Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

. (page 60 of 100)
Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 60 of 100)
Font size
QR-code for this ebook


> Pnrple, New York Joum. Med., May 1858, p. 819.

■ Saiiflon, Amer. Joum. Med. Sci., Feb. 1886, p. 614 ; from Gaz. des Hdpitaux.

* Spencer, Boston Med. and Surg. Joum, vol. xy. No. 11.

* QaitskiU, London Repository, vol. xv. p. 282.

* Petit Radel, Note to Boyer, Malad. Chir., yoI. y. p. 118.



Digitized by



Google



616 DISLOCATIONS OP THE SPINE.

instantly felt something give way in his neck, and foand it impossible
to move his head. Next morning his head was turned to the right
and bent down toward the shoulder. Every attempt to move his bead
caused great pain. He complained of weakness in his right arm, bat
all the other functions of his bodv were perfect. An attempt was
immediately made to reduce the dislocation by lifting him by the head,
but without success. On the 7th of Dec, the weakness and numbness
of the right arm had increased, and the attempt to reduce the bones
was renewed. The patient was laid horizontally upon a bed ,and ex-
tension made from the chin and occiput while counter -extension was
made from the shoulders. The force thus employed was gradually
increased until the patient and assistant felt a snap as of two bones
meeting, when it was found that the head was restored to its natural
position, and the power of moving it had returned. The next day his
arm was more powerless than before, and on the following day he had
vertigo, but these symptoms soon yielded to copious bleedings, and he
left the hospital cured on the ISth.^

Dr. Hickerman, of Ohio, has reported also, in the Ohio Medical
Journal^ a case of dislocation of one of the cervical vertebrae, the
original account of which I have not seen, but only an abridged state-
ment published in the Buffalo Medical Journal, By exploring the
pharynx a prominence was felt opposite the junction of the foarth
and fifth cervical vertebrae ; and the action of the heart was barely per-
ceptible. Seizing the patient's head under his left arm. Dr. Hickerman
in this manner made traction, while, with the index finger of the right
hand in the patient's throat, he made firm pressure obliquely upwards,
backwards, and to the left ; after continuing the pressure for about
forty or fifty seconds, the part against which the finger was placed
graaually yet quickly receded in the direction in which the pressure
was made, and instantly, as quickly indeed as the act could be possibly
executed, the patient opened her eyes, and natural respiration was es-
tablished. She then also immediately became conscious of what was
transpiring about her, and signified by signs, for she was yet unable
to speak, that she had sufiered pain in the epigastrium. Complete
recovery took place.*

Schranth received under his care a patient who had a luxation of
the "right transverse apophysis" of the fourth cervical vertebra,
without lesion of the spinal marrow, which he reduced on the seventh
day. The first attempt was unsuccessful ; but the second, made with
great caution, by the aid of four assistants, three of whom pulled the
head upwards while the fourth pressed with his whole weight upon
the shoulders, was completely successful. During the time that the
traction was being made, the head was occasionally rotated slightly
and moved laterally, and at the same moment the surgeon pushed
firmly against the displaced apophysis. The reduction was attended
with "various distinct crackings in the neck," which were loud enough

« Shuck, Amer. Joam. Med. Bci., July, 1841, p. 207.

' Hickerman, Buf. Med. Journ., vol. x. p. 702, April, 1S$5.



Digitized by



Google



X>ISLOCATIOKS OF SIX LOWER CBRVIOAL VERTEBBiB. 517

to be beard. After some days of repose he resumed his occupation,
X1.0 stiffness remaining in the movements of the neck.^

Dr. Edward Maxson, of Geneva, N. Y., was called on the 28th of
Oct. 1866, to see a child about nine years old, who had met with a
similar accident about forty hours before, namely a dislocation of the
x^ight articulating apophysis of the fifth or sixth cervical vertebra,
occasioned by suddenly turning her head around while at play. She
at first complained only of pain and inability to straighten the neck ;
"but whenever moved she became faint and irritable. A short time
l>efore the surgeon was called, the mother had, in attempting to move
Iier in bed, turned the face a little more to the left, when a severe
convulsion immediately ensued. On examining the neck, Dr. Maxson
discovered the displacement of the transverse process. Having ad-
vised the parents of the danger necessarily incident to an attempt at
replacement, and of the probable consequences of its being permitted
to remain as it was, they consented that the trial should be made. "I
grasped the head,'' says Dr. M., "with both hands, and proceeded
according to Desault's method, onlv I first carried or turned the face
very gently a little further toward the left shoulder, to, if possible,
disengage the process; then lifting or extending the head, I turned
the face very gently toward the right shoulder, when the difficulty
was at once overcome, and she exclaimed: 'I can move my eyes.'
Her countenance soon acquired a more natural appearance; the faint-
ness passed off; she rested quietly through the night; had no return
of the difficulty, and needed only an emollient anodyne to soothe the
irritation and slight swelling which remained at the point of injury."*
Bust," Wood, of this city/ and others, have seen and reported simi-
lar cases attended with like success.

