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.
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.
[Illustration]
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.
[Illustration]
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.