Part 73

The interval between the divided extremities of the tendon is filled up with coagulating lymph, which is often poured out in considerable quantities. As in other situations, it becomes gradually organised, and is finally converted into a firm, dense substance, not unlike the original structure.

The tendon of the posterior tibial muscle may be cut most advantageously about two inches above and behind the internal malleolus. The operation is conducted upon the same principles as in the preceeding case, and the only particular caution to be observed is to avoid the posterior tibial artery and nerve, which might be endangered by carrying the knife too deeply. The most favourable situation for dividing the anterior tibial muscle, is where it passes over the ankle-joint: the long flexor of the great toe may be cut in the sole of the foot, where, when it interferes with the rectification of the limb, it forms a tense, prominent chord.—ED.]

The phalanges of the toes in general resemble those of the fingers in their diseased actions. _Exostosis_ of the extremity of the distal phalanx, however, has no analogy in the upper extremity; it is by no means an uncommon affection, and usually occurs in the great toe. The growth is generally globular and rough in its extremity, narrow at its origin, attached on the dorsal aspect, projecting obliquely upwards, and always of similar structure with the phalanx. Sometimes they are met with of a size nearly equal to that of the bone from which they spring, but the majority are considerably smaller. The only one I have met with springing from a small toe is here sketched. At first the patient complains merely of pain in the part while walking; soon the pain increases so as to impede progression very seriously; then the nail is found to be raised at its margin, and to cover a hard, unyielding, and tender swelling. The elevation of the nail increases, and the tumour becomes more apparent, covered by hardened cuticle, causing great uneasiness, and almost entirely preventing walking exercise.

It has been recommended to expose the tumour by incision, and remove it at its origin. This affords temporary relief, but the disease is generally in no long time reproduced, and the incision must either be repeated, or the phalanx amputated. The preferable practice, according to my experience, is to remove the phalanx at once. It is less tedious and painful than the incision, produces very little, if any, impediment to progression, and of course is quite effectual in eradicating this most annoying though apparently simple disease.

_Of Fractures._—Deformity, shortening, loss of power, unnatural motion on extending and moving the part, pain, and grating, mark solution of continuity in bone, or fracture. Swelling, with spasmodic of these symptoms may be wanting; there is little deformity, and no shortening, when one of two or more action of the muscles, soon takes place. One or several parallel bones is fractured. In fracture of the extremities, extrication of air into the cellular tissue, about the ends of the bone, is not unfrequent, though difficult to account for—giving rise to crepitation, superficial, and quite a distinct sensation from that imparted by the broken bone.

Bones become brittle as age increases, and fragility is also induced by certain disordered and debilitated states of the constitution. In some patients, the bones give way on very slight force being applied, after what may have been supposed a rheumatic attack; the thigh is broken by turning in bed, or by walking from the bed to a chair. In one instance, I had put up a fracture of the thigh with a long splint, and in three weeks afterwards the humerus was broken over the end of the splint during an attempt by the patient at change of posture. In many such cases union either does not take place, or is very imperfect.

In children, the bones frequently contain little earthy matter, bend easily, and often break partially on the convexity of the curve. Even at the age of twelve or thirteen, bending of the bones from injury sometimes occur to a great extent, as of the forearm from a fall on the palm of the hand; in adjusting the parts, a slight crackling is heard when they are brought nearly straight. Complete solution of continuity, though more rare, is occasionally met with in very young subjects.

Fractures are generally the result of great force applied directly to the shaft of a bone, or to its extremity; but they are also not unfrequently caused by twisting of the limb whilst the muscles are in a powerful action. Bones are broken transversely; but more frequently there is a degree of obliquity in the fracture, and the fragments are generally detached. A bone may be split longitudinally, as from a musket-ball striking its shaft in the centre; and fissures often extend from a cross break to a considerable extent, sometimes into joints.

Swelling is often rapid, from extravasation of blood; at other times it is slow, and of a serous character. At first it is soft and yielding, but after a time painful inflammatory tumescence supervenes, the violence and extent of which will depend on the severity of the injury, and very much also on the treatment to which the parts are subjected. If the bones be put as nearly as possible into their original position, and retained so, judiciously—the limb being laid in a comfortable and unconstrained posture, and the bandages, splints, &c., properly adapted—little or no pain or inflammatory swelling will occur; no more action ensues than is required for reparation of the injury. If, on the contrary, the bones are allowed to remain unreduced—perhaps after being well handled—their broken ends, laying among the soft parts, are pulled out by violent spasms, lacerations of the muscles and vessels is increased, effusion, swelling, and violent inflammatory action occur, the pain becomes excruciating, fever and delirium follow; there is an imminent risk of gangrene, and extensive suppuration among the muscles is almost inevitable. If the patient recover, the union is bad, and the limb deformed.