So far the cases of successful reduction which we have d&scribed
are examples of dislocation of only one of the articulating apophyses,
and they are sufficiently numerous to establish the value of the prac-
tice. We have now to relate a case in itself unique, namely, a suc-
cessful reduction of a dislocation of the fifth cervical vertebra, in which
both apophyses appear to have been thrown forwards. It occurred
in the practice of Dr. Daniel Ayres, of Brooklyn, N. Y., and will be
best understood by a reproduction of his own published account of
the case : —

''E. K., the subject of this accident, was a laboring man, thirty
years of age, tall and muscular, but not fat, with a neck longer than
the average among men of equal height. On the evening of the 2d
of October he became intoxicated ; was brought home insensible, and
did not recover from the combined effects of the shock and his liba-
tions until the following morning, when he was supposed by his wife
to be laboring under cold and a stiff neck. She made some domestic
applications to the affected part, and administered a dose of cathartic
medicine. When it was thought sufficient time had elapsed without

1 Schranth, Amer. Joum. Med. BcL, May, 1848.
' Maxson, Buffalo Med. Joum., Jan. 1857, p. 476.

• Rust, CheliuB, no^e by Smith.

* Wood, New York Joum. Med., Jan. 1857, p. 18.



Digitized by



Google



618 DISLOCATIONS OF THE SPINB.

obtaining relief, he was seen by Dr. Potter, of this city, and afterwards
by Dr. Gullen, both of whom recogniased a condition which was not
only very unusual, but one which they had never before observed. I
was then requested to examine the case, which I did on the ninth day
after the accident. With some assistance and great personal ^oTti
he was able to get out of bed, moving very slowly and caatiously.
Desiring to expectorate, he was obliged to get down on his hands and
knees, which he accomplished with the same deliberation. When
seated in a chair, the head was thrown back and permanently fixed;
the face turned upward with an anxious expression. The anterior
portion of the neck, bulging forwards, was strongly convex, rendering
the larynx yery prominent. The integuments of this region were
exceedingly tense and intolerant of pressure. The posterior portion
of the neck exhibited a sharp, sudden angle at the junction of the
fifth and sixth cervical vertebrae, around which the integuments lay
in folds. It was difficult to reach the bottom of this angle even with
strong pressure of the fingers, and of course the regular line formed
by the projecting spinous processes was abruptly lost He complained
of intense and constant pain at this point, which was neither relieved
nor aggravated by pressure. With difficulty he swallowed small
quantities of liquid, pausing after each effort, and could not be induced
to take solid food, since the first attempt to do so after the accident
was followed by violent paroxysms of coughing and choking. His
breathing was obstructed and somewhat labored, being unable fully
to clear the bronchia of their secretion. This, however, seemed rather
an effect of the tense condition of the soft parts of the neck, than the
result of pressure upon the spinal cord, since he presented no evidence
of paralysis, either of motion or sensation, in parts below the neck.
The sterno-cleido- mastoid muscles of both sides were felt quite soft
and relaxed.

''Bat one conclusion could be formed upon this state of facts^ to
wit : that the oblique processes of both sides were completely dislo-
cated. The marked rigidity of the head seemed to preclude the pro-
bability of fracture through the vertebral bodies, and although the
cartilage might be separated anteriorly, yet the body not pressing
backwards sufficiently to produce paralysis of the cord, it was hoped
that the posterior vertebral ligament remained uninjured; it was,
therefore, determined to make an effort at reduction on the following
day. In addition to those originally connected with the case, I am
under obligations to Drs. Ingraham, Turner, Palmedo, Gr. D. Ayres,
and a number of other medical gentlemen, who were present by invi-
tation, all of whom confirmed the diagnosis, and rendered efficient
services.

