Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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benefit.* In 1858, Dr. Stephen Smith, of Bellevue, removed the arch of
the tenth dorsal vertebra, death occurring soon after.^ December 29th,
1857, ten days after the receipt of the injury, Dr. J. 0. Hutchinson,
of Brooklyn, operated upon a man at the City Hospital, Brooklyn,
removing the spinous processes of the eighth, ninth, and tenth dorsal
vertebrae, with the posterior arch of the latter. The patient survived
the operation ten days.' Ballingall says, a Dr. Blair has operated
successfully, but no particulars are given.

Dr. H. A. Potter, of Geneva, N: x., informs us that he has operated
three times. In the first case he states that he removed the posterior
portion of the three lower cervical vertebras. The patient died on the
fourth day. In the second case the doctor removed the spinous pro-
cesses of the fifth and sixth cervical vertebrae, and the entire posterior
arch of the fifth. The sheath was not broken, ''but the cord was much
injured." There was almost complete paralysis of the extremities,
and this condition was not remedied by the operation. Three years
later, the patient being still alive, but only a very slight improvement
having taken place, Dr. Potter ** removed the fourth, sixth, and seventh
cervical vertebrae." (We presume he intends to say the " posterior
arches.") At the time of the report, Jan. 1863, there was no further
improvement. Finally, the doctor reports a completely successful
case. The injury was of " five months' standing."* Packard says, in
a note to his translation of Malgaigne, that Dr. Potter operated on a
case of three months' standing, and the patient died on' the eighteenth
day. I suppose this to be the same case.

These are all of the cases of which we have any information in
which this operation has been made, and they have all, excepting the
two cases reported by Potter and the one by Blair, terminated fatally

1 Barton, Godman^s ed. of Sir A. Cooper on Disloc., &c., p. 421.
« Malgaigne, Amer. ed,, p. 341.

* Cheliurs Surgery, Amer. ed., vol. i. p. 590. Also, Velpeau's Op. Surgery, Ist
Amer. ed., vol. ii. p. 787.

< Rogers, Amer. Joum. Med. Sd., May, 1835.

* Yelpeau'B Surgery, Blackman's ed., vol. ii. p. 392 ; also, Dr. Hutchinson's
Paper, Trans. N. Y. St. Med. Soc, 1861.

^ New York Joum. Med., 1859, p. 87.

' Hutchinson, Trans. N. Y. Med. Soc, 1861, p. 98.

* Amer. Med. Times, Jan. 10, 1863.

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in a very few days. The case reported by Alban G. Smith, of
Kentucky, is not related in such a manner as to enable us to make
use of it safely, nor is it stated how long the patient survived the
operation ; Gibson says it gave no permanent relief. The example
mentioned by an English writer is equally unreliable, inasmuch as it
is given only upon rumor, and but a " few months" had elapsed since
the operation was performed. It was said to have been made in tbe
year 1888, by a surgeon of the name of Edwards, in South Wales;
and it was affirmed that the compression was relieved and that the
patient " did well."^ So unique a case would certainly have found
before this an ample confirmation. Indeed, we must say that none of
the cases reported as successful give any evidence of authenticity.

Experience, then, seems to have shown that we have little or nothing
to expect from this surgical expedient; and, notwithstanding the
strong hope expressed by Sir Astley that Mr. Cline^s operation might
hereafter prove a valuable resource, and contrary to the conclusions
which we in common with many other surgeons had drawn from the
anatomical relations of these parts, we are compelled reluctantly to
declare that the expedient is scarcely worthy of a trial. To the same
conclusion also many of the most distinguished surgeons have arrived;
among whom we may mention, as especially entitled to confidence,
Brodie, Listen, i^lexander Shaw, Malgaigne, and Gibson.

What more can be said of the attempt to raise the depressed bone
by seizing the spinous process with the fingers, or with a pair of strong
hooked forceps passed through the skin, or finally, if this cannot be
done, by laying oare both sides of the process and seizing upon it
with a pair of firm tenacula ? This is the alternative presented to
Malgaigne, and which he ventures to recommend as deserving a trial.
In the absence, however, of any testimony in its favor, beyond the
mere rational argument adduced by this distinguished writer, we must
waive any farther consideration of the subject; only expressing our
conviction that it will be found, after a fair trial, as useless and as
inexpedient as the more severe operation of Gline.

