Part 55

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.

In the slighter cases, it is sufficient to restrain the motions of the chest by a broad bandage applied firmly round it; and a split cloth, or a scapulary, may be passed over the shoulders and attached to the circular bandage to prevent its being displaced. Great and immediate relief is thus afforded. In those of a plethoric habit, blood may be taken from the arm, some hours after the injury, with relief and advantage; it may ward off an inflammatory attack—and it is absolutely necessary to adopt this practice on the slightest indication of such supervening. The appearance of the countenance, and the state of the pulse and respiration, must be watched; and on the first becoming anxious, the second strong and accelerated, and the third hurried and imperfect, active measures must be employed—venesection, antimony, purgatives, diaphoretics, anodynes—one or all according to circumstances. In the more severe injuries the same practice is pursued; and the symptoms are watched with great care. The air in the cellular tissue, if effused in great quantity about the neck and face, and interfering with the functions of the parts, is to be evacuated by punctures. If the emphysema is slight, and confined to the neighbourhood of the injured part, farther extrication is prevented by the timely and accurate application of a bandage; the air already in the cellular tissue speedily disappears. The effusion into the chest is also in general absorbed; but it may remain and increase, and from violence of action purulent secretion may be mixed with the serous. The breathing then becomes embarrassed, the chest swells, and the integuments are œdematous. The action of the lung is either much impaired or entirely arrested, as is ascertained by auscultation. In such circumstances, evacuation of the effused fluid may be required.

The Sternum is sometimes fractured, or, in young persons, the bones composing it disjoined; but the occurrence is exceedingly rare. The displacement is not great; and is rectified by changing the position of the trunk. The same treatment is required as for fracture of the ribs. Abscess has formed under the bone, as the result of the injury; but by antiphlogistic means, local and general, this may be in most cases prevented.

Fracture in the vicinity of the shoulder-joint requires to be most accurately examined, that a correct diagnosis may be formed, and the practice be judicious and decided.

Portions of the upper part of the humerus are torn off, along with the attachments of the short muscles, during violent exertions, particularly if the limb is in an awkward position. This is followed by want of power, great swelling, and considerable deformity. Some indistinct crepitation is perceived; the articulation is afterwards stiff, and the bone of an unnatural form. But these indications of the injury gradually disappear.

More extensive solution of the continuity of the bone takes place, generally in consequence of a direct and violent blow on the shoulder. The patient is unable to raise the arm, though with great pain it can be placed in any position that it occupies naturally; it can be abducted and raised, perhaps to a greater extent and more readily than when sound. The shoulder is flattened, and the limb apparently lengthened. The elbow is readily put to the side. On raising the humerus, rotating it, and moving it to and fro, crepitation is distinctly perceived—but not so readily after swelling has taken place. The swelling also obscures the appearances observed immediately after the infliction of the injury,—the flattening of the shoulder, and apparent elongation of the arm. By the fingers of one hand, pressed deep into the axilla, the head of the humerus can be discovered; and, on rotating the shaft of the bone with the other hand, grasping the elbow and pushing upwards at the same time, crepitation is perceived, and the upper portion of the bone is ascertained to be unaffected by the rotation of the shaft. The nature of the injury is then sufficiently apparent.

But the shaft of the humerus may, by such manipulation, be ascertained to be entire. Still, from the direction of the force which effected the injury, the flattening of the shoulder, the remarkable falling down of the arm, the loss of power, the free motion, and from the crepitation, though perhaps indistinct, it is evident that fracture has occurred. Then, by the fingers in the axilla, whilst the humerus is raised and moved in different directions, crepitation is recognised deeper and less distinct than in the former case; and the surgeon is warranted in believing that the glenoid cavity has suffered—that it is broken into fragments, or that it is separated from the body of the scapula by fracture of its neck; he is also warranted in adopting the means of cure suitable to such an accident. Many such injuries are supposed to occur, yet it is strange that preparations illustrative of it are scarcely to be met with in our collections of morbid specimens.