A fracture is said to be _simple_, where there is no wound of the superimposed integuments. The external parts may be bruised, or the deep structure much injured, with laceration of the vessels and rapid and great swelling; or there may be little or no injury of the soft parts. Great danger may exist without division of the integuments; these, yielding under the force, may remain entire, whilst by great and direct violence the bone is comminuted, the muscles broken up, and the vessels and nerves torn,—the limb is infiltrated with blood, and must become gangrenous as soon as reaction takes place. But usually these untoward circumstances do not exist in simple fractures, the soft parts being but slightly injured.

Fracture is _compound_ when the integuments are divided by the external force, so as to expose the broken bone. But the wound may not penetrate to the bone; and then the accident is termed fracture with wound, not compound fracture. The soft parts are often divided by the sharp end of the bone; this is frequently the case in oblique fracture, occasioned by a fall from a height, the lower fractured extremity being pushed forcibly upwards. The muscles are usually much injured. The wound is either large or small, lacerated or clean.

Fracture, simple or compound, is _comminuted_ when the bone is divided at the broken point into fragments, either small and loose, or large and adherent to the covering of the bone and other soft parts.

Fracture may be _complicated_ with wound or displacement of a neighbouring joint, and with laceration of large bloodvessels and nerves.

Union of divided bones, as of soft parts, is preceded by incited circulation in the part, and effusion of organisable matter. The extent of action is regulated by that of the injury, whether inflicted by accident or by operation. If the soft parts have not been much bruised, if the bone and its covering are merely separated and slightly displaced, and then speedily put in contact, the incited action and the effusion are limited to the divided parts. There is no irregularity afterwards at the point of fracture, the new matter that is not required being absorbed soon after deposition; the bone is smooth and even as before. The deposit of new matter under the periosteum and into the medullary canal is here well exhibited. By this means only is the bone kept together for a very considerable period; afterwards the broken ends are united, and the temporary callus absorbed. If, on the contrary, there is much displacement, and if that is not entirely removed, intense action ensues both in the soft and hard parts, there is great effusion of new matter, or callus, soft and yielding at first, but gradually becoming hard and dense—bony particles being deposited from the vessels ramifying in the extremities, or in the attached fragments, of the old bone. When detached portions of callus are found lying in the soft parts, a piece of old bone which retained its vitality has generally formed the matrix of the deposit. When the ends of bones have been badly placed, and meet each other at an angle or curve, occasionally osseous deposit seems to form in the concavity. This increases in size, unites with the portions of the shaft, and forms a sort of bridge uniting them. This by M. Gulliver has been termed accidental callus.

In badly reduced fracture the swelling is great and hard. The callus is exuberant, much being required for the union of the fractured ends that overlap, and are perhaps far from being in contact; the vascular action and accompanying effusion are great, according to the necessity for them. The bone at the united part is enlarged to perhaps double its original thickness, or even to a greater size. After some time, the ends of the old bone, and part of the new deposit, are rounded off by absorption of the protuberances, and the part becomes more shapely. The canal of the bone and the cancellated texture is again restored. The accompanying sketch of a section of the humerus shows a double fracture. The superior one near the neck, where there is still some thickening, had been well adapted, and the canal is quite perfect. In the other and more recent there is considerable overlapping. The portion of outer osseous shell projecting into the medullary canal would in the end have been removed by the absorbents, and the deformity much diminished.

When the ends of the bone are not well placed, or when they are moved occasionally whilst the uniting medium is still soft, there is danger of a false joint being formed—the callus either giving way, or being all along imperfect, and the extremities at the soft part becoming smooth and moveable on each other; or incited action may run high and terminate in suppuration, with death or ulceration of portions of the bone.

Fragments are sometimes entirely detached at the time of the accident, and perish at once; or are so slightly connected with the shaft that they lose their vitality on the first accession of inflammation, become surrounded by purulent matter, part from their slight attachments, and come towards the surface. Or the shaft itself may be so bruised by the violence of the injury as to be incapable of resisting incited action, though slight. By malpractice, such untoward consequences as the preceding, and many others beside, are frequently induced.

