Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

. (page 47 of 100)
Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 47 of 100)
Font size
QR-code for this ebook


obviate the shortening, and produce eschars, anchylosis, or troublesome
'arrests of the circulation. This is the price that is usually paid for
the employment of these complicated machines, and a shortening of a
quarter to three-quarters of an inch is not avoided after all. The
simplest apparatus that will maintain the adjustment of the fractured
femur, so that union may take place with shortening of only half an
inch, is the best."*

N^laton holds the following language : —

"A fracture of the body of the femur, with an adult, is always a
grave accident, inasmuch as it demands so long a confinement to the
bed, and especially on account of the shortening of the limb, which it
is almost impossible wholly to prevent; accordingly, Boyer recom-
mends to the surgeon, from the first day, to announce to the parents
of the patient the possibility of this accident. With infants, on the
contrary, it is almost always easy to avoid the shortening."*

While Malgaigne declares his opinion on this subject thus, at
length : —

" When we do not succeed in drawing back the misplaced fragments,
end to end, so that they may oppose themselves to the action of the
muscles, it is impossible to preserve to the member its normal length,
whatever may be the appareil or method employed. Surgeons are
not sufiiciently agreed upon this question.

"At a period quite recent, Desault pretended to cure all fractures
without shortening, and his journal contains several examples. In
imitation of Desault, various practitioners have modified, corrected,
and improved the apparatus for permanent extension, and they claim
to have themselves obtained as complete success. I ought then to
declare here in the most positive manner that I have never obtained
like results, either in the use of my own apparatus, or with that of
others, nor indeed where, in pursuance of my invitation, several
inventors have applied their apparatus in my wards. I have exam-
ined, more than once, persons declared cured without shortening, and
yet, upon measurement, the shortening was always manifest. The
misfortune of all those who believe that they have obtained those
miraculous cures is, that they have not even thought of instituting a

» System of Surgery, by Benjamin Bell, vol. vii. p. 21. Edinburgh, 1801.

* Peninsular Joum. of Med., vol. iii. p. 884; also Memphis Med. Joum., vol. iv.
p. 254, 1856.

« El^mens de Pathologie Chirurgicale, par A. N^laton, tom. prem., p. 752. Paris,
1844.



Digitized by



Google



892 FRACTURES OP THE FEMUR.

comparative measurement of the two limbs ; I will say even more,
that they are most generally ignorant of the conditions of a good and
faithful measurement. Sometimes, also, they have been deceived ia
another way — in falling upon fractures which were not displaced,
especially with young persons ; and they have believed that they have
cured with their apparatus a shortening -which had never existeid. In
short, when the fragments are not displaced, or even when they are
brought again into a contact maintained by their reciprocal dentica-
lations, it is easy to cure the fracture of the femur without shorten-
ing; aside of those two conditions, the thing is simply impossible.

" Several distinguished surgeons of our day have acknowledged this
impossibility, and have renounced, in consequence, permanent exten-
sion. They allege, moreover, that an overriding of even three centi-
metres is of little importance, and occasions no limping. I cannot
agree with this opinion. I have seen persons walk very well with a
shortening of one centimetre ; beyond this limit, either they limp, or
they have lifted the heel of the shoe, or, in short, the limping is only
concealed by a lateral deviation of the spine.^ We thus are made to
comprehend how a fracture with overlapping is always serious, and
how cautious we ought to be in our prognosis."*

That the foregoing remarks are intended by the author to be equally
applicable to other fractures of the shaft of the femur than to those of
the middle third, is made evident by what he has said before, when
speaking of fractures of the upper third.

" The prognosis is sufficiently favorable when the fragments are
denticulated (engrendes); when they ride, on the contrary, we must
look for a shortening as almost inevitable."^

Mr. Holthouse says* that in 1857 he examined all the fractured
thighs then under treatment in the different hospitals in London, and
in the case of adults all were shortened except three, and he thinks
it doubtful whether in these three cases his examinations were of any
value. In thirty-five examples the average shortening exceeded one
inch. In the case of children 40 per cent, were shortened.

