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.