L I E) R.AR_Y OF THE U N I VE:R.5 ITY or ILLINOIS en. 03 As3l THE INTERNATIONAL ENCYCLOPAEDIA SUEGERY. VOL. IV. Digitized by the Internet Archive in 2015 https://archive.org/details/internationalenc04ashh_0 THE INTERNATIONAL ENCYCLOPiEDIA OF SUEG-EET A SYSTEMATIC TREATISE ON THE THEORY AND PEACTICE OF SURGERY BY • AUTHOES OF yARIOUS l^ATIOT^S EDITED BY JOHIS" ASHHURST, Jr., M.B. PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OF PENNSYLVANIA, SURGEON TO THE PENNSYLVANIA HOSPITAL, ETC. ILLUSTRATED WITH CH ROMO-LITHOGRAPHS AND WOOD-CUTS m SIX VOLUMES VOL. IV. REVISED EDITION WILLIAM NEW YORK WOOD & COMPAl^Y 1889 WILLIAM Copyright : WOOD & 1 8 8 7. COMPANY, I THE IITERNATIOML ENCYCLOPAEDIA OF SURGERY. ARTICLES CONTAINED IN THE FOURTH VOLUME. Injuries of Bones. By John H. Packard, M.D., Surgeon to the Pennsyl- vania Hospital and to St. Joseph's Hospital, Philadelphia. Page 1. Injuries of the Back, including those of the Spinal Column, Spinal Membranes, and Spinal Cord. By John A. Lidell, A.M., M.D., Late Surgeon to Bellevue Hospital, ^^ew York; also Late Surgeon U.S. Yolunteers in charge of Stanton U.S. Army General Hospital, In- spector of the Medical and Hospital Department of the Army of the Potomac, etc. Page 261. Malformations and Diseases of the Spine. By Frederick Treves, F.R.C.S., Assistant Surgeon to, and Senior Demonstrator of Surgery at, the London Hospital. page 487 Injuries and Diseases of the Eyes and their Appendages. By E. Wil- liams, M.D., Professor of Ophthalmology in Miami Medical College, Cincinnati. Page 561. Injuries and Diseases of the Ear. By Albert H. Buck, M.D., of is^ew York. Page 681. Diseases and Injuries of the ^s'ose and its Accessory Sinuses. By George M. Lefferts, M.A., M.D., Clinical Professor of Laryngoscopy and Dis- eases of the Throat in the College of Physicians and Surgeons, Medical Department of Columbia College, '^qw York ; Consulting Laryngoscopic Surgeon to St. Luke's Hospital, etc. ■ Page 751. (V) vi THE INTERNATIONAL ENCYCLOPEDIA OF SURGERY. Injuries and Diseases of the Face, Cheeks, and Lips. By Alfred C. Post, M.D., LL.D., Emeritus Professor of Clinical Surgery in the Uni- versity of the City of ^ew York ; Consulting Surgeon to the i^ew York Hospital, St. Luke's Hospital, the Presbyterian Hospital, and the Woman's State Hospital. Page 849. Injuries and Diseases of the Mouth, Fauces, Tongue, Palate, and Jaws. By Christopher Heath, F.R.C.S., Holme Professor of Clinical Surgery in University College, London, and Surgeon to University College Hos- pital. Page 885. Surgery of the Teeth and Adjacent Parts. By jSTorman W. Kingsley, M.D.S., D.D.S., Late Professor of Dental Art and Mechanirsm in the l^ew York College of Dentistry. Page 943. ALPHABETICAL LIST OF AUTHORS. (VOL. IV.). ALBERT H. BUCK, GEORGE E. FENWICK, CHRISTOPHER HEATH, NORMAN W. KINGSLEY, GEORGE M. LEFFERTS, JOHN A. LIDELL, JOHN H. PACKARD, ALFRED C. POST, FREDERICK TREVES, E. WILLIAMS. /4 I CONTENTS. PAGE List of Articles in Vol. IY. . . . . . » v Alphabetical List of Authors in Vol. IV. , , . , vii List of Illustrations . . « . . . . xxi INJURIES OF BONES. By JOHN H. PACKARD, M.D., surgeon to the PENNSYLVANIA HOSPITAL AND TO ST. JOSEPH'S HOSPITAL, PHILADELPHIA Fractures . . . . . . . . . 1 Causes of fracture 2 Immediate causes . . . . . . . .3 Predisposing causes ....... 3 Spontaneous fractures . . . . . . .12 Mechanism of the production of fractures . . . . .13 Varieties of fracture . . . . . . . .16 Simple and compound fractures . . . , . - 16 Multiple, comminuted, and impacted fractures . . . .17 Transverse, oblique, and longitudinal fractures . . . .18 Varieties of incomplete fracture . . . . . .19 Epiphyseal separations or disjunctions . . . ' . .21 Complicated fractures . . . . , . . 