Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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out fracture of the articular processes; or, if those processes remain
unbroken, without a fracture through the bodies of the vertebrse."
He would not, however, be understood to deny the possibility of a
dislocation of the cervical vertebra, their articular processes being
placed more obliquely than those of the other vertebrad.

The accident is, no doubt, exceedingly rare, at least without the
complication of a fracture, and it is not improbable that the actual
number is smaller than the reported examples would indicate. Those
who make autopsies do not always perform their duties with that
exact fidelity which might be necessary to determine so nice a point
as a fracture of an oblique process, and it is quite likely that the cir-
cumstance may have been overlooked in some cases ; but a consider-
able number of well-authenticated examples of simple dislocations of
cervical vertebrae have accumulated within the last fifty years. The
reported examples of simple dislocations of the other vertebrsd are
not so numerous, nor as well attested.

The causes are in general the same with those which produce frac-
tures of the vertebrsB, such as falls upon the head, feet, or back, and
violent fiexions of the spine backwards or to the one side or the other.

Several examples are recorded of *' spontaneous" dislocations, the
result of some morbid changes in the bones or in the ligaments of the
spinal column; which accidents seem to belong more properly to
general treatises upon surgery.

The symptoms, also, partake of the same general character with
fractures ; the accident being accompanied with more or less complete
paralysis of those portions of the body which receive their nervoas
supply from below the point at which the dislocation has occurred;
the spinal column presenting at the seat of displacement an angular
projection or some form of irregularity; and the distortion being
attended with pain, especially when an attempt is made to move the
body.

In very many cases the symptoms are so nearly like those presented
in a case of fracture, that the diagnosis is rendered exceedingly diffi-
cult. The presence or absence of crepitus may aid in the diagnosis,
and yet it is well understood that this symptom is often absent in



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DISLOCATIONS OF THE LUMBAR. VBBTEBB^. 509

simple fractures, and that it may be present in all those examples of
dislocation which are accompanied with a fracture of an oblique pro-
cess, or of any other portion of the vertebrso, which class of examples
constitutes a large majority of the whole number.

There is usually present^ however, in the dislocation, whether partial
or oomplete, a peculiar fixedness or rigidity of the spine, which serves
to distinguish this accident from a fracture of the spine as plainly as
the preternatural rigidity of the limb in dislocations of the long bones,
serves to distinguish these accidents from fractures of the same bones.
The head or upper portion of the spinal column is bent forwards, or
backwards, or more commonly to one side, and in this position it
remains immovably fixed until the reduction is accomplished. Some-
time also, the surgeon may feel distinctly the lateral deviation of
the spinous process, and, in the' neck, the transverse processes become
an important guide in the diagnosis.

After these few general remarks, I shall proceed to speak of disloca-
tions of the spine in the same order in which I have treated of fractures
of the spine.

§ 1. Dislocations of thb Lumbar YsaTSBRiB.

Sir Astley Cooper plainly intimates that he does not believe a dis-
location can occur in either the dorsal or lumbar region without the
concurrence of a fracture, and Boyer affirms positively that it is
"entirely impossible."

Without wishing ourselves to insist upon the actual impossibility
of these accidents, we are prepared to affirm that no well-authenticated
case has yet been reported ; at least of a complete dislocation, unac-
oompani^ with a fracture of the articulating apophyses. We can
evea conceive it possible that 'a lumbar vertebra may be dislocated
forwards or backwards, and that a dorsal vertebra may be dislocated
laterally, without a fracture ; yet we hardly think either of these events
probable. What we urge, however, is that no evidence appears to be
famished that such a dislocation has actually occurred.

Cloquet mentions the case of a " tiler" who fell from the roof of a
house backwards, and dislocated one of the lumbar vertebrae. This
patient lived many years after the accident, and at the autopsy it was
found that the second lumbar vertebra had been luxated to the right
by a movement of rotation about the left articular process, the two
oblique processes of the left side preserving their connection, while
those of the right were separated quite half an inch. The right verte-
bral plate was broken, and the canal of the vertebra was thus thrown
open and widened.^

Dupuytren says that a man was crushed by the falling of a bank of
earth upon his loins, when in the act of bending forwards. On the
third day he was brought to Hdtel Dieu, when it was observed that
his lower extremities were completely paralyzed; and that there
existed in the upper part of the lumbar region a hard tumor, by pros-

* Cloquet, Halgugne, from Joum. des DiflTormit^s de Maisonabe, torn. i. p. 458.