In our own country several of the most distinguished surgeons have
testified to the constant difficulty, if not impossibility, of curing frac-
tures of this bone without a shortening. In a suit instituted against
a surgeon in New York city, for alleged malpractice in. the treatment
of an oblique, comminuted, and otherwise complicated fracture* of the
femur near its condyles, Dr. Mott is reported to have testified that
" more or less shortening of the limb is uniformly the result after
fractured thigh, even in the most favorable circumstances."*

» Dr. Buck, of New York, thinks that with a shortening of one inch, or even one
inch and a half, the patient may have ^* a useful limb, with little or no halting in
his gaif N. Y. Joum. of Med., vol. xvi. p. 294.

< Traits des Fractures et des Luxations, par J. M. Malgaigne, torn, prem., pp. 723,
724. Paris, 1847.

» Op. cit., p. 718.

* Holthouse, Holmes' System of Surgery. London, 1861, vol. ii. p. 61S.

* Boston Med. and Surg. Joum., vol. xxxiv. p. 450. See also opinions of Drs.
Keese, Post, Parker, Cheeseman, Wood, &c., in relation to the prognosis in this
particular case.



Digitized by



Google



FEACTUBES OP THE SHAFT OF THE FEMUR. 893

In a very interesting communication made to the author by Jona-
than Knight, of New Haven, late President of the American Medical
Association, occurs the following passage: —

"I have seen but few fractures of the femur in the adult, unless of
the most simple kind, in which there was not some remaining de-
formity ; often slight, so as liot to impair the usefulness of the limb,
and in others considerable and apparently unavoidable." Dr. Knight
adds, however : " In the greater proportion of the fractures in children
the recovery has been so nearly perfect that no marked deformity or
lameness has followed."

Dr. Detmold, in his remarks made before the New York Academy
of Medicine, at its meeting in March, 1855, declared his belief that a
shortening of the femur always occurs after fracture, and that "but
one inch of shortening in an average of twenty cases is a good result."^
Dr. J. Mason Warren, of Boston, writes to me as follows : "As you
are making observations on fractures, I would state that, after a long
and very careful observation, I have never yet seen, either in Boston
or elsewhere, an oblique fracture of the thigh, in a patient over seven-
teen years of age, in which there was not some shortening. I have had
cases shown to me in which it was averred that the limb was not short-
ened, but on measuring myself I have found the fact otherwise. In chil-
dren, I believe that union without shortening may be accomplished."
In a paper published by Dr. Lente in the number of the New York
Journal of Medicine for September, 1851, he states that he believes
the average shortening after treatment in the New York City Hospi-
tal to be three-quarters of an inch ; but subsequently, Dr. Buck, one
of the hospital surgeons, has furnished Dr. Lente with more exact
statistics. Says Dr. Buck : —

"After carefully scrutinizing over one hundred cases of fracture of
the femur, taken from the register of the N. Y. Hospital, and elimi-
nating such as involved the cervix, or condyles, or belonged to the
class of compound fractures, there remained an aggregate of seventy-
lour cases, of both sexes, and of all ages from 3 to 63, in which the
shaft of the femur alone was fractured. In all these cases the difier-
ence in the length of the fractured limb, resulting from the treatment,
was ascertained by careful measurement with a graduated tape, and
the following deductions were drawn from the analysis: —

" Of the 74 cases of all ages, 19 resulted without any shortening, a
proportion of about one-fourth. The average shortening of the re-
maining 55 cases was a fraction less than three-fourths of an inch.

" Seventeen cases in the above aggregate were under 12 years of
age, of which six resulted without any shortening, a proportion of
about one-third. The average shortening in the remaining 11 cases
was a fraction less than one-half an inch.

" Of the 57 cases over 12 years of age, 13 resulted without any short-
ening, a proportion of about one-fourth ; and the average shortening
in the remaining 44 cases was a fraction over three-fourths of an inch."*

* New York Joum. of Med., second series, vol. xvi. p. 261.
« Buffalo Med. Joum., vol. xv. p 22, June, 1859.
2tJ



Digitized by



Google



394 FRACTURES OF THE FEMURi

It is not to be denied, however, that a few surgeons in all parts of
the world have claimed, and still continue to claim, in their own prac-
tice, or from the adoption of their own peculiar plans of treatment^
much better success. Indeed, some of them do not hesitate to affirm
that, as a general rule, any degree of shortening is quite unnecessary.

