Part 74
In compound fracture the detached spiculæ are to be picked out, and the wound cleansed of blood and extraneous bodies; its edges are to be brought neatly together, and retained by one or more stitches, with slips of unirritating plaster. Inflammatory symptoms are to be warded off and combated by purgatives, antimonials, local abstraction of blood, and fomentations. Formation of matter in the nasal cavity is to be prevented, by scarification of the swollen membrane that fills the nostrils and precludes the passage of air; and if matter has been allowed to collect, it must be early discharged.
Opening into the frontal sinus, whether the result of accident or of exfoliation, may sometimes be closed by paring the edges of the integuments and bringing them together, or by covering the deficiency with a flap borrowed from a neighbouring part. Such measures should not be resorted to, in the case of opening from accident, till after all inordinate action has subsided, otherwise adhesion will fail.
Cases of fracture of the _superior maxilla_, _os malæ_, and _zygoma_, have been met with. Great displacement cannot occur, nor is any peculiarity of treatment required. If the fracture is compound, loose portions of bone may require removal.
The _inferior maxilla_ is exposed to violence, but from its construction and consistence is capable of resisting a great degree of force. It may be broken at various points; the usual site of fracture is where the canine or the first small molar tooth is implanted; but it not unfrequently gives way at the symphysis, or near the angle. The alveolar processes are often detached, with loosening of one or more teeth. The fracture is frequently compound; being produced by a direct blow, as the kick of a horse. The bone sometimes breaks at a part not struck, as at the symphysis from a blow near the angle. The accident is easily recognised; in fact, the patient, if sensible, has himself discovered fracture before he applies for assistance. There is distortion of the part, and the broken extremities, when moved, are felt grating on each other; there is discharge of blood, perhaps of teeth, from the mouth; and in compound fracture the ends of the bone are visible. At the symphysis the parts are not much displaced; they are more so when the fracture is in the site of the first molar. In the latter situation it is occasionally difficult to replace the bone, and retain it in its proper position.
The face swells to a greater or less extent, according to the severity of injury done to the soft parts, and the time which has elapsed before reduction. The parts within the mouth swell; often there is great infiltration of the loose cellular tissue under the tongue. Sometimes extensive abscess forms, showing itself in the mouth or under the chin.
The bone is to be brought to its former shape by pressure of the fingers on the outside, and of the thumbs placed within the mouth on the corners of the teeth. Motion is prevented, and the parts are retained in their proper situation, by a wedge of cork or wood interposed on each side of the jaw, and grooved so as to receive the teeth both above and below. The wedges are placed with their thick ends anteriorly, and are retained by the lower jaw being firmly bound towards the upper; sufficient space for the introduction of food must be left between the wedges at the fore part of the mouth. Pasteboard or leather is applied externally, cut so as to fit exactly the fractured bone; it is previously softened in warm water, that it may adapt itself to the shape of the parts, and form a case over them; a thin layer of tow or wadding is placed between it and the skin, and the whole is retained by a roller, which is preferable to split cloths. The patient should not talk, or in any way attempt motion of the injured bone, and the food given should not require mastication. Inflammation is to be kept down by the usual means, and abscesses, if they form, must be early evacuated. Detached teeth and splinters of the jaw are to be extracted at the first; if teeth loosen much during the cure, they should be considered as foreign bodies, and removed, otherwise they will keep up the discharge, and tend to prevent union.[61] From three to six weeks is generally sufficient time for consolidation of the fracture. In severe cases union may be prevented by necrosis of part of the bone; or, though the bone unite, the external wounds may not heal, and the discharge may continue till the dead portions separate and are discharged.
_Fracture of the Spinal Column_ is attended with alarming symptoms, and often terminates fatally, from the pernicious effects necessarily produced on the spinal chord, either immediately or consecutively, when the bones forming the column are disjoined to any great extent. The injury is effected by great violence—by the body being projected and alighting awkwardly—by a fall on the breech from a height, the head and trunk being bent forcibly forwards—by direct blows on the spine.
Displacement of the bones forming the spine, seldom takes place without fracture to a greater or less extent. Pure dislocation of the spine, from the rupture of ligaments and fibro-cartilage, is a very rare accident; few cases of it are on record, and in them the injury was in the cervical region; I have only met with two instances of complete and pure dislocation. The ligaments are of great strength, and the bones yield sooner than they do; and in the greater number of severe injuries of joints this is the case more or less.