The uniting medium of separated bones remains soft for some time, as was already observed; and often, whether from the state of the constitution, or the circumstances connected with the fracture, the parts remain long moveable. Pregnancy is said to prevent union; but I have often seen fractures in pregnant women unite as speedily and firmly as if the patients had been in that state, and otherwise in robust health; profuse uterine or vaginal discharges, or determination to particular parts or organs, will certainly retard union.

In ordinary cases, the limb, if not lying altogether straight, can be moulded into a proper form after the lapse of eight or ten days from the time of injury, without the patient suffering any great degree of pain, without the process of union being at all interrupted, or the cure protracted; even at the late period of five or six weeks, badly united fractures may sometimes be much improved by gradual pressure and change of position. A gentleman fell from his horse, and sustained simple fracture of both bones of the leg, near the middle. It had been laid and retained on its side. I saw him exactly six weeks after the injury; the leg was much curved forwards, and the foot turned outwards. The limb was placed on the heel, and a long splint, with a foot-piece, applied on the outside; by attention to its position, and by gradually tightening of the bandages, it soon became quite handsome. Care should be taken not to allow the patient to rest too soon on the fractured limb; for though quite straight, symmetrical, and of the proper length, when the retentive apparatus is discontinued, it may become short and deformed in a few days from even slight weight being put upon it.

The period at which firm union takes place varies; the process is more rapid in young people than in those advanced in life, and will depend more on the extent of the injury, and its vicinity to the centre of the circulation than on the size of the broken bone. The requisite length of confinement is regulated by these circumstances, and by the use to which the part is to be afterwards put; the lower limbs require longer time for consolidation than the upper.

In the treatment of fracture, as in solution of continuity in the soft parts, great advantage is gained by placing the disjoined parts as nearly in their original position as possible, retaining them so, and allowing of no motion. These indications ought to be accomplished very soon after the accident; many evils are thus prevented—the further laceration of the soft parts, the inflammatory effusion into all the tissues, and the consequent startings and spasms of the muscles. This cannot be too much insisted on. There is much folly and absurdity in allowing a broken limb to lie unrestrained—leaving the ends of the bones displaced, the one riding over the other—whilst attempts are being made to keep down the inflammation, by applying leeches, cold lotions, or large poultices—all perfectly ineffectual so long as the palpable cause of incited action remains unheeded. The circumstances which kindle and keep up inflammation should always be understood; they are easily discovered in fracture, and when understood should never be lost sight of. If the parts be replaced there will seldom be inflammation; if they remain displaced, the inflammation is so great that it is impossible to subdue it by any means short of removal of the cause. There is also an impossibility,—not to mention the patient’s sufferings,—of reducing bones to a good position some weeks after the accident. Such practice has been extensively followed and recommended by some, even modern writers; they set about reducing a fracture at a period after the accident, at which, by proper treatment, union would have been completed, or at least far advanced. The confinement and suffering of the patient are increased threefold, and after all the cure is bad, and there is a risk of false joint.

In all fractures, whether simple or compound, comminuted or complicated, if an attempt is to be made to save the limb, let reduction be immediate; coaptation and retention of the separated parts cannot be made too soon. A neglected case may be met with, in which the intensity of inflammatory action in all the tissues may forbid immediate interference. But even though inflammatory action has taken place to some extent, there are no surer means of arresting it than removal of its cause—the irregular ends of the bones being taken away from among the soft parts—provided it can be done without violence or increase of tension. Reduction is facilitated by proper position of the limb, by relaxation of certain sets of muscles. Extension and counter-extension are made, and but very little force is required; the surgeon extends the limb with one hand, and resists with the other; when the system is excited, and the muscles act spasmodically, an assistant may be required to steady the limb, and to resist the extending power which the surgeon employs. Then the position of the limb and of the patient, when long confinement is required, must be considered, and rendered as easy as possible, though at the same time secure. The apparatus for retaining the bones in the right position must be varied according to circumstances.