"The patient was placed upon a strong table, in a recumbent posi-
tion, with a pillow resting under the shoulders, the head being sup-
ported by the hand during the administration of chloroform, of which
an ounce was given before anaesthesia ensued. Counter-extension
being made by two folded sheets placed obliquely across the shoulders
and properly held, the head was grasped by one hand placed under
the chin, the other over the occiput^ and by steadily and firmly draw-



Digitized by



Google



DISLOCATIONS OP THE ATLAS. 519

ing the head directly backwards, and then upwards, an attempt was
xnade at reduction, but failed for want of sufficient power. Dr. Ingra-
laam was' then requested to place his hands immediately over my own
in the same position as before, and steady traction was again made in
^he same direction. Our united strength was required in drawing
t;he head backwards and upwards to

dislodge the superior oblique processes Fig. 229.

from their abnormal position. When

this was felt to be yielding by Dr.

Gullen (who kept one hand constantly

at the seat of dislocation), Dr. Potter

-was directed to place his hands under

our own, still in position, and assist in

l>riDging the head forwards; at the

same time the chest was depressed

toward the table. The bones were
• distinctly felt to slip into their places ;

the line of the spine was instantly re-
stored, the head and neck assuming
their natural position and aspect. As
soon as the patient became conscious,
he expressed himself ignorant of what
had taken place, but free from pain,
and, in his own language, ' all right.'
A bandage was arranged to support
the head and kieep it bent forwards.
He had an anodyne for two nights fol-
lowing, after which no further treat-
ment was necessary, and at the end of ^^^,. e,.eof biutenti dislocation of the
one week he had complete control over unh oervicAi reriebra.
the movements of the head and neck.

Beyond the debility and emaciation immediately dependent upon
protracted fasting and loss of rest, he has experienced no uneasiness
since the operation. His appetite is now good, and all the functions
perform their duty normally. In a subsequent inquiry, to determine,
if possible, the cause of the accident, he states that he distinctly
recollects going into a store in Atlantic Street, near the ferry, and
there having angry words with an acquaintance; that he left the '
store, and was proceeding up the street (which is here a rather steep
ascent), 'when he was violently struck from behind, over the lower
portion of the neck. He likewise remembers falling forwards, and
striking against some object, but does not know what it was, nor what
took place until the following morning."^

§ 4. Dislocations or the Atlas.

Surgeons have met with several forms of displacement between the
atlas and axis. First, a forced inclination forwards of the atlas upon
the axis; in consequence of which the body or anterior arch of the

1 Ayres, New York Joum. Med., Jan. 1857, p. 0.

Digitized by VjOOQIC



520 DISLOCATIONS OF THE SPINE.

atlas is made to recede from the odontoid process, and the transTerse
ligament glides upwards without breaking, so that the extremitj of
the odontoid process comes to occupy a position underneath or behind
the ligament) and thus presses upon the cord. It is apparent also that
this form of displacement cannot occur without a rupture of the ver-
tical ligaments which bind the transverse ligaments to the axis^ nor
without a separation of the atlas from the axis posteriorly and a rap-
ture of the posterior atlo-axoidean ligament. Second, a similar incli-
nation of the atlas, accompanied with a rupture of the transverse and
superior vertical ligaments, in consequence of which also the odontoid
process is allowed to fall upon the cord. Third, the atlas in the same
position, with the odontoid process broken at its base. Fourth, the
atlas displaced directly forwards or backwards ; and fifth, a displace-
ment of only one articular process in a direction forwards.

We have already, when speaking of fractures of the atlas, or of the
atlas and axis together, called attention to several examples of that
form of the dislocation which is accompanied with a fracture of the
odontoid process. The other forms of dislocation are characterized
by so few symptoms peculiar to themselves, or which can be regarded
as diagnostic and not already sufficiently studied in connection with
other dislocations of the neck, that we shall not deem it necessary to
do more than remind our readers that if permitted to remain unre-
duced a speedy and fatal issue is inevitable, and to point them to a
couple of examples of recovery, after reduction has been fortunately
accomplished ; for both of which I am indebted to Malgaigne. These
may alone suffice to show that Dupuytren was in error when be
declared that such accidents were wholly beyond the resources of
our art.