A very well marked specimen of luxation, without the slightest fracture of the fourth from the fifth cervical vertebra is delineated on the next page. The injury was occasioned by the person falling backwards over a high paling, on which he was sitting, and alighting on the back of the head: along with the proper ligaments, the spinal chord is seen to be torn. The patient, of course, did not survive many days, being almost perfectly paralysed.
In general, either the bodies or the processes of the vertebræ are broken, and sometimes comminuted; occasionally the bodies are broken entirely through, with considerable displacement, the upper or lower end, as may be, projecting. There is twisting or bending of the trunk or neck, the articulating processes on one side only being displaced, whilst the ligaments on the other remain pretty entire. In some cases, either the spinous processes, or the articular, are separated without yielding of the bodies of the vertebræ, or of the interposed substance; then there is bending of the trunk forwards.
The symptoms vary according to the site of the injury, and the extent of violence inflicted on the spinal chord. This important organ may suffer concussion without fracture or displacement of the bones; its functions may be consequently more or less disturbed, and paralysis occasioned of those parts that are supplied with nerves from below the injured point. Without fracture, too, vessels may give way within the canal, and by compression from effused fluid urgent symptoms will be produced.
The power of motion may be lost whilst sensation is retained, and _vice versâ_; but in general both are either impaired or destroyed. In one case that came under my care, there was power of motion in one limb and no sensation, whilst in the other there was no motion but the usual sensation.
Patients may recover from the effects of a severe blow on the spinal column and consequent concussion of the chord, but very frequently they do not. Changes may take place at a late period in the chord or its membranes, in consequence of the injury—as thickening of the coverings—bloody, serous, or lymphatic purulent effusion—disorganisation and softening of the medullary matter. Inflammation of the membranes, or of the chord itself, may supervene, either very soon after the accident, or long afterwards; its intensity and period of accession will depend on the extent of the injury, and on the treatment. The muscles act spasmodically, the circulation is excited, the sensorium and nervous system are disordered, delirium ensues, and is followed by paralysis and coma.
In some cases of displacement, even to no small extent, the spinal chord escapes being bruised, torn, or compressed; no bad symptoms may ensue; or paralysis to a greater or less degree occurs and gradually goes off, probably occasioned by bloody effusion, which is afterwards absorbed. This I have witnessed in several instances—in a boy who fell from a high rock—in a woman who fell from a window; both lighted on the breech, and the trunk was bent forwards. The lad remained stout, but his trunk was somewhat deformed by an excurvation; the woman recovered perfectly. In these cases there was evidently laceration of the interspinal ligaments, though probably not of the ligamenta subflava, for the spinal chord must be stretched or otherwise injured when these are torn.
The chord is more or less injured in the majority of cases of fractured spine. If the injury occurs high in the cervical region, immediate death ensues, from compression or laceration of the medulla oblongata. Respiration is arrested by compression or destruction of the chord above the origin of the phrenic and other respiratory nerves. If the chord is injured in the middle of the cervical region, there is paralysis of the upper and lower extremities, with distention of the bowels, and inability to void the urine; the lower bowels have become insensible to the stimulus of distention from want of nervous influence, and the sphincter ani is paralysed. The bladder becomes distended, and then incontinence of urine follows; and frequently there is priapism. The quality of the urine is changed, the secretion of mucus from the bladder is vitiated and increased. Slow inflammation of that organ is induced, the urine becomes bloody and mixed with ropy mucus; lymph is deposited on the lining membrane.
Bruises of the loins often lay the foundation for degeneration and abscess of the kidney, with many of the symptoms of calculus vesicæ, attended with red tongue and hectic, ultimately terminating fatally.
The effects of concussion of the spine are frequently developed long after the infliction of the injury. There is formication, numbness, and difficulty of regulating the motions, in one or more limbs. Still the muscles are not shrunk, nor unable to perform powerful movements; but the patient cannot put his hand or foot to the place he wishes, and cannot support the weight of the body without assistance. Sensation in the limbs is lost to a greater or less degree, their heat is diminished, and it is found difficult to preserve their temperature equable. The symptoms increase till the limbs become totally useless. Along with the lower limbs the bladder is affected, though not always. The urine is not voided with force, and incontinence occurs from distention. Sometimes excitement of the viscus follows; the secretions from its surface are increased, and often mixed with blood. Yet patients survive long under such circumstances, digestion and the other important functions are well performed, and the intellect is unimpaired.