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510 DISLOCATIONS OF THE SPINE.

sure upon which a crepitus was manifest. A second tumor coald be
distinctly felt in front through the abdominal parietes, and the length
of the spine was evidently diminished. This man died on the sixUi
day from a gradual asphyxia. When the body was examined it was
found that the last dorsal and first lumbar vertebraa had been poshed
forwards more than one inch, lacerating the spinal marrow, breaking
the transverse and oblique processes of the last dorsal and first two
lumbar vertebrae, and tearing ofi' a small fragment of the body of one
of the vertebrsB where the intervertebral substance adhered to it.*

These are all the cases of dislocation of the lumbar vertebrse of
which I am able to find any record. Both were accompanied with
fractures. In neither case was any attempt made to reduce the dis-
locations. In the second, it is scarcely probable that any means could
have been employed which would have succeeded in restoring the
bones to their places ; nor is it probable that if the bones bad been
restored to place, the patient would have survived the accident a
day longer, probably not so long. The cord was greatly lacerated,
and the diaphragm torn up and displaced, rendering a recovery almost
impossible.

In the first example, where the dislocation was less complete, and
the complications less grave, could reduction have offered any reason-
able chance for relief? By extension, combined with a movement of
rotation in a direction opposite to that in which the displacement had
taken place, it is possible that a reduction might have been accom-
plishea. The attempt certainly would have been justifiable ; but since
the man lived " many years" without the reduction, it is doubtful
whether the result of a reduction would have been more fortunate.

§ 2. Dislocations of the Dorsal YsBTEBRiS.

Malgaigne enumerates twelve examples of dislocations of the dorsal
vertebrffi. I have found reported by American surgeons, at dates too
recent to have been included in his analysis, two other examples ; but
of this number only three are claimed to have been simple dislocations,
unaccompanied with fracture. One of the fourteen was a dislocation
of the fifth dorsal vertebra upon the sixth, one of the eighth, two of the
ninth, five of the eleventh, and five of the twelfth. The relative fre-
quency of their occurrence in the different vertebrsB corresponding
with the observation of Weber, as to the points of the spinal marrow
which allow of the greatest freedom of motion, and are consequently
most liable to dislocations. The direction of the displacement in ten
cases was observed to be six times forwards, twice backwards^ and
twice to the one side.

Two of those which were unaccompanied with fracture, occurring
respectively in the tenth and sixth dorsal vertebne, were examples of
a dislocation forwards, and the third, belonging to the ninth vertebra,
was a dislocation backwards. A lateral luxation without fracture has
not been recorded. It is worthy of remark, also, that these three

> Dapuytren, Injuries and Dis. of Bones, 8yd. ed. p. 840.



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DISLOCATIONS OF THE DORSAL VERTEBRiB. 511

examples, being all which our science up to this moment possesses,
have happened in the experience of the same surgeon.^

A moment's consideration of the anatomy of these processes will
render it apparent that even a partial luxation forwards without a frac-
ture of the oblique apophyses is impossible, and that in the direction
back:wards the luxation can only occur to the extent of about one-
quarter of an inch, constituting only a species of articular diastasis,
without breaking off the articulating apophyses of the lower corre-
sponding vertebra. The first two examples, therefore, notwithstanding
they have been received without question by Malgaigne, I shall un-
hesitatingly reject. The third, which alone carries evidence of its
having been correctly reported, and which was only a partial disloca-
tion, is related as follows : ''A mason having fallen from a height in
such a manner as that the lower part* of his back struck upon the
angle, of the upper step of a ladder, died on the following day. After
death it was observed that the spinous processes of the dorsal vertebrsa
were prominent down to the tenth; and that the tenth process with all
of the processes below were depressed. It was also noticed that this
depression, very marked when the trunk was thrown backwards,
gradually diminished and finally disappeared altogether when the
body was bent forwards. On removing the soft parts it was found
that the ligaments were extensively torn asunder and detached, so as
to permit the articulating apophyses of the tenth vertebra to be carried
into contact with the back of the ninth. The spinal marrow had un-
dergone no visible alteration."*

Malgaigne thinks he has once observed the same thing on a living
subject, and that by simply bending the body forwards he accom-
plished the reduction and effected a perfect cure, except that a slight
curvature remained at the point of injury.