How both detachment and luxation of the head of the humerus should occur, can scarcely be explained. Luxation certainly cannot take place after fracture; no force can be applied to the head of the bone sufficient to displace it. It is barely possible, that after luxation, force may be applied to the bone so as to fracture its neck. This accident is of very rare occurrence, though by some supposed to be otherwise. I have had an opportunity of examining but one case, and that was very distinct; the head of the bone, completely detached from the shaft, lay in the axilla. Comminution of the head of the bone, with displacement of the fragments, is not uncommon.

Separation of the head of the bone occurs occasionally in young persons, presenting the same appearances and symptoms as fracture of the neck of the humerus in later life. Each, by a little care, is distinguishable from dislocation, even after swelling has supervened. And it is highly necessary that the diagnosis should be correct and prompt, otherwise atrociously cruel and unnecessary proceedings will be adopted, and irreparable mischief occasioned. Luxation is attended with flattening of the shoulder and elongation of the arm, to a greater or less degree, according to the position of the head of the bone. But the elbow does not come to the side, and the motions of the limb are abridged; it cannot be abducted to any extent, if the scapula is fixed. The head of the bone is felt under the pectoral muscle, or in the axilla; and on rotating the arm gently, by laying hold of the forearm, and using it, when bent, as a lever, the head and shaft are found to move simultaneously, all of a piece, and no crepitation is felt. Besides, the history of the accident is an excellent guide towards correctly ascertaining the nature of the injury. If the patient, in falling, have involuntarily stretched out his arm, in order to save himself, and alighted with his whole weight on the palm or elbow, dislocation will most probably have occurred. If, on the contrary, he have pitched upon the shoulder, without any intermediate breaking of the fall, fracture is to be expected.

The evil consequences of false diagnosis, and of treatment formed thereon, are very apparent. A dislocation may be put up and treated as a fracture, perhaps till too late for reduction; and the patient will possess but weak and imperfect motion of the limb, after having undergone long suffering. On the contrary, dreadful torments are inflicted on the patient when fracture is treated as luxation. The force applied with the view of reduction is in all circumstances very painful, but, when exerted on a fractured bone, must prove absolute torture; and during the whole treatment, the fragments are, perhaps, every now and then, by renewed attempts, torn separate, and union so prevented. Severe inflammatory action follows the reductive violence, and is kept alive or regenerated by the loose and projecting fractured ends of the bone; extensive suppurations, attended with fever, ensue, and may destroy the patient. Undetected fracture may also be treated as a bruise of the soft parts only; then every motion of the body and limb is productive of excruciating pain, and there is much risk of uncontrollable inflammation being excited—all which would have been warded off, by placing the bones in a proper and steady position in the first instance; the adaptation of a pad in the axilla is followed by immediate and great relief. Such mistakes are quite inexcusable. By one careful examination,—productive no doubt of considerable uneasiness to the patient in some conditions of the parts—the real state of matters should be ascertained; and then the practice founded on the knowledge so obtained will be followed with speedy cessation, or at least great diminution of pain, and with every probability of restoring the limb to strength and usefulness.

Fractures of the glenoid cavity, of the neck of the scapula, and of the neck of the humerus, are all treated by the same simple, though effectual, apparatus as employed for injuries of the clavicle. It requires to be re-adapted occasionally, to have the parts under the crossings of the bandage, and under the knots of the shawl retaining the pad, well protected by soft pads, and it must be worn for four or five weeks—perhaps, in some cases, even a short time longer. Then gentle passive motion of the limb is to be employed, gradually increased as the painful feelings abate. If the parts are at once placed in apposition, and accurately retained, no abstraction of blood, either general or local, is required at the time, and is not likely to be called for during any stage of the treatment. No cold evaporating lotions are necessary; fomentations are sometimes useful.