Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

. (page 19 of 100)
Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 19 of 100)
Font size
QR-code for this ebook


noticed in this case, also, that whenever he was turned over upon his
face, respiration almost entirely ceased, but it was immediately re-
stored by laying him again on his back. Many other similar exam-
ples have from time to time come under my notice.

Strains of the Ligaments and Muscles. — Dupuytren, Sir Astley Cooper,
South, and other surgeons have related cases simulating fracture, but
which proved to be straini of the ligaments uniting the cervical ver-
tebrae, accompanied with more or less injury to the spinal marrow.
In one instance, I have met with what has seemed to be a strain of
the ligaments and muscles of the neck, but which presented no symp-
toms of serious injury to the spinal marrow.

John Neuman, of Canada West, sdt 25, fell head foremost from a
height of fourteen feet^ striking upon the top of his head. He was
taken np insensible, and remained in this condition six hours. When
consciousness returned, his head was very much drawn backwards,
and it was impossible to move it from this position. There was no
lack of sensibility or of the power of motion in his limbs, and all the
functions of his body were in their natural state ; but he has suffered
with occasional severe pains in his arms ever since. The accident
happened on the twenty-fourth of November, 1857, and he called
npon me eight months after. His head was then forcibly bent for-
wards instead of backwards, into which position it had gradually
changed. In the morning he generally was able to erect his head
completely, but after a few hours it was constantly drawn forwards,
as when I saw him. There was no tenderness or irregularity over
the cervical vertebrse, and he was so well as to be regularly employed
as a day-laborer.

Concussion, — Sir Astley Cooper has collected four examples of what
he terms "concussion of the spinal marrow," all of which recovered
after periods ranging from a few weeks to many months ; but in only
one case is it stated that the recovery was complete.^ Boyer also
enumerates three cases of concussion which came under his own ob-
servation, all of which terminated fatally in a short time. In the first
example mentioned by Boyer, the autopsy disclosed neither lesion nor
effusion of any kind ; in the second case, it does not appear that any
autopsy was made. The third is related as follows : " A builder fell
from a height of fourteen feet^ and remained for some time senseless;
and, on recovering from that situation, found that he had lost the use
of his inferior extremities. He had at the same time a retention of
urine, an involuntary discharge of the feces, and some disorder in the

' A. Cooper, op. cit., p. 454.



Digitized by



Google



158 FRACTURES OP THE VBRTEBB^.

fuDction of respiration. Death followed on the twelfth day after the
accident. The body was opened, and the vertebral canal -wbs found
to contain a sanguineous serum, the quantity of which was sufficient
to fill a little more than its lower half."^ No doubt some of the cases
reported as concussion were only examples of paralysis from extrava-
sation of blood, a circumstance which is peculiarly likely to bappea
as a result of the rupture of one of those nunlerous large vessels
which surround the vertebrsB outside of the thecsa. It is seldom that
the vessels of the cord itself give out sufficient blood in these cases
to cause compression. Possibly examples of compression as a re-
sult of extravasation of blood may sometimes be recognized hy the
fact of the gradual approach of the paralysis after the lapse of seve-
ral hours, as has occurred recently in a case brought to my notice at
the Bellevue Hospital; and in which recovery finally took place.

4. Treatment of Fracture of the Bodies of the Vertebrx when thefrticiure
occurs in any portion of the column below the Second CervicaL

In a few instances, I have noticed among the recorded examples o£
fractures of the bodies of the vertebrae, that surgeons have made some
slight attempt to reduce the fracture, or rather to rectify the spinal
distortion, generally by the application of moderate extension to the
limbs, and by laying the patient horizontally upon a hard mattress.
But I have not been able to discover that in any case the patients have
derived benefit from the attempt, although it has been said occasionally,
by the gentlemen making the report, that the deformity was slightly
diminished. Nor am I aware that in any instance the patient has suf-
fered any damage from the attempt ; at least the reporter has in no
case thought it necessary to make this observation. I am confident,
however, that such manipulation can seldom serve any useful purpose ;
and I very much fear that it has been frequently a source of mischief.
Although in cases so generally fatal, it might be very difficult to esti-
mate with much accuracy the amount of injury done. If by any
possibility the fragments could be replaced, I know of no means by
which they could be kept in place ; and in truth we are much more
likely to increase the penetration of the spinal cord and the general
disturbance, than to diminish it, by extension or pressure. Moreover,
it usually inflicts upon the unfortunate sufierer great pain, and for
these reasons it ought generally to be discouraged.

