Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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such as may attend any severe injury of this organ, whether accom-
panied with a fracture or not, such as pain, swelling, difficult degluti-
tion, embarrassed respiration, loss of voice, cough, and perhaps bloody
expectoration, with emphysema, &c.

But none of these can be regarded as diagnostic ; although, when
taken in connection with the history of the accident, especially if a
very severe and direct blow has been received, or more certainly still
when symptoms so grave and complicated have followed an attempt
at strangulation by grasping the throat, they may be regarded as pro-
bable or presumptive evidences.

A positive diagnosis must depend upon the presence of a sensible
displacement, or motion of the fragments, with crepitus.

In the case related by Plenck, death followed almost immediately,
with convulsions, and without any outcry ; indicating, probably, some
severe lesion of the spinal marrow; while in M. Olliviers patient suflfb-
cation ensued, at first intermittent, and finally permanent.

In my own case, suffocation was throughout a prominent symptom,
with only such slight intervals of amelioration as might have been
occasioned by the extrication of the blood or mucus from the larynx.

General Prognosis. — The prognosis ought to depend rather upon
the complications and upon the gravity of the symptoms, than upon
the simple decision of the question of fracture. A fracture produced
by grasping the wings of the thyroid cartilage, and without any great
contusion or laceration of the soft parts, might reasonably be expected
to terminate favorably under judicious management ; but when, on the
contrary, the fracture is the result of great violence inflicted directly
upon the front of the cartilages, producing severe contusion and lace-
ration, and is followed by great swelling, emphysema, very difficult
respiration, complete aphonia, impossibility of deglutition, &c., the
prognosis cannot but be unfavorable.

General Treatment. — In examples of simple, uncomplicated frac-
ture, "silence, regimen, and a small bleeding" may suffice; but in other
cases it may become necessary to introduce a tube into the stomach,
to supply the patient with food and drinks, since deglutition may be
impossible. If, also, suffocation is imminent, there may remain no
alternative but a resort to tracheotomy or to laryngotomy.

Indeed, one of these operations ought, we think, to be resorted to in
all cases in which emphysema is prominent. Dr. William Hunt, of

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the Pennsylvania Hospital, in bis excellent paper on " Fractures of tbe
Larynx and Raptures of the Trachea/' in which he has arranged a
tabular synopsis of twenty -nine cases, says that of twenty-seven cases
ten recovered and seventeen died. Of eight cases in which tracheo-
tomy was perfbrraed, but two died. In the four oases in which recoverjr
took place without an operation no mention is made of bloody expec-
toration or of emphysema.*

As to a " reduction" of the fragments by manipulation, I believe it
will be found generally, if not always, impracticable. Whatever dis-
placement exists must be mostly inwards, and we can have no means
of forcing them again outwards. Nor, if once replaced, do I see anv
reason to suppose that they would not become immediately displaced.

Chelius has suggested the proprietv, in such cases, of cutting opea
the coverings of the larynx freely in the median line, and, after stanch-
ing the bleeding, proceeding at once to divide the larynx itself in its
whole length, and then replacing the broken cartilages.' The pro-
cedure has an aspect of severity, but I can well conceive of circum-
stances which would justify its adoption; not^ however so much for
the purpose of replacing the cartilages, as for the purpose of arresting
a fatal internal hemorrhage, and of giving a free admission of air to
the lungs. If this operation were to be practised, the wound ought
to be left open for a sufficient length of time to allow of the subsi-
dence of the inflammation, and then permitted to close with such
precautions as experience teaches are usually necessary after the
windpipe has been opened.

Active antiphlogistic measures, combined with fomentations to the
neck, so far as these latter are found to be agreeable and practicable,
are important measures, and not to be overlooked in the general plan
of treatment.

My own patient, also, found small pieces of ice, permitted slowly to
dissolve in the mouth, very grateful ; but he preferred very much, as
an external application, the warm fomentations to the cold lotions.



It will be convenient to divide fractures of the vertebrae into frac-
tures of the spinous processes, transverse processes, vertebral arches,
and bodies.

§ 1. Fbaottjres of the Spinous Processes.

