THE CLASSIC: Preface to “Deformities After Fractures”

Abstract

“As it is now, the unfortunate patient tries to retrieve his bad luck by levying upon the hard working surgeon without risking or staking anything for the chance of testing what may prove to be no case at all … The suit depletes the surgeon's pocket and ruins his reputation. To pay is ruinous, to defend is ruinous, and to live in constant dread is ruinous … The plaintiff carries around a lame leg with the surgeon's money to support it, and the surgeon carries around a lame reputation with nothing to support it.” These comments appeared in the Boston Medical and Surgical Journal on January 9, 1879.7 They point out that patients in the United States were as litigious in the 19th century as they are today, and most of the cases involved the end results of the treatment of fractures and dislocations.1 Four years prior to being elected president, Abraham Lincoln successfully defended two physicians sued by a patient whose fractured leg had healed with some shortening.4 That the results of treatment were often poor (and sometimes disastrous) is not surprising as anesthesia was not introduced until 1846, antisepsis and asepsis until 1867-1885, and X-rays until 1895. Reports on the end results of the treatment of fractures were limited, vague, and anecdotal, and provided no information on what result could be anticipated in an “average case.” This is why the publication by Frank Hastings Hamilton (Fig. 1) of statistical tables that detailed the end results in a large group of patients with a wide variety of fractures was so important. These tables served as a standard against which an individual case could be compared and “had an incalculable influence on the results of suits for malpractice.”5 Originally published piecemeal in the Transactions of the American Medical Association, they were collected into a single volume in 1855.2 It is the preface to that collection that is presented here. Hamilton was born in Vermont in 1813. He was educated in Schenectady, New York and obtained a bachelor of arts degree from Union College in 1830. He began to study medicine as a preceptee, attended the College of Physicians and Surgeons of Fairfield, New York, and received the degree of doctor of medicine from the University of Pennsylvania in 1833. He entered practice and taught at medical schools in Fairfield and Geneva. After an extended trip to Europe, where he visited the major clinics and hospitals, he became a professor of surgery at the medical school in Buffalo, New York, which opened in 1847. An early advocate of the use of ether anesthesia, Hamilton had a varied surgical practice. In 1854 he performed the first cross-leg pedicle graft.6 The majority of his practice involved the treatment of skeletal injuries. In 1859 he followed his colleague, Austin Flint, to the Long Island College of Medicine. A short time later the first edition of A Practical Treatise on Fractures and Dislocations appeared.3 This contained a good deal of material gleaned from his fracture tables and from his observations made during his foreign travels. It is noteworthy as being the first textbook in English to completely cover the subject. After a period of distinguished service in the Medical Corps during the Civil War, Hamilton returned to New York where he became a professor of surgery at Bellevue Hospital. An indication of his reputation can be seen in that he was called as a consultant after President Garfield had been shot. Hamilton died in 1886 from the effects of pulmonary tuberculosis. Leonard F. Peltier, MD, PhD I propose to deduce from my own experience, and from the experience of other surgeons, as recorded in this report, the true prognosis of fractures. This I shall endeavor to do with care and fidelity, avoiding, on the one hand, if possible, the error of encouraging the practitioner with a prognosis too favorable, and, on the other, the equal wrong of leaving him to expect too little. To this end, I shall draw from my hospital and private records such cases as have come under my immediate care, describing, as briefly as will be consistent with my purpose, all those circumstances connected with each fracture which might in any way modify the result, together with the plan of treatment, and finally, the precise amount and character of the imperfection, or maiming, if any, which remains. I shall not, however, confine myself to my own cases; but, so far as I am able, I shall record the cases which have been treated by other regularly qualified surgeons, and which have subsequently passed under my own observation. This is necessary not only as a vindication of my own practice and reputation, of which one must naturally feel jealous, but more especially that my conclusions may have, what you have a right to demand for them, the weight of authority. I shall, therefore, ask the liberty of reporting the practice of my contemporaries, and of mentioning their names, that you may judge for yourselves whether they constitute proper representatives of the present condition of our art. Of this, I trust, no one will complain, since without such permission I would not have ventured upon the duty assigned me, nor do I believe any one else would have consented to have occupied my place. It is certain that, up to this moment, no one has volunteered to state fully what have been the results in his own practice, or in the practice of the hospital, or other similar institutions, which have been under his immediate charge. In hospital records, you may find patients admitted with fractures, and reported as “dead,” or as dismissed “cured,” with the occasional interpolation of “a good leg;” and, upon these records, tables have been constructed to determine the average fatality of such accidents, and the probabilities