21 Intra-uterine fractures . . . , . . .22 Phenomena and symptoms of fracture ...... 24 Constitutional symptoms accompanying fracture . . . .28 Diagnosis of fracture . . . . . . . .29 Consequences of fracture . . . ' . . . .30 Thrombosis and embolism ....... 31 Fat-embolism . . , « . . . .31 Stiffening of neighboring joints 32 Atrophy ......... 33 Necrosis ......... 33 Development of morbid growths . . . . . .33 Greneral prognosis of fractures 34 Repair of fractures ... . . . , 35 (ix) X CONTENTS. PAGE Defects in the process of repair of fractures • • . • ,42 Delayed union . . . , , , , , 43 Dissolved union . . , , , , , • . 45 Fibrous union . . » , ► , , ,46 Complete separation . . . . , , .46 False joint or pseudartlirosis 47 Union with deformity . . , ► . , ^ ,47 General treatment of fractures 50 First attentions to the patient • , , , • . • 50 Reduction 51 Dressing the fracture 53 Solidifying dressings 54 After-treatment of fractures . , • » , ,66 Treatment of delayed union and false joint ► • • , 58 Treatment of union with deformity • . » , , 65 Fractures of special bones 67 Fractures of bones of face . . . , » , .67 Fractures of the zygoma . , , , , , . 68 • Fractures of the malar bone * , . ► , » , 69 Fractures of the upper jaw , , , , , ,69 Fractures of the nasal bones 70 Fractures of the lower jaw , . , » » ,71 Fractures of the laryngeal apparatus . , , , , .79 Fractures of the hyoid bone . . . , . ,79 Fractures of the laryngeal cartilages . , , , , 80~ Fractures of the ribs, costal cartilages, and sternum . , . , 82 Fractures of the ribs . . , , , , .82 Fractures of the costal cartilages ...... 86 Fractures of the sternum 88 Fractures of the pelvis ........ 90 Fractures of the acetabulum 93 Fractures of the sacrum . , , . , , ,93 Fractures of the coccyx 94 Fractures of the crista ilii . , , , , ,94 Fractures of the ischium ....... 94 Fractures of the clavicle . . . , . , .98 Fractures of the scapula . , . . . . . 113 Fractures of the humerus . , , . , , ,117 Fractures of the upper end of the humerus . , , . 119 Fractures of the shaft of the humerus . . . . .125 Fractures of the lower end of the humerus , , . . 133 Compound fractures of the lower end of the humerus . .146 Fractures of the bones of the forearm . . . . . .147 Fractures of the olecranon . , . , . .148 Fractures of the coronoid process of the ulna . . , .153 Fractures of the head of the radius , . . . .155 Fractures of the elbow , . . . , . .156 Fractures of the shaft of the ulna ..... 158 CONTENTS. XI Fractures of the bones of the forearm — Fractures of the radius Fractures of the lower portion of the radius Fractures of both bones of the forearm Fractures of the hand . Fractures of the carpal bones Fractures of the metacarpal bones Fractures of the phalanges Fractures of the lower extremity Fractures of the femur . Fractures of the upper part of the femur Separation of the upper epiphysis of the femur Fracture of the trochanter major Fracture of the lesser trochanter Fractures of the shaft of the femur Separation of the lower epiphysis of the femur Fractures of the condyles of the femur Fractures of the patella Compound fractures of the patella Fractures of the bones of the leg P>actures of both bones of the leg Compound fractures of the leg Fractures of the tibia Fractures of the fibula Fractures of the bones of the foot Fractures of the tarsal bones Fractures of the metatarsal bones . Fractures -of the phalanges of the toes Other injuries of bones . 