I have, however, met with two cases of fracture of the lumbar verte-
brae, in which relief was afforded by permanent extension. When
the fracture is below the middle of the vertebral column, extension, if
employed, should be made by adhesive straps, weights, and a pulley,
as will hereafter be directed in fractures of the femur ; the counter-ex-
tension being made by the weight of the body. It will be understood,
however, that when paralysis exists the ligation of a limb with band-
ages will expose the patient to great danger of ulceration and sloughing

> Boyer, Lecture on Diseases of the Bones, Amer. ed., 1805, p. 55.



Digitized by



Google



FRACTURES OF THE BODIES OF THE VERTEBRA. 159

at and below the points of pressure, and the amonnt of extension mast
be very moderate.

When treating of fractures of the arches of the vertebrae, I took
occasion to call attention to Mr. Cline's operation, occasionally recom-
mended and practised in such cases. I was not ignorant, however,;
that Mr. Gline and several other of the advocates of this operation
bad recommended it especially for fractures of the bodies of the
vertebraB when accompanied with displacement. Even Malgaigne
has preferred to consider the merits of this operation in its relations
to these latter fractures; but while I am prepared to admit the pro-
priety of an argument as to the value of Cline's operation considered
m reierence to fractures of the arches, I cannot admit its propriety in
reference to fractures of the bodies of the vertebrae. The proposition
appears to me too absurd to be entertained for a moment.

The treatment, then, ought to be, in a great measure, expectant.
The patient should be laid in such a position as he finds most com-
fortable, and, as far as possible, the spine should be kept at rest, since
the most trivial disturbance of the fragments, and even that which
may cause no pain to the patient, is liable to increase the injury to
the spine, and prevent the formation of a bony callus. Especially
ought the surgeon to be careful, while making the examination, not to
turn the patient upon his face, in which position the spine loses its
support and a fatal pressure may be produced. The urine should be
drawn very soon after the accident, and at least twice daily for the
next few weeks. Indeed, it is a better rule to draw the urine as often
as its accumulation becomes a source of inconvenience, or whenever
the bladder fills, which will in some cases be as often as every four or
six hours. It is especially necessary to attend to those urgent demands
of the patient during the first few weeks, when the paralysis is most
complete generally, and the mucous surface of the bladder, already irri-
tated and inflamed by the excessively alkaline urine, suffers additional
injury from any degree of painful distension of its walls. It is unneces-
sary to say that the frequebt introduction of the catheter may itself
prove a source of irritation, unless it is managed carefully and skilfully.
This duty ought never to be intrusted to an inexperienced operator.

I do not see what advantage the surgeon can expect to derive from
the administration of drastic purgatives, such as full doses of jalap,
castor oil, or spirits of turpentine, at any period. If in the first
instance the bowels are so completely paralyzed as that they seem to
demand such violent measures to arouse them to action, we may be
quite certain that the spinal cord is suffering from a pressure, or from
some lesion, which these agents have no power to remedy. The
bowels may possibly be made to act, but it would be difficult to show
how this is to relieve the suffering cord. So far from affording relief,
these measures add directly to the nervous irritation and prostration,
provoke vomiting and general restlessness. It is not desirable, we
think, to obtain a movement of the bowels during the first few days
by any means, however gentle. The effort to defecate, and the conse-
quent motion, will probably do much more harm than the evacuation
can do good ; and especially, for the same reason, ought we to avoid



Digitized by



Google



160 FRACTURES OF THE VERTBBRJB.

putting into the stomacH anything which will occasion nangea and
yomiting.