In compound fractures, when the wound is so small and clean that adhesion readily takes place, the cure is as rapid as in the simplest form of accident; but when the soft parts are much lacerated, the breach in them must be repaired by granulation; there will be profuse discharge from the wound, with risk of deep suppuration, and union of the bone will be slow. To accomplish reduction, long and sharp pieces of bone may require to be removed by means either of the saw or of the forceps, or else the wound must be dilated; both proceedings may be necessary in some cases. Detached portions of bone, and foreign bodies, if any, must be taken away; and the edge of the wound may be approximated when a reasonable chance of adhesion exists. The limb must then be properly placed and secured. Inflammatory action, should it threaten, must be kept down, but bleeding and purging are to be employed with caution. The action and its consequences are moderated by one or two depletions, but these must not be had recourse to without due consideration of circumstances; strength is required to effect the action necessary for union, and to withstand the subsequent suppurations, though these may be prevented or at least moderated by timely depletion. Abscesses are to be opened early, the parts are fomented, and then perhaps poulticed. The limb must all along be kept in a correct position, dead portions of bone must be removed when detached, and the strength supported by generous diet and wine. Opiates are of great use in alleviating the pains and twitchings in the limb. Poulticing is to be continued only for a short time; in many cases it may be altogether superseded by fomentations; and the latter should be used only when abscess is threatened, or when the patient is much pained at one or more parts of the limb. Support and gentle pressure are indispensable soon after evacuation of the matter, when no fresh collection is threatened.

The injury is often so great as at once to demand removal of the limb. There is no alternative, when, from laceration of the soft parts, superficial, deep, or both—comminution of the bone to a great extent—rupture of large vessels—and opening of joints—either gangrene or an overpowering suppuration are rendered not only probable but almost certain. The period at which the operation is to be undertaken requires judicious selection. Some patients are not affected constitutionally even by great and violent injury, such as dreadful laceration of the limbs; whilst others, even after slight wounds, are seized with delirium, tremors, vomiting, lowness of spirits, depressed circulation, paleness of the surface, and appear on the eve either of rapid sinking or of immediate dissolution. In the first class of patients immediate amputation may be had recourse to with safety and advantage. In the second, the patient must be reassured, and stimulated both by external and internal means; in short, reaction must be brought about, and then let the surgeon operate. If he amputate before this, his patient will most probably die on the table, or very soon after his removal from it; reaction will never take place, and sinking of the vital powers be accelerated by the ill judged interference. A greater or less time is required for the occurrence of reaction in different individuals; the usual period is from two to six hours. Commencement of it is a sufficient warrant for operation; the surgeon must not delay till inflammatory fever has been lighted up, for then he will interfere with great disadvantage. He must then subdue the inordinate action as much as possible, and wait for the suppurative stage. When the patient has become hectic from profuse and long continued discharge, when, perhaps, no union has taken place—then also the limb must be removed. In civil practice, patients as often recover from secondary as from primary amputation. But according to the experience of military surgeons, the result is otherwise—many recover after primary and few after secondary; much may depend on the accommodation of the patient afterwards. A great deal must necessarily be left to the judgment, discretion, and conscientiousness of the surgeon.

_Fractures of the cranium_ were treated of as connected with disturbance of the important organ which it protects.

The _bones of the face_ are occasionally broken and displaced. The frontal sinus is sometimes opened by fracture of the external plate. No small degree of force is required to effect this injury:—I recollect an instance of it, with opening into the sinus, occasioned by an attempt at suicide; the man had struck his forehead violently with a large stone, wishing to knock his head to pieces. The integuments are generally divided, and, during expiration, blood, sometimes frothy, is poured out through the opening. When there is no wound of the integument, emphysema of the forehead and eyebrows has resulted from disruption of the bones that compose this cavity, or others connected with the nostrils.

The _ossa nasi_ are fractured and displaced by direct violence. They may be broken and comminuted without much displacement, or separated from their connections and depressed without much fracture. Even slight cases are generally attended with laceration of the Schneiderian membrane, and with profuse hemorrhage from the nostrils. The soft parts over the bones are thin and tense, and consequently in many cases divided. Great swelling is apt to ensue, at first either bloody or œdematous. Inflammatory swelling to a great extent, both externally and internally, is to be dreaded and guarded against. Abscess of the Schneiderian membrane, frequently of the septum narium, occurs from slight injuries, if neglected; and, if not actively and properly treated, may terminate in loss of substance and consequent deformity of the features.

The existence of fracture of the ossa nasi is very readily ascertained; the part is distorted, being either uniformly depressed, or hollow at some points, and abruptly prominent and sharp at others. With the view of remedying deformity produced by displacement, and preventing the bad consequences already spoken of, the bones must be restored to their original position. They are to be raised by means of a strong probe or director, covered with lint, and introduced high into the cavity. Whilst, by means of this instrument, pressure outwards is made, the fingers of the surgeon are applied externally, so as to mould the organ into a proper shape. Unless force be again applied to the part, there is no risk of subsequent displacement; no apparatus is required to preserve the bones in situ.