Jeffries Wyman, of Boston, has met with eleven examples of frac-
tures of the vertebral arches occurring in the fourth or fifth lumbar
vertebras between the lower articulating and the transverse processes,
all of them old, ununited fractures. Be has also met with the same
fracture once in the third lumbar vertebra. The frequency of this
peculiar form of fracture in this region Dr. Wyman ascribes to the
fact that the upper and lower articulating processes are widely sepa-
rated from each other, and connected only by a narrow neck, in which
respect they contrast very strongly with the dorsal vertebras ; and he
supposes that the fractures may be caused by either a forcible bend-
ing of the body backwards, or by the shock resulting from a fall from
a height in which the force of the concussion is conveyed downwards
through the pelvis. In no case has the existence of this fracture been
recognized during life, nor is it probable that its occurrence would

> Edwards, British and Foreign Med. Rev., 1838, p. 162.

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cause any marked symptoms unless it had been caused by a blow re-
ceived directly from behind.'

As to the therapeutical treatment of the various symptoms belong-
ing to these accidents, and in relation to the prognosis, the remarks
which we shall make will be found equally applicable to fractures of
the bodies of the vertebrad, and we shall reserve the consideration of
these topics for the following section.


The same causes which produce fractures of the arches may produce
also fractures of the bodies of the vertebrsd, that is, blows received
directly upon the extremities of the spinous processes ; but in these
cases the arches are generally broken at the same time.

In other cases the bodies of the vertebrad are broken by falls upon
the top of the head, by which the vertebrsd are not only driven forci-
bly together, but often doubled forwards upon each other ; <}r the
patient may have alighted upon his feet or upon his sacrum.

Beveillon has reported a case of fracture of the fifth cervical verte-
bra from muscular action, which occurred in diving. The man was
taken out of the water unconscious, and died in a few hours, having
declared before death that his head did not strike the bottom, although
he had jumped from a height of seven or eight'feet, and the water
was only three feet deep.* The statement of the sufferer, under such
circumstances, could not really possess much value, and we think we
see good reasons to suppose that he was mistaken. South also relates
a case of fracture of the fourth and fifth cervical vertebras occasioned
by diving, in which it was supposed that the fracture was caused by
the concussion of the head upon the water.'

Malgaigne says the spine bends at three principal points ; comprised,
the first between the third and seventh cervical vertebrae, the second
between the eleventh dorsal and second lumbar, the third between the
fourth lumbar and the sacrum ; and that a majority of the fractures of ^
the vertebras occur at these points of fiexion. He makes an argument
from this also that these fractures '' are generally the result of counter-
strokes as the effect of forcible flexion of the column either forwards
or backwards." Malgaigne observes, moreover, that dislocations follow
the same rule.

The direction of the line of fracture varies greatly in the different
examples which we have seen ; some are crushed, and more or less
comminuted. In some cases a narrow piece is chipped from the mar-
gin, others are broken transversely, and others obliquely. In oblique
fractures the line of the fracture is generally from behind forwards
and from above downwards. Malgaigne thinks that a crushing or
comminution can only occur from a forcible flexion forwards; but I
have seen at least one example in which this was not the fact ; the

> Wyman, Boston Med. and Barg. Joam., Aae. 12, 1869.
« Reveillon, Chelins's Burg., note by Soath, vol. i. p. 584.
• South, ibid., p. 588.

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patient having fallen so as to strike with the back of his neck upon
an iron bar. This was the case of the sailor, to which I shall again
refer more particularly.

The upper fragment is almost always that which suffers displace-
ment; sometimes being simply driven downwards, and thus made to
penetrate more or less the lower fragment; at other times, as in cer-
tain transverse fractures, it is only displaced forwards, and in still
other examples, where the fracture is oblique, the upper fragment is
displaced both downwards and forwards.

In the first and last of these examples the spine becomes bent for-
wards at the point of fracture, producing an angle of which the most
salient point posteriorly is represented by the
Fig 34. extremity of the spinous process belonging

to the broken vertebra; in the second example
the spinous process of the broken vertebra is
depressed, and the process of the vertebra
next below is relatively prominent.

