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.
Fracture of the _shaft of the humerus_ is either oblique or transverse,
according to the direction of the force applied. There is considerable
displacement. The limb is always shortened to a certain extent, and
the natural contour destroyed; the arm is useless, and bent towards
the trunk, and the muscles are in a state of spasmodic contraction.
The nature of the injury is at once and readily recognised. There is
unusual and unnatural mobility of the arm, and distinct crepitation
at the fractured point. There is great pain from the pressure of the
lower extremity of the bone upon the nervous trunks. The large vessels
are seldom torn—though the branches of the humeral artery, and the
vessel itself, have in a few cases been ruptured—but there is often
considerable bloody swelling in this as in all fractures. Occasionally,
when the violence has been great, either the upper or the lower
fractured end is thrust through the skin.
When the inferior part of the shaft is broken, there is less
displacement than when the fracture is towards the middle of the bone.
Fracture above the condyles sometimes extends through them; and the one
may be detached from the other either with or without fracture of the
shaft. When such an accident is suspected, the position of the condyles
in regard to the ends of the bones of the forearm should be accurately
observed. Flexion and extension of the forearm can be readily
performed, though with pain; not so, when the bones are luxated.
Crepitation is detected along the line of fracture, during motion of
the limb, and when the condyles are laid hold of and moved upon each
other, or on the shaft.
In fracture of the middle of the shaft, coaptation is easily
accomplished; slight extension is made by one hand grasping the
elbow, whilst, by the other, the bones are brought together, and the
straightness and outline of the limb restored. The proper position is
readily maintained by two splints of bookbinders’ pasteboard, or of
leather prepared for the purpose; one applied from over the acromion
process to beyond the point of the elbow, the other from the axilla,
and also passing over the elbow on the inside; thus the neighbouring
joints are fixed, and the muscles rendered inactive. The conjoined
breadth of the splints should be sufficient to embrace the limb almost
entirely; some space being left, so that when the swelling subsides,
they may neither meet, and consequently lie loose, nor overlap each
other. They are softened by steeping in hot water, so that they may
embrace every part of the limb to which they are applied; and the
extremities should be rounded off, to prevent galling of the parts.
They are padded with soft flannel, lint, or cotton wadding, or, what
is better, with finely carded tow, and retained by a circular roller
applied from the points of the fingers up to the shoulder. The binding
should proceed from below upwards, to avoid swelling from obstructed
circulation, and do away with the necessity of removing the apparatus
arising from this cause. It is well to place a wooden splint on the
outside, retained by an additional bandage, so as to steady the parts
till the pasteboard or leather has dried, and formed a firm mould or
case for the limb; then the wood is no longer necessary, and should be
removed. The forearm is bent at right angles, and the humerus fixed
to the trunk. In simple fracture, there is in general no necessity
for interfering with the apparatus until the bandage slackens, in
consequence of the swelling subsiding; then, usually at the end of
eight days, it is to be reapplied. One splint is carefully raised,
whilst the other is kept fixed and the parts steadied, and the limb is
ascertained to be straight and of a proper length; if not, then, or
even later, the position of the bones may be rectified without causing
much uneasiness. The patient need not be confined to bed on account of
a simple fracture; he may walk about with the arm supported in a sling.
In compound fracture similar splints are applied, after due attention
has been paid to the wound and to the position of the bones. The
patient is placed on his back in bed; and the splints are retained by
slips of bandage, double, one end being passed through the loop and
secured to the other by a running noose. This method of deligation
affords facility for the removal of the splints, in order to examine
into the state of the limb and dress the wound. It also permits the
apparatus being slackened in the first instance during the swelling,
and of being afterwards tightened, without lifting the limb or
disturbing its position.
Fracture at the distal extremity of the humerus is managed most
conveniently with the limb in the straight position. The fragments are
placed accurately together, and one splint placed on the fore part,
another posteriorly. The forearm is kept in a state of supination. At
the end of about twenty days the apparatus should be removed, and the
position of the articulation changed if possible. The forearm is to be
bent slightly, and a splint applied,—made to fit accurately, and with a
joint corresponding to the bend of the arm. This should be occasionally
removed, provided consolidation of the fractured bones has advanced so
far as to admit of it, and slight passive motion of the elbow-joint
employed. Obstinate rigidity of the parts is thus guarded against.