Fractures of the spinous apophyses, independent of a fracture of the
arches, may occur at any point of the vertebral column; and they

^ Hunt, Amer. Joum. Med. 8ci., April, 1866.

' System of Surgery, Philadelphia ed., vol. i. p. 581, 1847.


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may be occasioned by a blow received apon either side of the spinal
column; or by a force directed from above or from below.

Symptoms and Pathology, — These accidents may be recognized by
the lively pain at the point of fractare, produced especially when the
patient bends forwards, which position renders the skin and muscles
tense and drives the fragments into the flesh; by the swelling, ten-
derness, and discoloration; but chiefly by the lateral displacement of
the broken process, and the mobility.

Duvemey met with a fracture of two of the processes in the same
person, and which could only be recognized by the mobility, since,
as the autopsy proved, there was no dis-
placement Nor would it be surprising ^K- 83.
if the displacement was absent in a ma-
jority of these accidents, inasmuch as the
attachment of the ligaments from above
and below with the strong and short
muscles upon either side, must prevent
a deviation in any direction until these
tissues were more or less torn. Sir Astley
mentions a case in which, however, such
lacerations did occur, and the lateral de-
formity was quite conspicuous.

A boy had been endeavoring to sup-
port a heavy weight upon his shoulders,
when he fell bent double. Immediately
he had the appearance of one suffering Fnetar« of the ipiaoaa proeets.
under a distortion of the spine of long

standing. Three or four of the processes were broken off, and the
corresponding muscles were detached so as to allow the processes to
fall off to the opposite side. There was no paralysis, and he was
soon discharged with the free use of his limbs, but the deformity

K the fragment is thrown directly downwards, as it possibly may
he, especially in the cervical or lumbar region, yet not without a rup-
ture of the supra-spinous ligaments, or of the ligamentum nuchas, then
the displacement will be more difficult to detect, and it may require
some more care not to confound it with a fracture of the vertebral
arch or of the plates from which the spinous processes arise. The
process not being felt in its natural position, nor upon either side, it
may seem to have been forced directly forwards, when in fact it is
only thrown downwards towards its fellow. The danger of error in
the diagnosis will be increased when to these conditions are added
paralysis of those portions of the body which are below the seat of
the fracture, and which, in this case, may be the result of an extra-
vasation of blood or of simply a concussion of the spinal marrow. Nor
do I think it would be possible now to determine positively whether
it was simply a fracture of a spinous process, of the arch, or of the.
body itself of the vertebra. In case, however, the paralysis results

> Sir Aetley Cooper, op. dt., p. 459.

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from concussion, the fact will in most cases soon become apparent by
a return of sensation and of the power of motion.

Prognosis, — Hippocrates affirmed that here, as in fractures of other
spongy bones, the union took place speedily. It is quite probable
that this venerable father of surgery has stated the fact correctly, and
yet in the only example known to me where the condition of this
process, as proved by dissection, has been carefully stated, the frag-
ment had not united by bone at all. This is the case related by Sir
Astley as having been examined by Mr. Key. A subject was brought
into the dissecting-room, in which one of the processes had been
broken, and, on dissection, a complete articulation was found between
the broken surfaces, which surfaces had become covered with a thin
layer of cartilage. The false articulation was surrounded with sy-
novial membrane and capsular ligaments, and contained a fluid like

Ordinarily the displacement continues, whatever treatment may be
adopted ; but Malgaigne says he has seen one instance in which the
twelfth dorsal spine, being broken and displaced laterally, resumed
its place spontaneously after a few days. Aurran mentions a similar

Treatment. — If in any case it should be found possible to act upon
the fragment, an attempt might be made to press it into place, and to
retain it there by means of a compress and bandage; but even this
would not be admissible so long as any doubt remained whether it
was not a fracture of the vertebral arch, since, if it were, any attempt
to restore the bone to place by pressure would be likelv to drive it
more deeply upon the spinal marrow. Yet what need is there of
surgical interference of any kind ? If the apophysis remains displaced
it cannot result in any serious, perhaps we may say in any appreciable,
deformity. The surgeon has therefore only to lay the patient quietly
in bed and in such a position as he finds most comfortable, enjoining
upon him perfect rest, and employing such other means as may be
proper to combat inflammation.