161 165 177 182 182 183 184 185 186 187 197 198 200 200 216 217 221 236 237 238 250 251 253 255 255 258 259 259 INJURIES OF THE BACK, INCLUDING THOSE OF THE SPINAL COLUMN, SPINAL MEMBRANES, AND SPINAL CORD. By JOHX A. LIDELL, A.M., M.D., LATE SURGEON TO BELLEVUE HOSPITAL, NEW YORK ; ALSO LATE SURGEON U. S. VOLUN- TEERS IN CHARGE OF STANTON U. S. ARMY GENERAL HOSPITAL ; INSPECTOR OF THE MEDICAL AND HOSPITAL DEPARTMENT OF THE ARMY OF THE POTOMAC, ETC. Injuries of the back ...... Injuries of the soft parts. . . . . » Incised and punctured flesh-wounds of the back Incised or punctured flesh-wounds of back of neck Incised or punctured flesh-wounds between shoulder-blades 261 263 263 263 268 xii CONTENTS. PAGE Contusions and contused wounds of the back ^ . •271 Lacerated flesh-wounds of the back • • . • , 273 Gunshot (small-arm) flesh-wounds of the back * ^ , .276 Sprains, twists, and wrenches of the back • . . , 280 In the cervical region . . . ^ ^ .282 In the dorsal region . . . , , ^ .280 In the lumbar region ....... 288 Inflammation of vertebral articulations from sprains, twists, or wrenches 290 Haematuria from contusions and sprains of the back . . .294 Hemorrhage into the vertebral canal from sprains, violent flexures, and twists, or wrenches of the back . . , . 300 Injuries of the vertebral column . , . , , 303 Dislocations of the vertebrae ..... 303 Dislocations in cervical region ..... 307 Dislocations in dorsal and lumbar regions .... 330 Fractures of the vertebrae ...... 340 Gunshot injuries of the vertebrae ..... , 365 Gunshot contusions of the spinal column , . , . 360 Gunshot fractures of the vertebrae . . , . . 368 On trephining (so-called) or resection of the spinal column . . 378 Injuries of the spinal membranes, spinal cord, and spinal nerves . . 380 Injuries of the theca vertebralis and meninges of the spinal cord . . 380 Injuries of the spinal cord and spinal nerves . . . .381 Concussion of the spinal cord . . . . . 382 Contusion of the spinal cord . . . . . . 335 Compression of the spinal cord . . . . . 389 Wounds of the spinal cord . . . , , , 393 Injuries of *the spinal nerves . . , . . . 399 Traumatic inflammation of the membranes and substance of the spinal cord 400 Traumatic spinal meningitis ...... 401 Traumatic myelitis . . . . . , . 409 Sacro-gluteal eschars, and other so-called bedsores arising from lesions of the spinal cord and spinal nerves . . . . .417 Disorders of the urinary organs arising from lesions of the spinal cord . 436 Paralysis of the bladder . . . . . .436 Alterations of the urinary secretion ..... 439 Inflammation of the urinary organs ..... 440 Tympanites arising from lesions of the spinal cord . . . 445 Priapism in consequence of spinal injuries . . . . 447 Injuries of the sacrum and coccyx ...... 45O Fractures of the sacrum ....... 450 Gunshot fractures of the sacrum . . . . . 453 Simple fractures of the coccyx . , . ... 460 Gunshot fractures of the coccyx o . . . , . 4Q2 Coccygodynia 462 Remote effects of spinal injuries, railway-spine, etc. .... 463 Railway-injuries of the spine ...... 475 Table of cases of resection of the spinal column .... 486 CONTENTS. xiii MALFOKMATIONS AND DISEASES OF THE SPINE. ASSISTANT SURGEON Bv FREDERICK TREVES, F.R.C.S., "O, AND SENIOR DEMONSTRATOR OF ANATOMY AT, Till HOSPITAI.. Spina bifida .... False spina bifida Congenital sacro-coccygeal tumors Attached foetus Congenital tumors with foetal remains Congenital cystic tumors Congenital fatty, fibrous, and libro-cellular tumors Caudal excrescences Antero-posterior curvatures of the spine . Cyphosis .... Lordosis .... Rachitic spine Spondylitis deformans Caries and necrosis of the spine . Intervertebral arthritis . Pott's disease of the spine Etiology . . . . Pathological anatomy Symptoms of Pott's disease . Diagnosis of Pott's disease . Progress, prognosis, etc. Treatment of Pott's disease . Disease of the atlo-axoid region . Additional remarks on spina bifida and Pott's disease LONDON PAGE 487 4DG 497 497 498 499 501 502 502 502 506 508 509 512 513 514 515 518 530 538 541 543 551 560 INJURIES AND DISEASES OF THE EYES AND THEIR APPENDAGES. By E. WILLIAMS, M.D., PROFESSOR OF OPHTHALMOLOGY IN MIAMI MEDICAL COLLEGE, CINCINNATI. PAGE Anatomy of the eye . . . . . . . .561 Diagnosis of ocular affections without the use of the ophthalmoscope . . 