An old man received upon his head a bundle of hay cast from the
top of a wagon. He fell with his head bent forwards so that his chin
touched the top of the sternum, and in this position it remained
immovably fixed ; all the other portions of his body preserved their
natural functions. A sur^n, who was indeed the father of Mal-
gaigne, being called, assured the patient that unless he could give him
relief he certainly would die ; but that inasmuch as the attempt might
itself prove fatal, he ought at once to put in order his aflbirs. Accord-
ingly the man partook of the sacrament ; then the surgeon seated him
upon the ground, and placing himself at bis back with his knees
resting upon his shoulders for the purpose of making counter-exten-
sion, and with a towel brought over his own shoulders and under the
chin of the patient for extension, he proceeded to act upon the neck in
the direction of the axis of the spine. The efforts were long and pain-
ful, but at last, while the head was lifted as far as possible, it was sud-
denly drawn backwards, and immediately it resumed its natural
direction. Absolute quietude was enjoined, and the patient recovered
in a short time and without any accident.

This patient was seen two years after by the younger Malgaigne, at
which time no trace of the accident remained, except an impossibility
of turning the head to the right or to the left.

The other example is related by Ehrlich, but in this case the dislo-



Digitized by



Google



DISLOCATIONS OF THE BIBS FBOM THE VEBTEBEiE. 521

cation was backwards. A young man, aet. 16, while carrying a sack
of flour up a ladder, fell backwards, and the sack falling over upon his
face and head came to the ground before him. He was found lying
with hie head thrown back and to the right, the head resting upon the
scapula of this side, but having so completely lost its " solidity" that
by its own weight it would fall from one side to the other. On the
front and left side of the neck there existed a prominence supposed
to be formed by the atlas; the patient was unconscious; the pulse was
scarcely perceptible, and the whole body was suffering under paralysis.
Ehrlich directed the shoulders to be held by one assistant, and the
head to be drawn upon by another, while he pressed with his own
hands forcibly upon the displaced atlas from behind. After several
fruitless attempts, the reduction took place, accompanied with a sound
distinctly audible to all of the assistants; the head resumed its posi-
tion firmly, and the arms began to move. The head was afterwards
maintained in place by a bandage. The cure proceeded rapidly, and
after a time no trace of the injury remained but a disagreeable tension
in the nape of the neck whenever he moved his head briskly to the
one side or the other.*

§ 5. Dislocations op the Head upon the Atlas, ob Occipito-Atloidean

Dislocations.

Lassus, Palletta, and Bouisson* have each reported one example of
this dislocation. In neither case was the dislocation complete, but
death occurred speedily in every instance. Dariste exhibited to the
Anatomical Society of Paris, in 1838, a specimen of incomplete luxa-
tion of the occipito-atloidean articulation, with stretching of the
transverse ligament. The patient from whom the specimen was taken
having lived more than a year after the accident, when he died from
a tubercle in the brain.'



CHAPTER IV.

dislocations of the ribs.

The ribs may be separated from the bodies of the vertebrae, from
the cartilages of the ribs, and from each other. The cartilages of the
ribs may also be separated from the sternum.

§ 1. Dislocations of the Ribs from the Vertebra.

The heads of the ribs are joined to the bodies of the vertebras by
strong ligaments. The articulations are ginglymoid, admitting of mo-

I Malgugne, Ehrlich, Malgaigne, op. cit., torn. ii. p. 884.

' Lassas, Palletta, Bouisson, Malgaigne, op. cit., p. 820.

' Dariste, Amer. Journ. Med. Sci., Not. 1838, p. 287, from Archives G6n., May,

1838.

34



Digitized by



Google



522 DISLOCATIONS OF THE RIBS.

tioD chiefly in the direction of the axis of the Bpine. The mohility t
gradually increases as we proceed from the first rib downward to the !
last. Each joint is furnished with a capsule. \

The necks and tubercles are also united to the transverse processes
by ligaments, and the articulations are furnished with synovial cap-
sules.

I am not aware that any examples have ever been reported of dis-
locations of the ribs from the transverse processes.

Examples of dislocation of the heads of the ribs have been mentioned
by Ambrose Pard, Branaby Cooper, Alcock, Donne, Henkel, Kennedy,
Buttet, and some others ; but most of these reputed cases have not
borne the test of a critical analysis, and while Yidal (de Cassis) is in
doubt whether the claims of even one have been fully established,
Boyer denies absolutely its possibility. We see no reason, however,
to question the authenticity of several of these examples.