§ 2. Fractures of the Transverse Process.

A fracture of a transverse process can scarcely occur except as a
consequence of a gunshot wound. Dupuytren relates a case of this
kind in which the ball had penetrated the transverse process of the
second cervical vertebra. The man bled very little at the time, and
his symptoms progressed favorably for ten days ; af\;er which second-
ary hemorrhage occurred, of which he ultimately died. The autopsy
showed that the vertebral artery had been injured, and that the inflam-
mation of its coats being followed by a slough, caused his death.'

I have also elsewhere reported the case of Charles Harkner, of Buffalo,
N. Y., who was shot with a pistol on the 21st of Jan. 1851. I did not
see him until the following aay. The ball had entered the chin, a little

' A. Cooper, op. cit., p. 459. » Malgaigne, op. cit., p. 412.

• Dapuytren, Diseases, &c. of Bones, 8yd. ed., p. 860.

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to the left side and below the inferior maxilla, but its place of lodgement
could not be discovered. He lay with his face constantly turned to
the right. The left side of his neck was swollen and crepitant ; the left
arm and leg were paralyzed ; he slept most of the time, but could be
easily aroused, and when aroused he seemed to be conscious, but was
ttnabte to speak. By signs he indicated to us that he was suffering
no pain. He gradually sank, without hemorrhage, and died in thirty-
six hours from the time of the receipt of the injury.

The autopsy, made four hours after death, enabled us to trace the
wound from the chin, through the left ala of the thyroid cartilage, and
also through the roots of the transverse process of the fourth cervical
vertebra ; immediately behind which, lying imbedded in the muscles,
was the bullet. The cavity of the tunica arachnoides contained con-
siderable serous effusion.

The emphysema in the neck was occasioned, no doubt, by the
wound of the larynx, the ball having opened freely into its cavity.
This circumstance also explained the aphonia; but the immediate
cause of his death seems to have been arachnoid effusion as a result
of meningeal inflammation.

The symptoms arising from this accident can only refer to the com-
plications, since a mere fracture of the process is not likely to present
any peculiar signs which could be recognized. Concussion or bloody
effusion may take place so as to occasion more or less paralysis, or,
at a later period, inflammation and its consequent effusions may give
rise to the same phenomenon.

In itself considered, and independent of these complications, it is
sufficiently trivial, but inasmuch as it has not been known to occur
except from gunshot wounds, nor is it likely to occur except from
penetrating wounds of some kind, the accident must always be re-
garded as exceedingly grave, if not actually fatal.

As to the treatment, nothing but strict rest and antiphlogistic
remedies can prove of any service.

§ 3. Fractures of the Vertebral Arches.

The vertebral arches, upon which both Fig. 83.

the spinous and transverse processes have
their principal support, may be broken
at any point of their circumference, by a
blow received upon the spinous process ;
but generally it is the lamellar portion,
or the " vertebral plate," which gives way
rather than the neck or pedicle«of the
arch ; and in all of the cases recorded
the plates have been broken upon both

On the first of May, 18>1, during a
violent storm of wind and -ain, a balus-
trade fell from the top of a high build-
ing, striking a man named John Larkin, Fractareoftherertebralareh.

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who was about forty years of age, upon the back of his head and neck.
He fell to the groand instantly, and did not again move his feet or
legs, although he never lost his consciousness until he died. I found
the bladder paralyzed also, and his lefl arm, but his right arm be
could move pretty well. He conversed freely up to the last moment,
and said that he was suffering a good deal of pain, which was at ways
greatly aggravated by moving. His death took place thirty-six
hours after the receipt of the injury.

Dr. Hugh B. Yandeventer, who was the attending surgeon, made a
dissection on the following day in my presence, which aisclosed the
fact that the plates of the sixth cervical vertebra were broken upon
each side, and that the spinous process, with a small portion of the areh
attached, was forced in upon the spinal marrow. There was no blood
effused, or serum at this point, but about one ounce of serum was
found in the cavity of the tunica arachnoides at the base of the brain.
The bodies of the vertebras were not broken. It was our opinion,
therefore, that the immediate cause of bis death was the direct pres-
sure of the spinous process.