Mr. Amesbury declares, that when the fracture is in the " middle
or lower third," under a "judiciously managed" application of his own
splint, "consolidation of the bone takes place without the occurrence
of shortening of the limb, or any other deformity deserving of par-
ticular notice."*

Mr. South, in a note, commenting upon an opposite sentiment ex-
pressed by Ohelius, and already quoted, remarks : " In simple fractures
of the thigh-bone, except with great obliquity, I have rarely found
difficulty in retaining broken ends in place, and in effecting the onion
without deformity, and with very little, and sometimes without any,
shortening. For the contrary results the medical attendant is mostly
to be blamed, as they are usually consequent upon his carelessness or
ignorance."^

Mr. Hunt, of the Queen's Hospital at Birmingham, who treats all
fractures with the apparatus immobile of Seutin, has published the
results of his observations; and of the simple fractures of the femur
only one presented, after the cure, any degree of shortening; and he
adds that all other fractures which he has treated by this method
were followed by " equally good results."" In relation to which state-
ments, Mr. Gamgee exclaims : " This is conservative surgery. What
other mode of treatment would have given such results 7 And those
cases are not exceptional. Mr. Hunt tells us he has selected them
from amongst many others equally successful. They accord with the
experience recorded in my little treatise on this subject ; and the works
of Seutin, Burggrseve, Crocq, Velpeau, and Salvagnoli Marchetli
record numerous cases no less remarkable and demonstratively con-
clusive."*

Desault, also, according to the passage from Malgaigne which I
have already quoted, " pretended to cure all fractures without short-
ening." I do not find, however, any other authority for this state-
ment, as here made; neither in his Treatise on Fractures and Luxa-
tions, edited by Bichat, nor elsewhere. Bichat even says positively
that " Desault himself did not always prevent the shortening of the
limb."' He declares, however, that " Desault has cured, at the H6tel
Dieu, a vast number of fractures of the os femoris, without the least
remaining deformity."*

Dr. Dorsey, of Philadelphia, who employed the apparatus of Desault,
as modified by Physick and Hutchinson (Fig. 184), was equally suc-
cessful.^

» Practical Remarks on Fractures, by Joseph Amesbury, vol. i. p. 884. London ed.,
1881. « Op. cit, vol. i. p. 627.

> Researches on Pathological Anatomy and Clinical Surgery, by Joseph Sampson
Gkungee. London ed., pp. 159, 160. « Op. cit., p. 167.

* A Treatise on Fractures and Luxations, etc., by P. J. Desault, edited by Xav.
Bichat. Amer. ed., p. 251. 1806. « Op. cit., p. 228.

f Elements of Surgery, by John Syng Dorsey, vol. i. p. 168. Philadelphia, 1818.



Digitized by



Google



n

a



FRACTURES OP THE SHAFT OF THE FEMUR. 895

Dr. Scott, of Montreal, Professor of Clinical Surgery in the McGill
College, and Physician to the Montreal General Hospital, has reported
19 cases of fractures of the long bones, taken promiscuously and
without selection, from his hospital service, of which 3 belonged to
the clavicle, 7 to the femur, 8 to the tibia and fibula, and 1 to the
condyles of the humerus. All of which recovered without any degree
of shortening or deformity ; except the case of fracture of the condyles
of the humerus, which resulted in death.^

Fig. 184.

^rn



Pht8ICK*8 Splivt.— The splint is intended to reftoh to the axilla, bnt the oonnter-extension is made by
a perineal band. Fhyslck employed a second, long, inside splint.

It is never a pleasant duty to call in question the accuracy of
another's statements as to what he has himself alone seen and expe-
rienced. The circumstances which would justify such an expression
of scepticism, where the witnesses, as in this case, are pi^esumed to be
intelligent and honest men, must be extraordinary. Such, however, I
conceive to be the circumstances in this instance. It is certainly very
extraordinary that a few gentlemen of acknowledged skill, but whose
means and appliances are concealed from no one, are able to do what
nearly the whole world besides, with the same means, acknowledges
itself unable to accomplish. Such is the fact, nevertheless; and our
lack of faith in their testimony is only a necessary result of our expe-
rience, and of the experience of the vast majority of practical surgeons
as opposed to theirs.

I might properly enough dismiss this subject with no farther argu-
ment than may be found in the overwhelming testimony of practical
surgeons, that broken femurs do in their experience rarely unite with-
out more or less shortening ; but I cannot avoid calling attention to
the evidence of the falsity of the opposite opinion, which is furnished
by the testimony of the very persons who themselves claim to have
obtained such fortunate results.