577 xiv CONTENTS. PAGE Injuries and diseases of the orbit , , - , .581 Tumors of the orbit . - , . * „ 584 Injuries of the eyeball . . * « . , , , ggQ Foreign bodies in the eye . « . , . , .590 Accidental wounds of the eyeball . . , . . .592 Penetrating wounds of the eye 593 Sympathetic ophthalmia . . . , , , ^ 599 Treatment of wounds of the eyeball • • . . . 604 Diseases of the conjunctiva ...... , 608 Conjunctivitis . . . . , , ^ , 608 Conjunctivitis granulosa ; granulous lids ; trachoma • . , 613 Diseases of the cornea . . . . , , . .619 Keratitis . . . , , . , , ^ gX9 Staphyloma 625 Diseases of the iris . . . , « , , , g27 Malformations of the iris , . • * , , .627 Iritis 627 Tumors of the iris 630 Cataract . . . ' . . , , , . 631 Congenital cataract 633 Senile cataract . . . , , , ^ .634 Traumatic cataract 635 Treatment of cataract • . ♦ . , , . 635 Glaucoma •••...«•. 644 Simple glaucoma 646 Acute glaucoma . . . . , ^ , , 647 Chronic inflammatory glaucoma • . . , . , 647 Secondary glaucoma . . . , , ^ .648 Hemorrjiagic glaucoma . . . , ^ , .648 Treatment of glaucoma 648 Strabismus . g^Q Definition and varieties . . , , . . g^Q Causes of strabismus ....... 651 Treatment of strabismus . . . . * . , 653 Diseases of the eyelids . . . , , , , ^ ggO Blepharitis . . . , . , , -660 Chalazion 662 Sebaceous tumors of the eyelids • . , , . . 663 Lagophthalmus 663 Ptosis . . . . ^ , • . . , 664 Entropium and trichiasis 665 Canthoplasty ........ 667 Ectropium .... . • . . ♦ 667 Symblepharon . . , . , , , .668 Erectile tumors of the eyelids . . , , . , 669 Diseases of the tear-passages . . , . . , , 670 Sipiphora 670 Dacryocystitis and lachrymal fistula . . , , ,671 CONTENTS. XV PAGE Ophthalmoscopic diseases . . • . • • .0/5 Intra-ocular tumors . . . . • • • . G78 Retinoscopy : the shadow test . . . • • • . G79 Explanation of plates illustrating Injuries and Diseases of the Eyes . . 680 INJURIES AND DISEASES OF THE EAR. By ALBERT H. BUCK, M.D., OF NEW YORK. Examination of the patient 681 Tests of the hearing power . . . . • .681 Instruments and methods of examination . • • • > 683 Diseases and injuries of the auricle ...... 687 Eczema of the auricle ....... 687 Simple diffuse inflammation of the auricle ..... 688 Perichondritis of the auricle ...... 688 New growths of the auricle ...... 689 Contusions and wounds of the auricle . . • .. . 690 Deformities of the auricle . . . . • • • f'91 Frost-bite and burns of the auricle . . • • • , ('»91 Diseases and injuries of the external auditory canal .... 692 Impacted cerumen Furuncles or boils of the external auditory canal . . . • 693 Diffuse inflammation of the external auditory canal . . . 694 Ulcers, polypoid growths, and bone-caries . . . . f 697 Syphilitic ulcers and condylomata Foreign bodies in the auditory meatus . . . . . 697 Wounds of the auditory meatus ...... 698 New growths of the external auditory canal .... 699 Methods of examining the middle ear . . . . . . 699 Diseases of the middle ear ....... '^^^^ Non-suppurative inflammation, or simple catarrh .... '^^06 Acute purulent inflammation of the middle ear . . . .711 Chronic purulent inflammation of the middle ear .... 719 Diseases of the mastoid process . . ' . ... • • "^^^ Subacute condensing mastoid osteitis ..... 732 Acute diffuse mastoid osteitis ...... 733 Chronic ulcerative inflammation of the mastoid antrum . . . 738 Significance of certain phenomena occasionally met with in diseases of the mastoid process . . • • • • .739 Fractures of the temporal bone . . . • • • .740 Miscellaneous conditions of the ear 743 Atrophy of the membrana tympani ..... 