In a pretty large proportion of cases also
the fracture- of the body of the vertebra is
complicated, as we have already stated, with
a fracture of the arches, in some instances
with a fracture of the oblique processes, and
with a dislocation.

Symptoms, — Severe pain at the seat of frac-
ture, felt especially when the part is touched
or the body is moved, tenderness, swelling,
^ , ecchvmosis, occasionally crepitus, a slight

Oblique fracture of the bod J -. j- . *• c j.v^ ' • i

ofarertebm. angular drstortiou of the spine, or simply a

trifling irregularity in the position of the pro-
cesses, and paralysis of all the parts whose nerves take their origin
below the fracture, are the usual signs of the accident.

The paralysis may be due to the mere pressure of the displaced
fragments, but it is much more often due to a severe and irreparable
lesion of the cord itself. I have, in one instance, seen the cord almost
completely separated at the point of fracture, although the displace-
ment of the fragments was inconsiderable.

Accompanying the paralysis of the bladder, there has been generally
observed an alkaline state of the urine, and subacute inflammation of
the coats of the bladder. Priapism is present in a certain proportion
of cases.

Those who die immediately seem to be asphyxiated ; while those
who die later seem to wear out from general irritation, this condition
being frequently accompanied with an obstinate diarrhoea and vomit-
ing. A few become comatose before death.

It will be seen, moreover, that a certain proportion finally recover;
but scarcely ever are all the functions of the limbs and of the body
completely restored.

We shall render this part of our description of these accidents more
intelligible if we regard them as they occur in the various portions of

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the spinal colamn, since the symptoms, prognosis, and treatment have
reference mainly to the point at which the fracture has occurred.

1. Fracture of the Bodiee of the Lumbar Vertebras.

The spinal cord terminates, in the adult, at the lower border of the
first lumbar vertebra, but in the child at birth it extends as low as
the third lumbar vertebra. The remainder of the vertebral canal is
occupied by the leash of terminal nerves, called collectively the cauda

The nerves which emerge from the intervertebral foramina below
the fourth and fifth lumbar vertebras, nnite with the sacral nerves to
form a plexus which supplies the sphincter and levator ani, the peri-
neal muscles, the detrusor and accelerator urinaB, the urethra, the
glans penis, and a great proportion of the lower extremities. It will
be apparent, therefore, that a fracture, with dbplacement, of even the
last vertebra of the column, involves the possibility of more or less
paralysis of all those parts supplied by this plexus, and that in pro-
portion as the fracture is higher in the vertebral column, will the pro-
oability of additional complications be increased. In other words, in
addition to the more or less complete loss of function in the organs,
supplied by the ilio-sacral plexus, there will probably be associated
loss of function in other organs, supplied from sources above this
point of the vertebral canal.

A fracture, however, of the bodies of the fourth or fifth lumbar
vertebra, produced by a direct blow, is exceedingly rare, owing to
the protection which it receives from the alee of the pelvis.

Dr. Alexander Shaw has reported four cases of fracture below the
second lumbar vertebra, which were unaccompanied with any degree
of paralysis, and which were followed by speedy recovery,* a circum-
stance which he ascribes to the fact that the cauda equina is composed
of nerves possessing considerable firmness, and suspended loosely
t<^ther; for this reason they escape pressure by slipping among
themselves, and suffer less injury from the same amount of compression
than the medulla spinalis.

In the two following cases the results were less fortunate, yet reco-
Yeries seem to have taken place.

A boy was admitted into St. George's Hospital, in Sept. 1827, with
a fracture and considerable displacement of the third and fourth lum-
bar vertebrae, the displacement being sufiicient to cause a manifest
alteration in the figure of his spine. His lower limbs were paralytic.
An attempt was made to restore the displaced vertebrae, but it was
attended with only partial success. At the end of a month he had
slight involuntary motions of the lower extremities, and at the same
time he began to recover the power of using them voluntarily. Three
or four months after the receipt of the injury he left the hospital, and
the history of his case was interrupted at this date.'

Dr. Thompson, of Gteshen, N. Y., reports, also, a fracture of either

> Shaw, London Med. (}az., vol. xrli.
' Brodie. Sir Aat. Cooper on Disloc., op. cit, p. 471.