It is not, as might have been supposed, one particular form of dress-
ing, which, in itself peculiar, and more perfect than all others, has fur-
nished these results. On the contrary, the plans of treatment have
been constantly unlike, and sometimes quite Opposite. Thus, Desault
used a straight splint, with extension and counter-extension, and he
refused to adopt the flexed position recommended by Pott, because
his experience, and the experience of other French surgeons, had
taught him its inutility.^ Adopting the straight position, he made
perfect limbs; with the flexed position, he found it impossible to do so.

Dorsey used the splint of Desault, as modified by Physick and
Hutchinson.

South, whose success seems to have been equal to that of Desault
or Dorsey, adopts also the straight position ; but he makes- no perma-

» "Medical Chronicle'' of Montreal, vol. i. No. 7, 1853.
* Works of Desault, op. cit., p. 225.



Digitized by



Google



398 FRACTURES OF THE FEMUR.

nent extension, except what may be accomplisbed through the mediam
of four long side splints applied after " gentle" extension has been
made by the assistants.

Mr. Amesbury, on the other hand, made perfect limbs only with his
own double-inclined plane; and speaking in general of the varioas
plans hitherto contrived, not excepting that invented by Desaalty or
the method practised by South, which had already been recommended
by several surgeons, he declares that "they are seldom able to prevent
the riding of the bone, and preserve the natural figure of the limb.
Indeed, so commonly does retraction of the limb occur under the ase
of the diflFerent contrivances usually employed, that I have heard a
celebrated lecturer (now retired) in this town publicly assert that he
never saw a fractured thigh-bone that had united without riding of
the fractured ends!"^ And in his " Oeneralln/erencts^^ he uses the
following emphatic language: "The contrivances which are com-
monly used in the treatment of these fractures do not sufficiently
resist the operation of the forces above mentioned, but suffer their
influence to be exerted upon the bone, in all cases more or less inju-
riously, and at the same time often assist in producing displacement of
the fractured enfls ; so that deformity, differing in kind and degree in
different cases, is almost the constant result of fractures of the femur
treated by these means.'**

On the other hand, Mr. Gamgee broadly contradicts the statements of
Desault, South, Dorsey, and Amesbury, and does not hesitate to ad-
Fig. 135.




Liston's method, recommended by Samuel Cooper, Fergossoa, PIrrle, and olhera.

minister a severe rebuke even i:^pon the illustrious Listen : " Pott's
plan, the long.splint, Mclntyre, and their modifications, as a rule entail
sensible deformity, which in many cases is very considerable. . It is a
significant fact that though the example established in University
College Hospital by the late Mr. Listen, of treating fractures of the
thigh by the long splint, and of the leg by the modified Mclntyre (a
double-inclined plane), which are admitted equal, if not superior, to
other splints, was rigidly followed in that institution, the patients
admitted with broken thighs or legs were frequently discharged with
manifest deformity."'

With how much force Mr. Gamgee's own remarks as to the expe-
rience of the University College Hospital will apply to the starched
bandages used by himself, the reader will be able to determine when
referred to the opinion of Velpeau, already quoted, who claims no

» Amesbury on Fractures, &c., vol. i. p. 810. « Op. cit, vol. i. p. 884.

» Advantages of the Starched Apparatus, by Joseph Sampson Gamgee. London,
1853, pp. 54, 55.



Digitized by



Google



FRACTURES OF THE SHAFT OF THE FEMUR. 897

result better than an average shortening of half an inch. M. Velpeau
prefers and advocates the starched bandage, but he does not claim to
be able to prevent a shortening of the bone.

"What other modes of treatment would have given such results ?"
This question, propounded, no doubt honestly, by Mr. Gamgee, has
here its fair and satisfactory answer. Almost any of the various
modes named ; for if we must receive his testimony, we are equally
bound to receive the testimony of Desault, South, Dorsey, Amesbury,
and Scott. If we give credit to Mr. Gamgee, so far as to doubt the
statements of these latter as to the degree of success claimed by them,
by the same rule we must doubt his own statements also as to the
degree of success claimed by himself. This I say with all sincerity
and kindness, fully believing that these gentlemen are mistaken, and
not that they intentionally misrepresent the facts.