Prognosis in injuries of the spine is unfavourable, as well as in disease of the chord, whether the result of injury or not.
From the treatment much need not be expected; but still no chance is to be thrown away, even in the most unfavourable cases. The attention must be directed towards alleviation of the symptoms. The comfort of the patient must be looked to in regard to the situation of the injured bones and other parts, even where there is reason to believe that the chord is lacerated or completely divided, and that there is no chance of recovery. In less severe cases, by placing the injured parts in their proper position, and retaining them by splints placed along the sides of the spinous processes;—by keeping down inflammatory action, palliating all the symptoms as much as possible, and attending to the state of the bladder if necessary—unlooked for recoveries have taken place.
It has been proposed to treat the spine, in cases of severe and alarming fracture, in the same manner as the cranium—by trephining; and some have recommended this in almost all kinds of injuries. I allude to the practice only to condemn it. The spinal chord is generally displaced and compressed by the lower portion of the fractured body of the bones. One cannot easily comprehend what an operation is to effect in such cases. Further notice of this proceeding is unnecessary, seeing that, as far as I know, it has been unanimously discarded by the profession from amongst the list of surgical operations.
When the patient has borne up against the shock of the injury, and the more immediate consequences, and when partial loss of sensation and motion has supervened, great benefit is obtained from counter-irritation, by blisters, issues, or moxa. But these are not advisable, but to a certainty injurious, till after time has been allowed for subsidence of the immediate effects—for union of the divided parts, and disappearance of acutely excited vascular action. The endermoid application of strychnine is also efficacious in many cases where the injury has been slight—as in the following. A young man was struck on the back of the neck with a leaden plummet. The immediate effects were loss of power and sensation in the whole body. The use of the upper limbs was regained gradually and completely; and when he applied to me, the remaining symptoms were diminished sensation and irregular muscular action in the lower limbs. The mode of progression was very remarkable; supported on the points of the toes and assisted by a staff, he made two or three quick steps as if running, and then suddenly stopped, a few more rapid steps and another abrupt halt, and so on. A succession of small blisters was applied along the sides of the spine in the dorsal and lumbar regions, On the raw surface strychnine was sprinkled, commencing with half a grain daily, and gradually advancing to a grain and a half. He made a perfect recovery in less than three weeks.
In another patient, in whom sensation in one limb without motion, and in the other motion without sensation, remained after severe injury of the spine by a fall from a high window, complete recovery was obtained by the internal use of strychnine, and repeated application of the moxa.
Slow degenerations of the spinal chord are not easily combated with success. Considerable changes of structure have taken place, as shown by the symptoms, before the patient becomes alarmed and applies for relief. He has had a feeling of distention about the lower part of the bowels, and voids his urine with some difficulty; perhaps he suspects stricture of the urethra as the cause. He lifts his feet awkwardly, sets them down clumsily, and all of a piece; his knees totter, there is no feeling about his buttocks, and a numbness round the anus. At length he is for the first time alarmed by incontinence of urine having supervened, or by the limbs having sunk under the weight of the trunk, and by his coming to the ground with violence. The remedial means are local abstraction of blood from over the seat of the disease, followed by friction and counter-irritation. Strychnine may be tried in some cases. But it is indeed seldom that the progress of the case is satisfactory.
_Fracture of the Clavicle._—This bone is liable to be broken by indirect violence, as by falls on the point of the shoulder, from horseback, or from the top of a carriage; or by a fall with a carriage, the person being inside—of this accident I have met with three or four instances. It may also be broken by direct violence, as by a blow on the bone, or by the person striking it against a hard substance in a fall. It generally gives way about the middle. The fracture, when occasioned by force applied to the acromial extremity, is usually oblique; transverse when the force is applied to the shaft of the bone. The displacement is in most cases great; but when the fracture is at the bend near the scapular extremity,—a not very uncommon accident,—disjunction of the fractured extremities is prevented by the attachments of the conoid and trapezoid ligaments. In ordinary cases, that fractured extremity projects which is attached to the sternum, whilst the scapular portion is depressed and carried inwards. In short, the scapular portion is displaced, the sternal is nearly in situ; though, from the depression of the former, the prominence of the latter appears to arise from displacement. The arm falls forwards and downwards.