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the third or fourth lumbar vertebra, followed by recovery. The
patient fell from the roof of a house, striking first upon his feet and
then upon his buttocks. This occurred in October, 1853. The usual
signs of a fracture were present, such as paralysis, &o. A bed-sore
formed above the top of the sacrum, and a piece of bone exfoliated
which seemed to belong to the last lumbar vertebra. He was con-
fined to his bed seven months. After eighteen months he began to
use crutches. At the end of about three years
^S' 36. all improvement ceased ; at which time he could

not quite stand alone, yet with the aid of appa-
ratus he was able to get about the country and
vend books, prints, &c. This was also his con-
dition one year later.^

A patient in Guy's Hospital, under Mr. Key,
with a fracture of the first lumbar vertebra,
lived one year and two days. On examination
after death it was ascertained that bony union
had occurred between the fragments, and that
the spinal marrow was completely separated at
the point of fracture.*

Mr. Harrold relates a case of fracture of the
first and second lumbar vertebras, in which the
patient survived the accident one year lacking
frfunmbl^Tert'Ib™"'' *'''*'* nine day s; death having resulted finally from
/ a sore on the tuberosity of the ischium and

disease of the bone. After death it was ascertained that the fracture
had united by bone, and that the spinal marrow was almost com-
pletely cut in two, the divided extremities being enlarged and sepa-
rated nearly an inch from each other.*

2. Fractures of the Bodies of the Dorsal Vertebrae,

In these examples the same organs are paralyzed as in the fractures
lower down, in additioA to which there is generally considerable dis-
turbance of the functions of respiration, irregular action of the heart,
indigestion accompanied with a tympanitic state of the bowels.

Dupuytren, who reports several examples of fractures of the dorsal
vertebrae, has not taken the pains to record the length of time they
survived the accident except in two instances, both of which were
fractures of the eleventh vertebra. One died of suffocation on the
tenth day, and the other on the thirty-second. In Sir Astley Cooper's
cases, mention is made of a fracture of the twelfth dorsal vertebra,
which the patient survived fifty-two days, one of the tenth dorsal,
which terminated fatally in six days, and another of the ninth dorsal,
which did not result in death until after nine weeks.

In 1853 Dr. Parkraan presented to the Boston Society for Medical
Improvement a specimen of fracture of the fifth dorsal vertebra, the

> Thompson, Amer. Joum. Med. Sci., Oct. 1857. Lente^s paper.
« Key, A. Cooper on Disloc, Ac, op. cit., p. 467.
* Harrold, A. Cooper, op. cit, p. 464.

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bodies of the third and fourth being also displaced forwards, in which
position thej had become firmly ossified. The spinal cord had been com-
pletely separated, yet the patient survived the accident two months.*
Dupuytren has related also two examples of fractures, one of the
tenth and the other of the last dorsal vertebra, from which the patients
completely recovered after from two to four months' confinement.' A
similar case is related by Lente, of New York. Barney McGuire,
having fallen a distance of twelve or fifteen feet upon his back, was
found with nearly complete paralysis of his lower extremities, and of
bis bladder. Swelling existed over the lower dorsal vertebraa, and
tbis point was very tender. Subsequently, when the swelling subsided,
the prominence of the spinous processes of the tenth and eleventh
dorsal vertebra put the question of a fracture beyond doubt. Gradu-
ally, under the use of cups, strychnia, mineral acids, laxatives, buchu,
and electricity, his symptoms improved. In six months he was able
to walk about the streets, and four years after the accident he was
employed in a foundry under reguiar wages, being able to stand fif-
teen or twenty minutes at a time, and to walk half a mile without
resting. At this time there remained no tenderness in the spine, but
the projection of the^ process was the same as at first^

3. Fractures of the Bodies of the five lower Cervical Yertebrse.

We shall now have added to the symptoms already enumerated,
paralysis of the upper extremities, greater embarrassment of the res-
piration, and more complete loss of sensation and volition in the lower
part of the body. In general, also, the eyes and face look congested,
owing to the imperfect arterialization of the blood, and death is more
speedy and inevitable.

In ten recorded examples of fractures of the five lower cervical
vertebrad which I have been able to collect, one died within twenty-
four hours, four in about forty-eight hours, one in eleven days, one
lived fifteen weeks and six days, one about four months, one fifteen
months, arid one, reported bv Hilton, survived fourteen years.* The
most common period of death seems therefore to be about forty-eight
hours after the receipt of the injury.