After the lapse of a few days, if reasonable hopes begin to be enter-
tained of a recovery, it will become important to establish regular
evacuations of the bowels, either by a judicious management of the
diet, by gentle laxatives, or by enemata. At a still later period, when
the inflammatory stage is past, and the nerves remain inactive or .para-
lyzed, nothing could be more rational than the employment of strych-
nia in doses varying from the one-twelfth to the one-eighth of a grain
three times daily. Nor do I think that any single remedy has more
often proved useful in my own practice, or in the practice bf other
surgeons with whom I am acquainted. In order, however, to derive
benefit from this or from any other remedy, it must be continued for
a long time ; perhaps for a year or more. Electricity, setons, issues^
and blisters are no doubt also sometimes useful. Care must be taken
that setons, &c., do not produce bed-sores. Passive motion and fric-
tions, good fresh air, and nourishing diet, become at last essential to
recovery. From an early period, and during the whole course of the
treatment, great attention should be paid to the prevention of bed-
sores, by supporting all those parts of the body upon which the
pressure is considerable. For this purpose we may employ circular
cushions, air-cushions, and air-beds ; but water-beds are very much
to be preferred to air-beds as a means of preventing bed-sores. Water-
beds must be filled with water of the temperature of 68^ Fahrenheit^
and they must be secured in position by side boards, or a kind of
shallow box, the sides of which are elevated six or seven inches. Perma-
nent extension can be employed upon these beds as well as upon ordinary-
beds. Sometimes a section of a bed, three feet square, is found quite
as serviceable as an entire bed, inasmuch as the back and nates are the
only parts which are liable to bed-sores. They may be obtained from
the manufacturers, Hodgman & Co., corner Nassau St. and Maiden
Lane, New York city, at prices ranging from $15 to $25. Of late
we have found the wire-beas, manufactured at 59 Pearl St., Hartford,
Conn., excellent substitutes for water-beds. They are less expensive,
more easily managed, more durable, and admit of a much better regu-
lation of the temperature. Whether they are quite as efficient in the



Fig. 86.




Wli«.bed.



prevention of bed-sores as water-beds, I cannot say positively, but
they have been much used under my observation at Bellevue and in
the hospital for Ruptured and Cripples, and I have seen no bed-sores
occur where they were in use.

When sores have formed, they should be treated, if sloughing, with
yeast poultices, or the resin ointment I find also the resin ointment



njgitized by



Google



FBACTURSS OF THE AXIS. 161

an excellent dressing for the sores after the slooghs have separated.
In case the surface is only slightly abraded, simple cerate forms the
best application.

§ 5. FaAOTUBXS OF THB Axis.

The phrenic nerve is derived chiefly from the third and fonrth cer-
vical nerves. If, therefore, the second cervical vertebra is broken,
and considerably depressed upon the spinal cord, respiration ceases
immediately, and the patient dies at once, or survives only a few
minutes. In such examples of fracture of this bone as have not been
attended with these results, the displacement and consequent compres-
sion have been inconsiderable, or there has been no displacement at all.

Mr. Else, of St. Thomas's Hospital, says that a woman in the vene-
real ward, and who was then under a mercurial course, while sitting in
"bed, eating her dinner, was seen to fall suddenly forwards ; and the
patients, hastening to her, found that she was dead. Upon examina-
tion of her body, it was discovered that the processus dentatus of the
axis was broken off, and that the head in falling forwards had driven
the process backwards upon the spinal marrow so as to cause her death.^

Sir Astley also relates the case of a man who was shot by a pistol
through the neck, breaking and driving in upon the spinal marrow
both the " lamina and the transverse process" of the axis. He died
on the fourth day.*

Malgaigne has collected three cases of fracture of the odontoid
apophysis, all of which were accompanied with a displacement of the
atlas. The first, reported by Richet, died on the seventeenth day ;
the second, reported by Palletta, died after one month and six days ;
and the third, by Oostes, lived four months and two weeks.

Bokitansky says that there is a specimen contained in the Vienna
Museum, taken from a patient who survived the accident some time,
although the fragments never united.

The following case is reported by Parker: —

" The patient, Mr. G. B. Spencer, was a man forty years of age, a
milkman by occupation, of medium height, nervo-sanguine tempera-
ment, of active business habits, and capable of great endurance. His
life was one of constant excitement, and he was addicted to the free
use of liquors. He suffered, however, from no other form of disease
than occasional attacks of rheumatism, for which he was accustomed
to take remedies of his own prescribing, which were generally mer-
curials followed by liberal doses of iodide of potassium, ' to work it
all out of the system.'