By a reference to my " Eeport on Deformities after Fractures," it
will be seen that the average shortening in fractures of the upper third
of the femur, in the cases examined by me, was about four-fifths of an
inch ; in the lower third it was a fraction over three-quarters, and in
the middle third a fraction less than three-quarters of an inch ; and
the average of the whole number was almost exactly three-quarters
of an inch (three-quarters and -sf^). These analyses were made upon
simple fractures, and were exclusive of those in which no shortening
at all occurred. An analysis which included also those which had
not shortened, reduced the average shortening to half an inch and
about one-tenth.

An examination of cabinet specimens does not present a result so
favorable even as this. Of nineteen fractures of the shaft of the femur
contained in Dr. Mutter's cabinet, not one seems to have been short-
ened less than one inch. Specimen B 63, fracture of the middle
third, is vmited with a shortening of two inches and a quarter; and
specimen B 180, imperfectly united after a fracture through the mid-
dle third, is overlapped three and a half or four inches.

In conclusion, I wish to say briefly that, in view of all the testimony
which is now before me, I am convinced —

First. That in the case of an oblique fracture of the shaft of the
femur occurring in an adult, whose muscles are not paralyzed, but
which offer the ordinary resistance to extension and counter-extension,
and where the ends of the broken bone have once been completely
displaced, no means have yet been devised by which an overlapping
and consequent shortening of the bone can generally be prevented.

Second. That in a similar fracture occurring in children or in per-
sons under fifteen or eighteen years of age, the bone may quite often
be made to unite with so little shortening that it cannot be detected
by measurement; but whether in such cases there is in fact no short-
ening, since with children especially it is exceedingly difficult to
measure very accurately, I cannot say.

Third. That in transverse fractures, or oblique and denticulated,
occurring in adults, and in which the broken fragments have become
completely displaced, it will generally be found equally difficult to
prevent shortening; because it will be found generally impossible to
bring the broken ends again into such apposition as that they will rest
upon and support each other.



Digitized by



Google



398 FRACTURES OF THE FEMUR.

Fourth. That in all fractures, whether occurring in adults or io
children, where the fragments have never been completely or at all
displaced, constituting only a very small proportion of the whole
number of these fractures, a union without shortening may always be
expected.

Fifth. That when, in consequence of displacement^ an overlapping
occurs, the average shortening in simple fractures, where the best
appliances and the utmost skill have been employed, is from half to
three-quarters of an inch.

If we consider the muscles alone as the cause of the displacement
in the direction of the long axis of the shaft, the shortening of the
limb, other things being equal, must be proportioned to the nunnber
and power of the muscles which draw upwards the lower fragment.
This will vary in different portions of the limb, but nowhere will this
cause cease to operate, nor will its variations essentially change the
prognosis.

I have not intended to say that other causes do not operate occa<
sionally in the production of shortening, but only that muscular con-
traction is the cause by which this result is chiefly determined, and
that its power will be ordinarily the measure of the shortening.

Ih'eatment. — ^AU the early surgeons, so far as we know, adopted
the straight position in the treatment of fractures of this bone ; either
with simple lateral splints, or with long splints, with or without exten-
sion, or with only rollers and compresses, or with extension alone.

Such was the unanimous opinion and practice of surgeons until
about the middle of the last century, at which time Percival Pott wrote
his remarkable treatise on fractures ; a work distinguished for the origi-
nality and boldness of its sentiments, and which was destined soon to
revolutionize, especially throughout Great Britain, the old notions as
to the treatment of fractures, and to establish in their stead, at least for
a time, what has been called, not inappropriately, the " physiological
doctrine ;" the peculiarity of which doctrine consisted in its assump-
tion that the resistance of those muscles which tend to produce short-
ening can generally be sufficiently overcome by posture, without the
aid of extension ; and that for this purpose, for example, in the case
of a broken femur, it was only necessary to flex the leg upon the thigh,
and the thigh upon the body, laying the limb afterwards quietly on
its outside upon the bed.

Very few surgeons, even of his own day, ever gave in their full ad-
hesion to the exclusive physiological system as taught and practised

Fig. 186.




Boable-incUned plane employed In Middlesex Hotpital, London.



Digitized by



Google



FRACTURES OF THE SHAFT OF THE FEMUR. 899

by Pott himself; but multitudes, especially among the English, adopted
ia general his views, only choosing to place the patients upon their
backs rather than upon their sides, and laying the limbs flexed over a



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 47 of 100)