of cure; but I have not yet seen any published reports declaring what was the exact amount and value of the “cure”-how much the bone was shortened, or bent, or otherwise maimed and deformed. In short, they still fail to inform us what are the “deformities after fractures,” which, under fair treatment, may reasonably be expected. Dr. Wallace published, in 1839, a statistical account of the eighteen hundred fractures which had been treated in the Pennsylvania Hospital from its foundation up to the year 1838; and Dr. Norris published, soon after, a similar report of the fractures treated in the same institution between the years 1830 and 1839, inclusive; but neither of these gentlemen make any reference to a shortening, or to any degree of deformity which may have occurred in the cases reported as cured. Dr. Peirson, in his report of the statistical tables of all the fractures which had occurred in the Massachusetts General Hospital up to the year 1840, notices, under the head of “Remarks,” many interesting facts, such as delayed or non-union, the occurrence of ulcers, gangrene, &c. &c.; but there is nothing exactly pertinent to the subject of our inquiry. Dr. Lente, who has recorded the statistics of fractures treated at the New York Hospital for the twelve years preceding 1851, has attempted to supply the deficiency, which he declares does exist in the hospital records, upon this subject, by his own “personal experience of several years in the practice of the hospital, and by conversation with other surgeons who have been connected with it.” But he has limited his statements to what he believes to have been the average results, as regards shortening, in the treatment of fractures of the femur. The statistics furnished by Lonsdale, of the Middlesex Hospital of London, and by Fricke, of the General Hospital at Hamburg, are equally silent upon the subject of deformities or shortening. The same disinclination to approach this subject is manifested by those who have written special or general treatises upon fractures, and who, with the single exception of Malgaigne, will be found either to have ignored prognosis altogether, or they have seemed to speak of it only casually, and without any numerical basis for their calculations, since, among writers of equal experience and reputation, there exist the widest discrepancies of opinion. An example will illustrate what I have said. Chelius, writing of fractures of the thigh-bone, says: “Fracture of the thigh-bone is always a severe accident, as the broken bones are retained in proper contact with great difficulty. The cure takes place most commonly with deformity and shortening of the limb, especially in oblique fractures, and those which occur in the upper and lower third of the thigh-bone.” To which Mr. South, the translator, and Surgeon to St. Thomas's Hospital, appends the following note: “In simple fractures of the thigh-bone, except with great obliquity, I have rarely found difficulty in retaining the broken ends in place, and in effecting the union 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 on his own carelessness or ignorance.” (Chelius's Surgery, by South, American edition, vol. i. p. 627.) Even Malgaigne, to whose recent work, entitled, Traité des Fractures et des Luxations, I shall hereafter have frequent occasion to refer, and who speaks generally with a precision which indicates a careful observation of the facts, does not intimate the existence of any exact records, either in his own practice or in the practice of others, from which his conclusions have been deduced. In looking for an explanation of this seeming indifference, or palpable ignorance, upon a subject of such manifest importance both to surgeons and to their patients, I find several probable causes. I suppose that most practical surgeons have a tolerably correct appreciation of prognosis in fractures. I say tolerably, because I wish to imply a qualification. I do not think that a majority of even “practical” surgeons have a full appreciation of the subject. I am frank to confess that, until I commenced these investigations, I had not any just notions of the frequency of deformities after fractures. Nor can I now understand how any surgeon, who does not carefully measure limbs with a rule or with a graduated tapeline, can have possessed himself of any very accurate information upon that point. Yet I appeal to surgeons whether this has been their constant or even their general practice? or whether they have not usually adopted, in measuring the lower extremities, that more simple, yet always unreliable method of placing the limbs parallel, knee to knee and heel to heel? or whether they have not as often contented themselves with the averment of the patient himself, that the limb was perfect? and, indeed, whether, in case of a fractured arm or radius and ulna, they have, in one case out of ten, instituted any sort of inquiry or examination by which their relative length might be determined?