidents,

» Report on Deformities after Fractures, Cases 16 and 18.

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0S8A NASI. 93

we shall generally see plainly enough that death is inevitable, and that
our services will be of no value.

Occasionally, I have observed, the bones are neither broken at their
lower ends nor through their central diameters, but only at their
lateral, serrated, or imbricated margins. This is rather a displace-
ment, or dislocation, than a fracture. It is more likely to happen, I
think, in childhood than in middle or old age, as in the following
example :—

Thomas Kelley, aged four years, was kicked by a horse. Two
hours afterwards, when he was first seen by a surgeon, the nose and
face were much swollen, and the fracture was overlooked.

One year after the accident, I found both nasal bones depressed
through nearly their whole length, and especially in the lower halves.
The right nasal process was also much depressed, and the right nostril
obstructed. The lachrymal canals upon this side were closed.

Sometimes the lower ends of the nasal bones are bent backwards,
or laterally, constituting a partial fracture.

A lad, aged ten years, was hit by one of his mates accidentally with
his elbow, upon the left side of his nose. I was immediately called,
and found the lower end of the left os nasi displaced laterally and
backward, so that it rested under the lower end of the right os nasi.
There did not appear to be any fracture beyond that which was in-
evitable by the mere separation of its serrated margins from the bone
adjoining. The angle formed by the bone at the point where the
bending had occurred was smooth and rounded, and not abrupt as in
a complete fracture.

With a steel instrument^ introduced into the left nostril, I attempted
to lift the bone to its place. The membrane was very sensitive, and
the patient very restless under my repeated efforts. 1 pressed up-
wards with considerable force, and succeeded at length m bringing
the bone nearly into position.

If there is more complete displacement^ the upper ends are not
nsuaMy forced backwards, but rather a very little forwards, from their

Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 10 of 100)