743 xvi CONTENTS Miscellaneous conditions of the ear — Rupture of the drum-membrane , , , . , .744 Otalgia 745 Affections of the auditory nerve , . , , , .745 Explanation of plates representing appearances of membrana tympani in health and disease DISEASES AND INJURIES OF THE NOSE AND ITS ACCESSORY SINUSES. By GEORGE M. LEFFERTS, M.A., M.B., CLINICAL PROFESSOR OF LARYNGOSCOPY AND DISEASES OP THE THROAT IN THE COLLEGE OF PHYSICIANS AND SURGEONS, MEDICAL DEPARTMENT OF COLUMBIA COLLEGE, NEW YORK ; CONSULTING LARYNGOSCOPIC SURGEON TO ST. LUKE'S HOSPITAL, ETC. Introduction ; description of instruments, etc. . . . , .751 Instruments for examination of the nasal cavities . , , .751 Anterior rhinoscopy . . . , , .754 Posterior rhinoscopy . « . . » , ^ 755 Instruments for treating affections of the nasal cavities . . .758 Methods and instruments of medication ..... 760 Diseases of the nasal passages . . , , ^ ^ .764 Acute coryza 764 Idiosyncratic coryza 767 Chronic coryza 768 Hypertrophic nasal catarrh , , • . , .770 Atrophic nasal catarrh . . , ^ , , , 773 Ozaena . . . . , , , , .780 Syphilitic affections of the nasal passages . . , , , 782 Ulcerative diseases of the mucous membrane of the nose • . • 784 Glanders ..... . • • , 785 I^upus ......... 785 Tuberculosis of the nasal mucous membrane . • . . 786 Submucous inflammation and abscess of the nasal cavity . . . 787 Profuse watery discharge from nostrils . , , , , 787 Epistaxis ..... ; . , .788 Stenosis of the nasal passages 794 Closure of the nostrils . , » , , . ,796 Affections of the septum - . » , , . , 797 Extravasations of blood in septum . , . . . 797 Abscess of septum ...•».,. 797 Syphilitic induration of septum 798 Submucous infiltration of septum . , , , ^ , 799 CONTENTS. xvii i pa(;e Affections of the septum — Deflection or deviation of septum . . • • , .71)9 Fractures and dislocations of septum . . • • ,801 Tumors of septum ...... 801 Congenital occlusion of posterior nares ..... 802 Bifid septum ........ 804 Foreign bodies in the nasal passages ...... 804 Nasal calculi, or rhinolites 80G Parasites of the nasal cavity ....... 808 Tumors of the nose . . . . , . . .810 External tumors . . . . . . . .810 Tumors of the nasal passages . . , . , .810 Mucous polypus, or myxoma . . . . . ,813 Fibrous polypus . . . . . . . ,817 Cartilaginous growths ....... 824 Osseous growths . . . . . , . ,824 Sarcomatous growths . , . . . , ,825 Carcinoma ........ 825 Other nasal tumors 82(5 ' Neuroses of the nasal passages • . . , . , ,826 Anosmia ......... 827 Hyperaesthesia . . . , . . , .829 Sternutatio, or excessive sneezing . . , , , . 829 Spasmodic twitching of the nose ...... 830 Paralysis of the nostrils ....... 830 Nasal cough, and the existence of a sensitive reflex area in the nose . 830 Injuries to the nose . . . . . . , .831 Fractures of the nasal bones . . . . . .831 Dislocations of the nasal bones ...... 833 Wounds of the nose ....... 833 Injuries to the nose with lodgment of foreign bodies ... 833 Burns and scalds of the nose 834 Deficiencies and deformities of the nose 834 Injuries and diseases of the frontal sinus ..... 83(> Fractures of the frontal sinus 836 Inflammation and abscess of the frontal sinus .... y;3G Dropsy of the frontal sinus . . . . . .837 Tumor of the frontal sinus . , . . . ^ 337 Foreign bodies in the frontal sinus * • . . . 839 Diseases of the ethmoidal cells ....... 839 Diseases of the antrum of Highmore ...... 840 Inflammation and abscess of the antrum . . . , .840 Effusions of blood in the antrum ...... 843 Tumors of the antrum ....... 843 Diseases of the skin and subcutaneous tissues of the nose , . . 843 Note on pathology of hay -fever . . . . . , ,843 Appendix : Rhinoplastic operations. (By the Editor.) ^ . . . 