Among the cases reported as having been complicated with fracture,
the following example, reported by Dr. Graves, of New Hampshire, to
Dr. Parker, of this city, possesses unusual interest: —

On the second day of Jan., 1852, a man, aet. 25, was struck on the
back while in a stooping posture by a falling mass of timber, causing
a dislocation of the last dorsal upon the first lumbar vertebra. His
lower extremities were completely paralyzed, and priapism continued
for several hours. The surgeon determined to make an attempt at
reduction, and for this purpose he placed the patient upon his face, and
secured a folded sheet under his armpits and another around his hips,
directing four strong men to make extension and counter-extension by
these sheets. Chloroform was administered, and when the patient was
oompletely under its influence the extending and counter-extending
forces were applied, and in a few minutes the vertebrae glided into
place with a distinct bony crepitus. The restoration of the line of
the vertebral column was found to be nearly but not quite perfect.

On the sixteenth day he began to have slight sensations in his feet^
and at the end of six or eight weeks he was able to control the evac-

1 Melchiori, Gaz. Medica, stati sardi, 1860. • Melchiori, loc. cit.



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512 DISLOCATIONS OP THE SPIKE.

uations from the bladder and rectum. Several months later he had
recovered so completely as to walk with only the aid of a cane.'

I know of only one similar case. Badiger has published an acoonnt
of a dislocation obliquely backwards and to the right side, which
occurred at the same point in the spinal column. The subject was a
musketeer, who had been struck upon his back by a falling wall
which he was endeavoring to pull down. Rudiger laid him upon bis
belly, and by the assistance of others he was able, but not without
causing pain, to reduce the bones. Immediately, however, when the
extension was discontinued, the action of the muscles caused the dis-
placement to recur. The surgeon then directed four men to make
extension, while another man retained the bpnes in place by pressing
upon them with his hands. After several hours this method of pres-
sure was replaced by a board underlaid with compresses and sustain-
ing a weight of more than fifty livres. On the following day it was
found sufficient to bind compresses over the projecting bone, and in
this condition the patient remained fifteen days ; during all of which
time he lay upon his belly with his shoulders more elevated than his
pelvis. On the twentieth day he could lie upon his back, and in
about six weeks he was so completely restored as to be able to pursue
his trade as before I' This is certainly a very extraordinary case,
whether considered in reference to the means employed to restore the
bones to place, or to its results ; and if the statements are to be re-
ceived at all, it must be with some hesitation and allowance.

On the other hand, we are able to present at least one example in
which, although no reduction has been accomplished, the patient has
survived the accident many years; yet it must be admitted that his
recovery is far from having been as complete as in the two cases jost
mentioned.

Joseph Stocks, set. 11, in the spring of 1826, was crushed under the
body of an ox-cart in such a manner as to produce a dislocation of
the last dorsal from the first lumbar vertebra, causing immediately
almost complete paralysis of all the parts below. This young man
was seen by Dr. Swan, of Sprrngfield, Mass., in the summer of 1834, at
which time he was occupied as a portrait-painter. His lower extremi-
ties remained paralyzed and of the same size as at the time of the
receipt of the Injury. He was unable to sit erect, owing to the mobility
of the spine at the seat of dislocation, and he had therefore lain con-
stantly upon his side. The upper portion of his body was well de-
veloped, and his intellectual faculties were of a high oraer.^

It is not, however, with a life of perpetual deformity that the two
examples of reduction already described are to be contrasted. A resalt
so fortunate as this, where the bones remained unreduced, is unique; in
all the other cases reported the patients died miserably after periods
ranging from a few days to one year or a little more.

Charles Bell has related the case of an infant who was run over
by a diligence, and who died thirteen months after the accident. On

« Graves, N. Y. Joum. Med., March, 1S52, p. 190.