"On the 12th of August, 1852, while driving a 'fast horse' at the
top of his speed on the plank road near Bushwick, L. I., he was thrown
violently from his carriage by the wheel striking against the toll-gate.
He alighted upon his head and face about fifteen feet from the carriage.
Upon rising to his feet he declared himself uninjured, but soon after

> Else, A. Cooper on Disloc., Ac, op. dt., p. 483.
* A. Cooper on Disloc., etc., op. dt, p. 476.



Digitized by



Google



162 FRACTURES OP THB VBRTEBRJB.

complained of feeling faint; after drinking a glass of brandy he felt
better, got into his carriage with a friend, and drove home to Riving-
ton Street in this city, a distance of more than two miles. There was
so little apparent danger in his case, that no physician was called that
night. Early on the morning of the following day, Dr. B. was called
to visit him. He found his patient reclining in his chair, in a restless
state, and learned that he had suffered considerable pain in the back
part of his head and neck during the night. He was entirely incapaci-
tated to rotate the head, which led to the suspicion of some injury to
the articulations of the upper cervical vertebr» ; but so great a degree
of swelling existed about the neck as to prevent efficient examina-
tion. There was no paralysis of any portion of the body, his pulse
was about 90, and his general system but little disturbed. Warm
fomentations were applied to the neck, and a mild cathartic adminis-
tered. On the following day there was no particular change in his
symptoms, but as there existed considerable nervous irritability, tinct.
hyoscyami was prescribed as an anodyne, and fomentations of hops
applied locally. On the third day, leeches were applied to the neck,
and after this the swelling so much subsided, that on the fifth day an
irregularity was discovered to exist in the region of the axis and atlas,
which had many of the features of a partial luxation of these vertebras.

"At this time he began to walk about the room, having previously
remained quiet on account of the pain he suffered on moving. He
persisted in helping himself, and almost constantly supported his head
with one hand applied to the occiput. He often remarked, if he could
be relieved of the pain in his head and neck, he should feel well. He
began to relish his food, and the swelling nearly disappeared at the
end of a week, leaving a protuberance just below the base of the
occiput, to the left of the central line of the spinal column, with a
corresponding indentation. Notwithstanding strict orders to remain
quietly at home, on the ninth day after the accident he rode out, and
in a day or two after returned as actively as ever to his former occu-
pation of distributing milk throughout the city to his old customers.
During the following four months no material change took place in
his symptoms, although he constantly complained of pain in his head.
For this period he did not omit a single day his round of duties as a
milkmaU; which occupied him constantly and actively from five
o'clock in the morning to nearly noon. On the first of November,
Prof. Watts examined bim, and inclined to the opinion that there was
a luxation of the upper cervical vertebr».

"About the first of January, 1853, the pains, from which he had
been a constant sufferer, became more severe, and he was heard to
complain that he could not live in his present condition ; he remarked,
also, that he had heard a snapping in his neck. After going his daily
round on the eleventh of January, be complained of feeling cold, and
afterwards of numbness in his limbs. In the evening he bad a chill,
and complained of a pain in his bowels. He passed a restless night,
and arose on the following morning about six o'clock ; he was obliged
to have assistance in dressing himself, and experienced a numbness of
his left, and afterwards of his right side. He attempted to walk, but



Digitized by



Google



• FRACTURES OP THE AXIS. 163

could not without help, and it was observed that he dragged his feet.
He sat down in a chair and almost instantly expired, at 8 o'clock
A. M., on the 12th of January, precisely five months from the receipt
of the injury.

"The autopsy was made thirty hours after death, by Dr. C. E.
Isaacs, in presence of several medical gentlemen. Muscular develop-
ment uncommonly fine. An unusual prominence discovered in the
region of the axis and atlas. On making an incision from the occiput
along the spines of the cervical vertebrae, the parts were found to be
very vascular. These vertebrae were removed en masse, and a care-
ful examination instituted. -The transverse, the odontoid (ligamenta
moderatoria), as also all the ligaments of this region, excepting the
occipito-axoideum, were in a state of perfect integrity ; this latter
was partially destroyed. A considerable amount of coagulated blood
was found effused between the fractured surfaces, some of it apparently
recent, but much of it was thought to have oc-
curred at the time of the accident, and after- iFig. 87.
wards to have prevented the union of the bones.
The spinal cord exhibited no appearances of any
lesion. The odontoid process was found in the
position well represented in the accompanying
illustration, completely fractured off, and its
lower extremity inclining backwards towards
the cord. Death finally took place, doubtless,
from the displacement of the process during
some unfortunate movement of the head, by
which pressure was made upon the cord. The
destruction of the occipito-axoid ligament,
which would otherwise have protected the
contents of the spinal cavity, must have fa-
vored this result."^ Practure of the odontoid pro-