The case mentioned by Bransby Cooper, although very briefly
narrated, leaves no room for doubt as to its real character. " Mr.
Webster, surgeon at St. Albans, when examining the body of a
patient who had died of fever, found the head of the seventh rib
thrown upon the front of the corresponding vertebra, and there
anchylosea. Upon inquiry, Mr. Webster learned that this gentle-
man, several years before, had been thrown from his horse across a
gate, for which accident he had been subjected to the treatment usually
followed in fractures of the ribs, and there is every reason to believe
that it was at this time the dislocation occurred."'

These accidents seem to have been generally occasioned by a fall
or a blow upon the back, and the dislocation has been accompanied,
usually, with a fracture of some other rib, or of the transverse or
spinous processes of the corresponding vertebrsB. The head of the
rib has always been found to be displaced inwards. The lower ribs,
including the false and floating, are those which have been most fre-
quently displaced.

It would be difficult, if not impossible, during the life of the patient,
to make a positive diagnosis, since the symptoms resemble so closely
those which accompany a fracture of the rib near its posterior ex-
tremity. The nature of the accident producing the dislocation, the
depression, mobility, and pain, are equally indicative of a fracture;
while the failure to detect crepitus might easily be explained by the
thickness of the muscular walls at this point, or by the riding, or by
other displacements of the broken fragments.

Chelius speaks of a peculiar " rustling," perceived when the body and
ribs are moved by the surgeon or by the patient himself, and which
is different from the sensation produced by emphysema or fracture.

The treatment ought to be the same which would be adopted in
case the rib was broken. Bepiacement of the dislocated bone must be
regarded as impossible; and it only remains that we insure quiet as
far as possible in this portion of the chest, and combat the pain and
inflammation by suitable remedies. The circular bandage, however

' Webster, B. Cooper's ed. of Sir Astley Cooper, Amer. ed., p. 450.



Digitized by



Google



DISLOCATIONS OF THE CARTILAGES OF THE RIBS. 628

Tecommended in these cases by Sir Astley Cooper, could only be
serviceable in dislocations of those ribs which have an attachment to
the sternum ; the floating ribs, which have been found dislocated quite
as often as either of the others, could derive no support from circular
pressure, or from any other mechanical contrivance.

§ 2. Dl8r/)CATI0NS OF THE CARTILAGES OF THE RiBS FROM THE StEENUM.

The cartilage of the first rib has no proper articulation at either
extremity, but the remaining six upper ribs, where they join the
sternum, are furnished with synovial capsules. In old age these
articulations generally disappear, yet not always.

Charles Bell observes: "A young man playing the dumb-bells and
throwing his arms behind him, feels something give way on the chest;
and one of the cartilages of the ribs has started and stands prominent.
To reduce it, we make the patient draw a full inspiration, and with
the fingers knead the projecting cartilage into its place. We apply a
compress and bandage, but the luxation is with difiiculty retained."

Bavaton, Manzotti, and Monteggia have each, according to Mai-
gaigne, reported one example of traumatic dislocation; in all of which
the cartilages were thrown forwards in advance of the sternum.

When treating of fracture of the sternum, I have related one case,
which has come under my own observation, of dislocation of three or
four cartilages at the same time.

By pressure alone they have generally been replaced, the cartilage
resuming its position suddenly and with a sound. The reduction
may, nevertheless, be facilitated by bending the trunk backwards or
by directing the patient to make a full inspiration.

To maintain the reduction has been found more difiicult, and Sir
Astley directs that " a long piece of wetted pasteboard should be
placed in the course of three of the ribs and their cartilages, the
injured rib being in the centre ; this dries upon the chest, takes the
exact form of the parts, prevents motion, and affords the same support
as a splint upon a fractured limb. A flannel roller is to be applied
over this splint, and a system of depletion pursued, to prevent inflam-
mation of the thoracic viscera." Instead of the pasteboard, we might
use either felt, sole-leather, or gutta percha.

The patients spoken of by Bavaton and Manzotti were both cured
in about one month.

Mr. Bransby Cooper says that a baker's boy applied for relief at
Guy's Hospital, who was the subject of displacement of the cartilages
of the fifth and sixth ribs from their junction with the sternum, pro-
duced partly by the constant action of the pe^storal muscles in kneading
bread, but principally by his defective constitution. Mr. Cooper stated



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 60 of 100)