844 VOL. IV.— B. xviii CONTENTS. INJURIES AND DISEASES OF THE FACE, CHEEKS, AND LIPS. / By ALFRED C. POST, M.D., LL.D., EMERITUS PKOFESSOU OF CLINICAL SURGEKY IN THE UNIVERSITY OF THE CITY OF NEW YORK ; CONSULTING SURGEON TO THE NEW YORK HOSPITAL, ST. LUKE'S HOSPITAL, THE PRESBYTERIAN HOSPITAL, AJ^D THE woman's STATE HOSPITAL. Wounds of the cheek Facial paralysis Salivary fistula .... Facial neuralgia or tic douloureux Burns of the lips and cheeks Frostbite of the lips and cheeks . . Facial erysipelas Malformations and deformities of the cheeks and lips Harelip . . . . . Wounds of the lips Furuncle and carbuncle of the lips J'issures of the labial margin, or cracked lips Ulcers of the cheeks and lips Cancer of the lip . . . Telangeiectasis of the lips Port-wine marks Cysts of the lips Tumors of the lips Hirsuties .... Cheiloplastic operations PAGE 841) 850 850 851 853 853 854 854 856 860 861 861 861 862 863 864 865 865 865 865 INJURIES AND DISEASES OF THE MOUTH, FAUCES, TONGUE, PALATE, AND JAWS. By CHRISTOPHER HEATH, F.R.C.S., HOLME PROFESSOR OF CLINICAL SURGERY IN UNIVERSITY COLLEGE, LONDON, AND SURGEON TO UNIVERSITY COLLEGE HOSPITAL. Injuries of the mouth, fauces, and tongue ..... 885 Wounds of the tongue 885 Wounds of the fauces .... iiiip. CONTENTS. XIX PAGE Injuries of the mouth, fauces, and tongue — Wounds of tlie pharynx . . . . . . . 88G Foreign bodies in tiie pharynx ...... 886 Diseases of the mouth and fauces ...... 886 Inflammatory affections of the mouth and fauces .... 886 Stomatitis ......... 887 Tonsillitis ......... 887 Pharyngitis ...... . . 888 lirysipelas of the fauces and pharynx ..... 888 Hyi)ertrophy of the tonsils ....... 888 Hypertrophy of the uvula ....... 890 Ulceration of the tonsils . . . . . . .801 Tumors of the tonsils . . . . . ... 801 Follicular disease of the pharynx ...... 802 Tumor of the pharynx ....... 80.') Diseases of the tongue ........ 803 Tongue-tie ........ 893 Ranula ......... 803 Inflammatory swelling beneath the tongue . . . . g<)4 Hypertrophy with prolapse of the tongue, or macroglossia . . . 804 Atrophy of the tongue . . . . . . . 895 Naevus of the tongue ....... 805 Congenital tumor of the tongue ...... 895 Lymphangeioma of the tongue . . . . . . 805 Glossitis ......... 895 Abscess of the tongue ....... 89(> Gummata of the tongue ..... . . 896 Chronic glossitis ........ 896 Alterations in the cuticle of the tongue ..... 897 Simple ulcer of the larynx ....... 898 Syphilitic ulceration of the tongue ...... 898 Tubercular ulceration of the tongue . . . . . 899 Cancerous ulceration of the tongue ..... 899 Operations for removal of the tongue . .... 900 Malformations and diseases of the palate . . . . . 907 Cleft palate ........ 907 Staphyloraphy ....... 999 Uranoplasty . . . . . . . .911 Ulceration of the palate . . . . . . .913 Nodes of the hard palate . . . . . . .913 Necrosis of the hard palate . . . . . .913 Tumors of the palate . . . . . . .914 Diseases of the gums . . . . . . . • . 915 Hypertrophy of the gums . . . . . . .915 Naevoid condition of the gums ...... 91.3 Gingivitis or inflammation of the gums . . . . .916 Spongy condition of the gums . . . . . .016 Transparent hypertrophy of the gums . . . . .910 XX CONTENTS. Diseases of the gums — Epulis .... Myeloid tumors of the gums • Papilloma of the gums Ulceration of the gums , , Diseases of the jaws Inflammatory deposit in the lower jaws Alveolar abscess Chronic abscess of the lower jaw . Suppuration or empyema of the antrum Periostitis and necrosis of the jaws . Hyperostosis of the jaws Odontoma .... Cysts of the jaws . Tumors of the jaws Fibroma of the jaws . Enchondroma of the jaws Osteoma of the jaws . Pulsating tumors of the jaws . Cystic sarcoma of the jaws Sarcoma of the jaws Carcinoma of the jaws Operations