The fracture is sometimes compound. The wound is generally small, and occasioned by the projection of the sternal portion; or the integument may be divided by the external force.
The nature of the accident is readily recognised. The deformity is very apparent. There is swelling, from extravasated blood, over the bone; the shoulder is unnaturally approximated to the chest, and depressed. The motions of the extremity, those above the shoulder, are impaired. Crepitation is felt on raising the arm, and carrying it backwards so as to bring the fractured surfaces into contact.
When the patient is seen immediately after the accident, the bones are to be placed in apposition, and retained, without delay, and before inflammatory swelling has come on. No complicated apparatus is required. A pad, firm, though of soft material, and large enough to fill the arm-pit completely, is rolled in a shawl and placed in the axilla; it is retained by tying the shawl over the opposite shoulder, a soft pad being interposed between the knot and the skin to prevent excoriation, and is farther secured by tying the ends under the axilla of the uninjured extremity, which should also be protected by a small cushion. A few turns of a roller, or a handkerchief, are placed round the arm and chest, so as to secure and fix the limb; so the retentive apparatus is completed. The shoulder is thus raised, and removed from its unnatural position; and the fractured extremities of the clavicle, previously placed in accurate contact, are prevented from being again displaced. The elbow and forearm should be supported by a sling, otherwise the unsupported weight of the limb dragging on the shoulder will cause considerable pain, and subsequent displacement will be apt to occur. In order to prevent swelling, it is sometimes advisable to support by a bandage the hand and forearm. The apparatus should be looked to occasionally, adjusted and tightened; and the cushions should be replaced by fresh ones, to prevent excoriation and uneasiness. The bone will be found to lie quite smooth, to remain of its proper length, to unite, generally within twenty days, and that without any unseemly exuberance of callus. No evaporating lotions are necessary. No compresses or splints need be applied over the bone. If the patient be bruised in other parts, and become feverish, it may be requisite to abstract blood and exhibit antimonials, purgatives, &c. But all inflammation, arising from the fracture, subsides on the accomplishment of reduction, adaptation, and retention of the portions. If the fracture be compound, the edges of the wound should be brought together and retained, so as to favour immediate union.
The _body of the scapula_ is broken, generally by a severe injury of the chest, as by a hard and heavy body passing over it. There is little or no displacement; and the accident is not easily detected, more especially after swelling has taken place.
It is sufficient to restrain motion; and this is effected by passing a bandage round the chest, over the scapula, and round the arm.
The _acromion process_ may be broken off; but the accident is rather uncommon. The fracture is produced by direct violence—a blow or a fall on that point. The spine of the bone also is sometimes broken by a like cause. Portions of the acromion may be separated along with the ligaments connecting the clavicle to it, in the accident of dislocation of the scapular extremity of that bone. The acromion is occasionally broken into fragments by heavy falls on the point of the shoulder.
There is a slight appearance of flattening of the shoulder at first, and then great swelling. Crepitation is felt by pressing gently and alternately with the points of the fingers over the fractured part.
The arm requires to be raised and supported by a sling.
_Fracture of the Ribs._—One rib, or more, may be broken by injuries in various ways—by blows of the fist—falls on hard bodies—pressure on the chest by heavy bodies passing over or falling upon it. They generally give way anteriorly to the angles, at the most convex point; but sometimes near the spine or the sternum. At the same time they may be partially luxated at either of the extremities. The fracture is generally transverse; occasionally, and rarely, oblique. Sharp portions are seldom detached. The skin is sometimes divided, but more frequently the pleura and lungs are torn by the spiculæ projecting internally; hence effusion into the chest, and emphysema of the subcutaneous cellular tissue near the fracture, take place. The emphysema, if permitted, extends over the greater part of the chest, and even farther.
Fracture of the ribs is attended with pain, particularly during full inspiration; and if the injury is severe, the patient is incapable, without great pain and exertion, of accomplishing full inspiration. He uses his handkerchief, sneezes, and coughs, with the utmost difficulty. Crepitation is felt by the patient, and is easily detected by the surgeon, by placing the hand on the suspected point, and desiring the patient to attempt full inspiration so as to grate the surfaces on each other. Motions of the trunk, and often of the upper extremities also, are attended with aggravation of the symptoms. In some cases attentive examination is necessary to discover crepitus—in certain situations, and when perhaps one rib only has given way, especially if some time have elapsed betwixt the infliction of the injury and the application of the patient for relief.