In the case related by Prout, of Alabama, the man having died
within forty-eight hours after the receipt of the injury, the arch of the
fifth cervical vertebra was found to be broken in three places, and the
spinous process was driven in upon the spinal marrow. There was
a slight effusion of blood between the sheath of the spinal marrow
and the bone, and a considerable effusion between the sheath and the
cord. There was no material lesion of the cord or of its membranes,
and the body of the bone was neither broken nor dislocated.^

It is probable, also, that in the following example the arch was
broken, but that the force of the blow having been somewhat oblique,
the process was but little if at all thrown in upon the spinal marrow.

R L., of Erie County, N. Y., aged about forty years, was thrown
from a loaded wagon in February of 1851, striking, as he thinks, upon
the back of his neck. He was stunned by the injury, and remained
insensible several hours ; on the return of consciousness, he found that
his lower extremities and bladder were paralyzed. During four weeks
his bladder had to be emptied by a catheter. Nine months after the
injury was received he consulted me, and I found the spinous process
of the last cervical vertebra pushed over to the left side. His head
was strongly bent forwards, and he was unable to straighten it. He
could walk a few steps, but not without great fatigue; and he suffered
almost constant pain in his lower extremities, accompanied with ex-
cessive restlessness and watchfulness, for which he was obliged to take
morphine in large quantities.

In the case related by Alban Q-.«Smith, of Kentucky, to which I
shall refer again presently, the deviation was lateral, and so also in
OUivier's case, mentioned by Malgaigne.

Symptoms. — We can imagine a case of fracture of the vertebral arch,
with a lateral displacement only, in which the symptoms might not

« Prout, Amer. Joum. Med. Bel., Nov. 1887, vol. xxl. p. 276, from Westem Joum.
of Med. and Phys. Sci.

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differ essentially from a simple fracture of the spinous process ; and
it is quite possible that some of the cases which have been supposed
to be examples of this latter accident^ and in which a speedy recovery
has taken place, were really examples of fracture of the arches; yet it
must be admitted that such a fortunate result is only possible, since
the arches can hardly be broken without communicating a severe
concussion to the marrow, nor without lacerations, inflammation, and
effusions, which will be most certain to produce compression and
paralysis, and probably death.

If, however, it is possible for us to confound a fracture of the process
with a fracture of the arches, it is still more possible for us to confound
a fractiire of the arches with a fracture of the bodies of the vertebras.
If, as is usually the fact, the process, in case of a fracture of the arch,
is less prominent than natural, and that portion of the body receiving
its nervous supply from below this point is paralyzed, we may have
reasons to believe that the arch is broken and the process driven in
upon the spine; but dissections have shown that in many of these
cases, or in most of them, indeed, the bodies of more or less of the
vertebras are broken also, and in still other cases the bodies were
alone broken.

If, as in the case mentioned by OUivier, we can feel the plates move
separately, the diagnosis might be made out, so far at least as to deter-
mine that the plates were broken ; but we should be still unable to
i^y that the bodies of the vertebras were not broken also.

Something perhaps may be inferred from the direction and manner
of the blow which has produced the fracture. Thus, a fall upon the
top of the head would most often produce a comminution of the bodies
by crushing them together, while a blow upon the back could scarcel v
break one of the vertebras without breaking the corresponding arch
also. We might thus be led to infer, in the first instance, that the
arches were not broken; and, in the second instance, if we could con-
vince ourselves that the arches were not broken, we might rest pretty
well assured that the bodies were not.

In the case related by Prout, there was no external mark of injury
over the point of fracture, but a distinct crepitus was perceptible on

Treatment. — ^If the fragments are not displaced, nothing but rest and
a cooling regimen are indicated ; but if they are forced in upon the
marrow, an important question is presented, and which has received
from different surgeons different solutions. Shall an effort be made
to reduce the fragments? and if so, by what means shall the indica-
tion be attempted ?