on the jaws . Removal of the upper jaw . , Removal of the lower jaw , Closure of the jaws . . , 917 917 917 917 918 918 918 919 919 921 923 923 924 927 927 928 928 929 929 930 933 934 935 937 938 SURGERY OF THE TEETH AND ADJACENT PARTS. By KORMAE^ W. KimSLEY, M.D.S., D.D.8., LATE PROFESSOR OF DENTAL ART AND MECHANISM IN THE NEW YORK COLLEGE OF DENTISTRY. Surgery of the deciduous teeth * . Lancing the gums . Extraction of deciduous teeth Surgery of the permanent teeth Extraction of permanent teeth Irregularities of the teeth Dental caries Toothache . Alveolar abscess Cystic tumors of the jaw Prothetic dentistry Mechanical treatment of lasions of the palate 943 943 944 945 945 946 949 953 954 954 955 960 LIST OF ILLUSTRATIONS. CHROMO-LITHOGRAPHS. PLATE XXVII. Morbid conditions of the eye . XXVIII. Morbid conditions of the eye as seen by the ophthalmoscope XXIX. Normal and morbid appearances of membrana tympani XXX. Normal and morbid appearances of membrana tympani XXXI. Epithelioma of the face , , • PAGE 670 676 747 748 861 WOODCUTS. FIG. 802. Diagram supposed to represent extra-capsular fracture of the cervix fem oris. An impossible line of fracture 803. Comminuted fracture .... 804. Transverse, oblique, and longitudinal fractures 805. Longitudinal fracture of tibia 806. Voluminous callus in fractured femur 807. Diagram of false joint .... 808. Smith's apparatus for ununited fracture of the leg 809. Smith's apparatus for ununited fracture of the thigh 810. Pancoast's screw for ununited fracture . . • 811. Improved drill for ununited fracture 812. Blandin's bone-director .... 813. Taylor's osteoclast . . • • 814. Fractures of the lower jaw 815. Comminuted and fissured fracture of lower jaw . 816. Fracture of lower jaw at angle 817. Fracture of lower jaw at symphysis and angle 818. Fracture of sternum .... 819. Multiple fracture of the pelvis 820. T-fracture of the ilium .... 821. Fracture of clavicle with downward displacement of outer fragment 822. Levis's apparatus for fracture of the clavicle 823. Sayre's dressing for fractured clavicle ; application of first strip ( xxi J4 17 18 19 37 47 59 59 61 61 62 65 72 73 75 75 89 92 94 101 110 111 xxii LIST OF ILLUSTRATIONS. FIG. 824. 825. 826. 827. 828. 829. 830. 831. 832. 833, 834. 835. 836, 838. 839. 840. 841. 842. 843. 844. 845. 846. 847. 848. 849. 850. 851. 852. 853. 854. 855. 856. 857. 858 859. 860. 861. 862. 863. 864. 865. 866. Sayre*s dressing for fractured clavicle completed. Front view The same. Back view . . " , Fracture of the scapula • . . . . Application of compress and adhesive plaster to overcome deformity fracture of surgical neck of humerus Diagram illustrating tilting of lower fragment in fracture of humerus near elbow . . Splint of binder's board for fracture of lower part of humerus Diagram showing transverse fracture of lower end of humerus and line of epiphyseal disjunction ....... Diagram of T-fracture of lower end of humerus with lines of fracture of internal condyle, epitrochlea, and internal condyle Fracture of lower end of humerus Hinged splint for elbow, with Stromeyer's screw Bond's splint for fracture of the radius Coover's splint for fracture of the radius . 837 Levis's splint for fractured radius Ligamentous bands beneath synovial capsule of hip-joint. (After Ames bury.) . . . Diagram showing lines of fracture in upper part of femur Shortening of cervix femoris consecutive to fracture Diagram showing a femur united by a bridge of callus Smith's anterior splint for treatment of fractured thigh Hodgen's suspension splint for treatment of fractured thigh Deformity in " Pott's fracture" Fracture-box with movable sides . Frame for suspending fracture-box Wire frame for suspending leg . Mode of supporting leg with strips of bandage . Side splint for making