> Rudiger, Joum. de Chir. de Desault, torn. til. p. 59.

* Swan, Bost. Med. and Surg. Joum., vol. xxii. p. lOd, March, 1S40.



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1>ISI-OCATIONS OP SIX LOWER CERVICAL VERTEBRA. 518

examination after death, the last dorsal vertebra was foand to be
completely luxated backwards and to the left, npon the first lumbar
vertebra.*

With these facts before us, I think we cannot hesitate, when the
nature of the accident is fully made out^ and especially when the dis-
location has occurred in the lower dorsal vertebrae, to attempt the
redaction by forcible extension, united with judicious lateral motion,
or with a certain amount of direct pressure upon the projecting spines.

§ 3. Dislocations ov the Six Lower Cervical Yertebrs.

It is much more common to meet with simple luxations of the ver-
tebrae of the neck uncomplicated with fractures, than of either of the
other vertebral divisions. This is doubtless owing to the greater
extent of motion which their articulating surfaces enjoy.

They may be dislocated forwards or backwards. The forward lux-
ation may be complete or incomplete; with both sides equally advanced
{" bilateral" of Malgaigne), or one of the articulating apophyses may be
dislocated forwards, leaving the opposite apophysis in its place {" uni-
lateral" of Malgaigne).

Schranth' has collected twenty-four examples of luxation of the
cervical vertebrae, of which four are recorded as dislocations forwards,
two back, and six to the one side or the other. Three of this number
were dislocations of the atlas, two were dislocations of the second
vertebra, five of the fourth, two of the fifth, two of the sixth, and
one of the seventh. In the other cases the seat was not stated.

Malgaigne has brought together forty -five examples; of which
twenty-one were complete forward luxations, nine incomplete forward
luxations, nine unilateral and forwards, and four were backward
luxations. Three were dislocations of the second vertebra upon the
third, four were dislocations of the third vertebra, ten of the fourth,
eleven of the fifth, fifteen of the sixth, and two of the seventh.

The bilateral forward luxations are generally caused by a fall upon
the top and back of the head, or upon the top of the head while the
neck is very much flexed forwards. The unilateral is caused gene-
rally by a direct blow upon the back of the neck, the blow being
probably directed somewhat to one side or the other. The number of
backward luxations which have been reported are too few to enable
us to indicate very accurately the general causes, but it seems proba-
ble that they are most often occasioned by a fall upon the fore and top
part of the head, received while the neck is bent forcibly back.

In dislocations of the cervical vertebrae forwards the head is usually
depressed toward the sternum, in dislocations backwards the head is
thrown back, and in unilateral dislocations the head is turned over
one of the shoulders. Neither of these malpositions of the head is
uniformly present in these several dislocations, and indeed not un-
frequently, especially in case the system is greatly shocked by the

> Charles Bell, on Injaries of the Spine. 1S24.

* Schranth, Amer« Joam. Med. Sci., May, 1848, from Archly furPhys. Hellkonde.



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514: DISLOCATIONS OF THE SPINE.

acoident, the head and neck assume a preternatural mobility, and may
be turned easily in any direction.

The spinous process, unless the patient is very fleshy or consider-
able swelling has supervened, can easily be felt, and its deviatioi:^ to
the right or to the left, forwards or backwards, furnish as with the
most valuable and important sign of the dislocation. Even the trans-
verse processes may be felt sometimes, especially in the upper part of
the neck, with sufficient distinctness to render them useful in the
diagnosis.

To these circumstances we may add paralysis of the body below the
seat of injury, with pain and swelling at the point of dislocation. In
some cases also the patient has himself distinctly felt a cracking or
sudden giving way in the neck at the moment of the accident.

Prognosis, — The complete bilateral luxations, whether backwards or
forwards, have in most cases terminated fatally within a short time,
generally within forty-eight hours. Unilateral luxations are less
speedy in their results, but when the dislocation remains unredaced,
death generally takes place in a month or two. Lente relates a case
of incomplete dislocation of the fifth cervical vertebra backwards,
unaccompanied with fracture, which accident the patient survived
five days.^ A patient of Eoux's lived eight days ; but in the case
of a second patient mentioned by Lente, with a complete luxation,
without fracture, of the fifth vertebra, the patient survived the injary
only two hours.'