It will be remembered that in nearly all of these cases we must
remain in doubt, even after the most careful examination, as to the
actual condition of the fracture. It may be that what we suppose to
be a fracture of the arch is only a fracture of the apophysis, or that, on
the other hand, it is a fracture of the body of the bone itself; and if we
are expert enough to make out clearly a fracture of the arch, it is not
possible for us to say that the body is not broken also, indeed it is
quite probable that it is broken. With a diagnosis so uncertain, can

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we ever find a justification for surgical interference? Mr. Cline and
Mr. Cooper thought that we might. According to them, the case pre-
sents in no other direction a point of hope or encouragement. Death
is inevitable, sooner or later, if the fragment is not lifted, and we can
scarcely make the matter any worse by interference. If it proves to
be a fracture of the apophysis, as happened to be the case in a patient
upon whom Sir Astley operated,* our interference was unnecessary,
but it has done no harm. If the body of the bone is broken, the ope-
ration affords no resources, but the patient is probably beyond suffering
damage at our hands. If the diagnosis is correctly made out and the
arch only is broken, and if, as was the fact in the case of Larkin already
mentioned, there is no bloody effusion, or laceration of the membranes
or of the marrow, and if the concussion was not sufficient to deter-
mine much inflammation of the cord, then it would seem possible that
an operation might save the patient.

Paulus ^gineta first suggested that the compressing fragments
ought to be removed by excision ; and in 1762 Louis removed from
a man who had received a gunshot wound in his back, after the lapse
of five days, several loose pieces of bone belonging to the arch of the
vertebra^ and the patient recovered, but not without a partial para-
lysis of his lower extremities. Of course nothing could be more ra-
tional or simple than this procedure, adopted by Louis, in any case of
an open wound, where the fragments could be easily reached ; but the
younger Cline was the first, in the year 1814, to put into practice the
more ancient suggestion of Paulus ^gineta, namely, to attempt the
removal of the fragments in a case of simple fracture. He made an
incision upon the depressed bones as the patient was lying upon his
face, raised the muscles covering the spinal arch, removing, by means
of a circular saw, chisel, mallet, and trephine, &c., the spinous processes
of the eleventh and twelfth dorsal vertebras, and the arch of one of the
vertebras. The patient was in no manner relieved, and died on the
fourth day after the receipt of the injury and the third after the opera-
tion.' Mr. Oldknow repeated this operation in 1819 in a case of
fracture of ttie arch of the seventh vertebra. The patient died on the
sixth day.' In 1822, Mr. Tyrrell operated at St. Thomas's Hospital on a
man who had been injured four days previously, removing the spinous
processes of the twelfth dorsal and first lumbar vertebra. The opera-
tion was accomplished with considerable difficulty, and resulted in
only a partial return of sensibility. He died on the thirteenth day after
the operation.* In 1827, Tyrrell operated a second time, and death
resulted on the eighth day.* On the 30th of August, 1824, Dr. J.
Bhea Barton, of Philadelphia, operated upon a man who had been
received into the Pennsylvania Hospital twelve days before, with a
fracture of the arch of the seventh dorsal vertebra. On the third day
he was attacked with a violent chill, and death took place twelve hours

» Chelius's Surgery, Amer. ed., note by South, vol. i. p. 693.
• Cline, Chelius^B Surgery, Amer. ed., vol. i. p. 590.
' Sir A. Cooper on Disloc. and Frac., Amer. ed., 1851, p. 479.
Sir A. Cooper's Loc., by Tyrrell, 8d Amer. ed., 1881, vol. ii. p. 17.

* Med.-Chir. Rer., vol. x. p. 601.

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after. The dissection showed about half a gallon of blood in the
posterior mediastinum, and bloody effusion existed along the whole
length of the spinal canal.^ The patient whom Laugier trephined at
the base of the spinous process of the ninth dorsal vertebra, died on
the fourth day.* The operation has been repeated unsuccessfully by
Wickham, Attenburrow, Holscher, Heine, and Roux.'

February 6th, 1884, Dr. David L. Rogers, of New York, operated
upon a man who had fallen two days before, breaking the arch of the
first lumbar vertebra, and forcing the spinous process upon the cord.
This man died on the eighth day.*

In 1854, Dr. Blackman, of Cincinnati, operated, his patient dying
on the fourth day. During the same year also, Dr. B. removed a por-
tion of the sacrum for an injury of four years' standing, with no

Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 17 of 100)