The example of the patient who survived the accident fifteen" weeks
and six days, is recorded by Mr. Greenwood, of England. A woman,
Mary Vincent, »t. 47, was injured by a blow on the back of her neck,
but she was not seen by Mr. Greenwood until after eleven days, at
which time she was breathiiig with difficulty, occasioned by paralysis
of the intercostal muscles, respiration being carried on by the dia-
phragm and abdominal muscles alone. This was the extent of the
paralysis. There seemed to be a depression opposite the fourth and
fifth cervical vertebrae, and pressure at this point occasioned universal
paralysis, as did also the action of coughing and sneezing. About

> Parkman, New York Joum. Med., March, 1853, p. 386.
« Dupuytren, op. dt., pp. 866-7.
• Lente, Amer. Journ. Med. Sci., Oct. 1857, p. 361.
« HiHon, Lond. Lancet, Oct. 27, 1860.

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three weeks after the accident, she attempted for the first time to move^
in order to have her clothes changed, when she was immediately seized
with paralysis in the right arm and hand. After this she lost her appe-
tite, had frequent attacks of parging, and thas she gradually wore out.^

The patient who surviyed about four months was admitted into
H6tel Dieu, under the care of Dupuytren, in 1825, on account of a
fracture of the fourth cervical vertebra, caused by a fall on the back
of his neck, and suffering under paralysis of the bladder and extremi*
ties. After two months and a half of entire rest, he was convalescent
and quitted the hospital, with only slight weakness in his left leg, and
with his head a little bowed forwards. In returning from a long walk
he fell paralyzed, and remained in the open air all night. From this
time he continued to fail, and died thirty-four days after the second
fall. On examination after death, the body of the vertebra wag
found to be broken, and also the processes of the fifth, allowing the
fourth to slip forwards and compress the cord. A true callus existed
in front of these bones, which looked as if recently broken. The cord
itself exhibited an annular constriction, which Dupuytren conceived
to be the seat of the original lesion narrowed by cicatrization.'

The following example furnishes a fair illustration of the usual
phenomena which accompany fractures of the third or fourth cervical

On the 25th of July, 1857, a sailor fell backwards from the wharf,
striking with the nape of his neck upon a bar of iron. I saw him on
the following day, in consultation with his attending physician. Dr.
Edwards. He was lying upon his back, breathing rapidly. His
lower extremities were completely paralyzed ; legs and feet swollen
and purple; right arm completely paralyzed, and his left partially;
from a point below the line of the second rib, there was no sensation
whatever ; his bowels had not moved, although he had already taken
active cathartics; the urine had been drawn with a catheter; the pulse
was slower than natural, and irregular. He was constantly vomiting.
In reply to questions, he said that he felt well, articulating distinctly
and with a good voice. His eyes and face were somewhat congested,
but with this exception his countenance did not betray the least phy-
sical disturbance. He lived in this condition about forty hours, only
breathing shorter and shorter, and his consciousness remaining to the
last moment.

In proceeding to examine the spine a few hours after death, and
before any incision was made, we were unable, upon the most minute
examination, to detect any irregularity of the processes of the cervi-
cal vertebrae, or any crepitus ; but^ on dissecting the neck, we found
that the arches of the third and fourth vertebrae were broken, and
the spinous processes slightly depressed upon the cord. The bodies
of the corresponding vertebrae were comminuted, and the vertebras
above were driven down upon them, carrying the processes in the same
direction. The theca and the spinal marrow were almost completely
severed upon a level with the foarth vertebra.

* Oreenwood, Sir A. Cooper on Disloc, p. 472.
« Dupuytren, Qp. cit., p. 858.

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•A roan residing in Erie Co., N. Y., was thrown backwards suddenly
from the back end of a wagon, alighting upon the top of his head.
Dr. Mixer having requested me to see this patient with him, I found
the symptoms almost an exact counterpart of those which belonged
to the case which I have just described, except that a crepitus and a
mobility of the fragments could be distinctly felt in the upper and
back part of his neck. His death occurred in very much the same
xoanner after about forty-eight hours. No autopsy was allowed. We

Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 18 of 100)