On the other haiid, occasional examples are presented of partial or
complete recovery with the luxation unreduced.

Horner, of Philadelphia, presented to the class of medical students
of the University of Pennsylvania, in 1842, a lad ast. 10, who had fallen
a distance of twenty feet, alighting upon his head. He was found
senseless and motionless, with his' head bent under his body. He
gradually recovered from the shock, but his neck wa& sti£^ distorted,
and motionless, his face being inclined downwards to the right side.
Two days after, his " common and accurate perceptions returned, but
he was afiected for some time with tingling and numbness in his left
arm." When presented to the class the transverse processes, from the
fifth upwards, were about half an inch in front of those below, showing
that the left oblique process of the fourth was dislocated forwards
upon the fifth. The rotary motions of the neck could now be exe-
cuted to some extent, but much more freely to the right than to the
left. Professor Horner refused to make any attempt to reduce the
dislocation.*

Dr. Purple, of New York, has reported a case of what was called a
dislocation of the fifth and sixth cervical vertebr», producing complete
paralysis of the lower part of the body, in which the patient survived
the accident many years ; but his lower extremities were so useless
and cumbersome as to induce him, in the year 1851, six years after
the injury had been received, to submit to the amputation of both at

« Lente, New York Jouni. Med., May, 1850, p. 284. « Lente, ibid., p. 897.

* Homer, Amer. Joum. Med. Sci., April, 1843, from Med. Exam.



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DISLOCATIONS OF SIX LOWEK CERVICAL VERTEBR-fi. 515

the bip-joint. In 1852, having become very intemperate, he died, but
no aatopsj was obtained, so that the exact character of the injury was
never ascertained.' Sanson, of Paris, has reported also a case which
came under his observation at Hdtel Dieu, of dislocation of the " third
cervical vertebra backwards," from which, although unreduced, the
patient partially recovered. The character of this accident was not
mnch better determined ; for, although he felt a severe and sharp pain
at tbe moment of the injury, which was greatly aggravated by
motion, and his head was bent forwards and to the left, ^' the chin
being fixed on the upper part of the sternum," there was no paralysis
of either the motor or sentient nerves. After the lapse of about four
months he left the hospital, still unable to lift his chin more than four
inches from the sternum ; after which he resumed his usual occupa-
tions, suffering no further inconvenience than what was occasioned
by the unnatural position of his head.' Notwithstanding the authori-
tative testimony of Sanson that this was a dislocation backwards, one
cannot avoid the conclusion that it was either a unilateral subluxa-
tion, or perhaps a mere diastasis of the articulation, or else that it was
an example of sprain oi the muscles, and consequent contraction of one
set, or paralysis of the opposing set of muscles. It is certain that it
was not a complete luxation ; nor, since there was no paralysis of the
hody below the point of injury, can it be properly made use of as an
argument for non-interference where such paralysis does actually exist.
Let us see now what encouragement an attempt at reduction may
offer, in a case which presents so little ground of hope where the
redaction is not accomplished.

Dr. Spencer, of Ticonderoga, N. Y., relates that a man, set. 50, fell
backwards from a board fence, striking upon the superior and anterior
portion of his head, dislocating the second from the third vertebra of
the neck. His head was thrown back so far as to prevent his seeing
his own body, and all below the injury was completely paralyzed.
Bepeated attempts were made to reduce the dislocation, '' but the trans-
verse processes had become so interlocked that every effort proved
abortive," and he died forty-eight hours after the injury was received.*
Gaitskill also attempted reduction in a case of dislocation of the seventh
cervical vertebra, but failed.* Boyer failed in two cases. It is related
by Petit Badel, that a young patient at La Oharitd expired in the
hands of the surgeons, upon such an attempt being made a few days
after the accident;^ and Dupuytren says '' the reduction of these dislo-
cations is very dangerous, and we have often known an individual
perish from the compression or elongation of the spinal marrow which
always attends these attempts."

Dr. Shuck, of Vienna, relates that a man, aat. 24, while engaged at

his work on the 5th of Dec. 1838, twisted his head suddenly round,

* in consequence of one of his companions roaring into his ear, when he



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 59 of 100)