The following interesting paper, extracted from the Medical Repository,
Hexad: ii. vol. i. p. 122 ... 124, will give the reader a better idea,
than he can receive from any other source, of Dr. Physick’s new and
successful method of treating an old and obstinate fracture of the os
humeri.
_A Case of Fracture of the Os Humeri, in which the broken ends of
the bone not uniting in the usual manner, a cure was effected by
means of a seton. Communicated to Dr. Miller by Philip S. Physick,
M. D._
“Isaac Patterson, a seaman, twenty-eight years of age, applied to me
in May, 1802, in consequence of a fracture of his left arm, above the
elbow joint, which had taken place several months before; but the ends
of the bone not having united, rendered his arm nearly useless to him.
“The history he gave me was, that on the 11th of April, 1801, after
having been at sea seven months, his arm was fractured by a heavy sea
breaking over the ship. Nothing was done for his relief until next day,
when the captain and mate bound it up, and applied splints over it.
No swelling supervened, nor did he suffer any pain, Three weeks after
this accident, he arrived at Alexandria, when the state of the arm was
examined by a physician, who told him, that the ends of the bone were
not in a proper situation. After making an extension, the splints and
bandages were again applied. He remained in Alexandria four months,
when, finding his arm no stronger, he left off all dressings, and went
on board the New-York frigate as steward: in this capacity he remained
near the Federal City six months, and by being under the necessity of
using his arm as much as possible, he found the connexion between the
ends of the bones became looser and looser, till, at length, the arm
bent as easily as if a new joint had been formed at the place of the
fracture. From the frigate he went to Baltimore, where an attempt was
made by machinery to extend the arm, and keep the ends of the bone
in apposition, by continuing the extension. Under this treatment he
remained two months, but experiencing no benefit, he was advised to
come to Philadelphia.
“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.