* I address hospital surgeons as well as surgeons in private practice. Let them answer to themselves these interrogatories. If such examinations can be shown to have occasionally been made, we still venture to affirm that, in no instance, for any considerable length of time, have regular records of exact results been kept. Nor do I expect that, upon my humble remonstrance, such records, fairly made, will hereafter be kept. Surgeons who have the charge of public hospitals understand that the eyes of their pupils, their governors, their confrères, and of the public even are upon them, and it is attributing to them nothing more than a common frailty to charge that they dare not record faithfully their results in the treatment of fractures. To be honest in the admission of shortcomings in a branch of our art, where the difficulties are so little understood by those who constitute themselves our judges, would be suicidal. Do you not see that jealous and designing colleagues would have no such discreditable results? Pupils would draw unfavorable comparisons, and desert the wards where failures were so common; rival hospitals would secretly or openly seize upon such records to their own advantage; and the patients themselves would, no doubt, often return the diligence, skill, and honesty of their surgeons with imprecations and prosecutions. There is, gentlemen, no lack of charity in these suppositions. We are to take men as they are, and as they are well enough known to be, and not as we would have them; and it is in vain to deny that such are the fair risks which strict honesty in this matter must incur. The instinct of self-preservation, therefore, prompts to silence, or to the most favorable representations. Students will continue to go out from our hospitals with a belief that perfect union of broken bones is the rule, and that exceptions imply generally unskilful management; and if, when hereafter they have themselves occasion to treat a fractured femur, the result falls short of their standard of perfect success, they, taught also by the same instinct of self-preservation which actuated their teachers, will conceal the truth from others, and even from themselves, if possible. Nay, I fear that sometimes, under the same urgent promptings, and where the moral sense is not superior to all other considerations, they may hesitate to regard the sanctity of an oath! How else shall we explain the testimony of that man who, with uplifted hand, affirms that he has “seen and treated ten fractures of the femur, in adult persons, and not one of them is in any way shortened or deformed?” Or what less charitable construction will you place upon the published averment of a hospital surgeon in a neighboring province, who, in his remarks upon my “fracture tables,” as reported by my late pupil, Dr. Boardman, some years ago, declares that he has lately treated at the hospital under his care one case of fractured inferior maxilla; three cases of broken clavicles, two of which were at the outer third; seven of fractured femur, one of which was compound and one comminuted; eight cases of fracture of the tibia and fibula, two of which were comminuted and one compound-in all nineteen cases, and that, with the exception of one who died, every case resulted in a perfect cure? It is more than probable that the writer will not escape similar criticisms hereafter, and that his report may be regarded as giving a true representation of American surgery, but as scarcely applicable to the surgery of others. In reply to a sentiment so illiberal, I beg to say, in anticipation, that having myself visited a majority of the large hospitals of Great Britain, and very many upon the continent of Europe, and having observed carefully their methods of treatment, and, in some measure, noticed their success, I am prepared to affirm that, in so far as I have yet seen, the practice of American surgeons, in the management of fractures, compares favorably with that of any other people. The English themselves are constantly proclaiming their deficiency in this department of surgery. It is now more than one hundred years since Pott, then Surgeon to St. Bartholomew's Hospital, inquired of his brethen if it was not “notorious” that in England broken thighs and legs were “often, very often, left deformed, crooked, and shortened?” But, notwithstanding Pott believed that he had discovered the true cause of these deformities, and had devised a remedy which must in future secure to his countrymen comparative eminence in this branch, yet today Mr. Skey, the very distinguished successor of Mr. Pott in the same great hospital, finds occasion to say: “One is therefore at a loss to find any apology for those surgeons to whose want of care, and even of humanity, may be attributed the numerous examples of distorted and contracted members, which have cast a reproach on the surgery of Great Britain.” (Skey's Operative Surgery, American edition, p. 140.) For myself, while I take these admissions as evidence that Americans are quite as expert in the dressing of broken bones as the English, I am nevertheless much more charitable to their failures than they are themselves. To me these admissions only confirm a long-nourished conviction that neither in Great Britain nor in the United States, nor in any other part of the world, has the art of treating fractures attained that degree of perfection which surgeons have almost universally claimed for it. If my reviewers deny the correctness of my conclusions, I trust they will do me the justice to accompany their denial with proofs of the same specific character, and obtained in the same careful manner, with those evidences which I shall present. Finally, no man can be more sensible than myself of the imperfect manner in which I have accomplished the duty which you have imposed upon me, and especially since, while I have only contributed a limited experience to the elucidation of a very important subject-the subject of Prognosis in Fractures-I have, to an extent still more limited, contributed suggestions or experience in relation to better or more successful modes of treatment. Yet I trust no one will, for that cause, censure an humble beginning. Others may yet complete what I have only commenced. “Admit that bones and patients are and always have been contumacious and refractory.” What then? “What good,” do you ask, “can be accomplished by exposing our failures, unless we have found the remedy, in which alone the world can claim a final interest?” I reply, that the first step towards improvement in any art or science must be the faithful exposure of its wants and deficiencies.