Dr. Philip Bevan presented to the Surgical rB™L«"';«I:'t'<Z:
Society of Ireland, m 1862, a specimen ob- toid process,
tained from the dead-room, and which was sup-
posed to be an epiphyseal separation of the odontoid process, occur-
ring in early life. The history of the case is not known, although
the woman was forty years old when she died. It does not appear
very clear to us whether this was really an epiphyseal separation, or
the result of some morbid process.^

At the meeting of the New York Pathological Society, Nov. 12,
1868, Dr. Austin Flint presented a case of separation of the odontoid
process of the axis.

Dr. W. Bayard, of St. John, N. B., has, however, reported a case of
separation of the odontoid process in a child, followed by complete
recovery. In August, 1864, Charlotte Magee, of St. John, aet. 6 years,
previously in excellent health, fell five feet, striking on her head and

" Bigelow, New York Joum. Med., March, 1853, p. 164.
« Bevan, Am. Joum. Med. Sci., April, 1864. From Dublin Med. Press, Feb. 18,
1863.



Digitized by



Google



164 FRACTURES OF THE VSRTEBR^.

neck, causing an immediate immobility of the head, which continned
about two years and a half, when an abscess formed in the back of
the pharynx, and the bone was spontaneously discharged. Since
then she has been able to move the head freely, and her recovery may
be said to be complete.^ The specimen was subsequently presented
to the N. Y. Pathological Society, and no doubt remains that the en-
tire process was thrown off.

Dr. Stephen Smith has kindly furnished me with a risumi of a pa-
per he is now preparing for the presa» upon the subject of fractures
of the odontoid process. He has already collected nineteen cases, and
he does not think the enumeration is yet complete.. The ages of the
patients range from 8 years to 68. Three recovered ; one of whom was
the girl Magee, to whom reference has been made, afte^ the separation
and escape of the odontoid process ; the second was a person aged 38,
in which case the body of the axis was discharged, and the process
was retained ; the particulars of the third case are not given. Two
are recorded as sudden deaths ; three lived five days, and the remain-
der survived several weeks or months, one dying so long as twenty-
seven months after the fracture. Of the whole number, tyiro were dis-
secting-room subjects, and the histories are not known.

§ 6. Fragtubxs of thb Atlas.

I have been able to find only one example of a fracture of the atlas
alone, and this is the case .related by Sir Astley Cooper as having
come under the observation of Mr. Cline.

A boy, about three years old, injured his neck in a severe fall; in
consequence of which he was obliged to walk carefully upright, as
persons do when carrying a weight on the head ; and when he wished
to examine any object beneath him, he supported his chin upon his
hand, and gradually lowered his head, to enable him to direct his
eyes downwards. In the same manner, also, he supported his head
from behind in looking upwards. Whenever he was suddenly shaken
or jarred, the shock caused great pain, and he was obliged to support
his chin with his hands, or to rest his elbows upon a table, and thus
support his head. The boy lived in this condition about one year,
and after death Mr. Cline made a dissection, and ascertained that the
atlas was broken in such a manner that the odontoid process of the
axis had lost its support, and was constantly liable to fall back upon
the spinal marrow.'

§ 7. Fractures of the First two Cervioal Yertedrjb (Atlas and
Axis) at the same time.

A woman, set 68, fell down a flight of steps, striking upon her fore-
head, and died immediately. Upon making a dissection, it was found
that the atlas was broken upon both sides near the transverse pro-

> Bayard, Canada Med. Joum., Deo. 1869.
* Cline, Sir Astley Cooper, op. cit., p. 459.



Digitized by



Google



7BACTUBES OF THE STEBNUM. 165

cesses, and the odontoid process of the axis was broken at its base^
These fractures were accompanied with a rapture of the atloido-odon-



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 19 of 100)