extension in fractures of the leg Extension-splint adjusted .... Posterior view of vertebral column, ribs, etc. (Sibson ) Knife -wound of dorsal spine Arrow-head impacted in fourth dorsal vertebra . Shell-wound of the back .... Shell-wound of lumbar and gluteal regions Cicatrix of same wound nine years afterwards Distribution of occipitalis major, occipitalis minor, and auriculo-temporal nerves to scalp. (Hilton.) ... Course of sixth and seventii dorsal nerves. (Hilton.) Forward luxation of fourth cervical vertebra Fracture witliout displacement of fifth cervical vertebra Thermograph of fatal case of fracture of fifth cervical vertebra Transverse fracture of first lumbar vertebra Fractures of fifth, sixth, and seventh cervical vertebrae. (Hilton.) Caries of cervical vertebrae from gunshot contusion Gunshot fracture of ninth dorsal vertebra Gunsliot fracture of third lumbar vertebra LIST OF ILLUSTRATIONS. Xxili FIG. PAGE 867. Gunshot perforation of first lumbar vertebra .... SiV.) 868. Interior view of vertebrae shown in preceding illustration . , 370 869. Gunshot perforation of lumbar vertebrae ..... 370 870. Gunshot fracture of dorsal vertebrae . * . . . .371 871. Musket-ball in spinal canal . . ... . ,371 H72. Gunshot fracture of seventh dorsal vertebra . . . .371 873. Pistol-ball lodged in last dorsal vertebra ..... 372 874. Gunshot fractures of last dorsal and first lumbar vertebrae . . 372 875. Musket-ball imbedded in intervertebral substance . . • 372 876. Gunshot-fracture of second lumbar vertebra . . . .376 877. Spinal cord and roots of spinal nerves, etc. .... 382 878. Musket-ball compressing cord in lumbar region .... 393 879. Laceration of spinal membranes from fracture of first lumbar vertebra . 397 880. Pistol-ball lodged in spinal foramen of fourth lumbar vertebra « . 404 881. Efi'ects of traumatic spinal meningitis and myelitis . . , 407 882. Sacro-gluteal eschar of neuropathic origin .... 422 883. Penetration of sacral canal by bed-sores , . . . .431 884. Shot-fracture of sacrum and ilium ..... 455 885. Shot perforation of sacrum ...... 455 886. Gunshot fracture of sacrum . . . . . . 455 887. Sacrum grooved by musket-ball ...... 455 888. Sacrum grooved transversely by musket-ball - . - .456 889. Ball impacted in left upper sacral foramen - . . . 456 890. Posterior view of same specimen . . v . . « . 456 891. Sacrum with ball impacted ...... 457 892. Shot fracture of sacrum ....... 457 893. Shot penetration of sacral canal ...... 458 894. Gunshot perforation of sacrum ...... 458 895. Ball lodged in spinal canal . . . . .459 896. Conoidal ball extracted from sacrum with ramrod . . . 460 897. Distribution of nerves to sacrum, coccyx, etc. (Hilton.) . . 462 898. Lower part of spinal cord and distribution of spinal nerves. (Swan and Hilton.) ........ 466 899. Taylor's apparatus for treatment of Pott's disease of spine . . 545 900. Suspension of patient for application of rigid jacket by Sayre's method . 546 901. Tripod for suspending patient in applying rigid jacket . . . 546 902. Jury mast for support of head in cases of Pott's disease above the third dorsal vertebra 550 903. Frontal section of adult skull through middle of orbit. (After Merkel.) . 562 904. Horizontal section through orbit of adult male. (After Gerlach.) . 563 905. Transverse section of optic nerve. (After Merkel.) . . . 564 906. Longitudinal section of entrance of optic nerve into eyeball. (After Merkel.) 564 907. Cross-section of optic nerve at point of passage through lamina cribosa. (After Merkel.) . . . . . . -564 908. Diagram showing shape of eyeball. (After Merkel.) . . . 565 909. Sagittal section of eyeball. (After Merkel.) .... 567 910. Meridional section of anterior half of eyeball. (After Gerlach.) . . 567 911. Ciliary muscle. (After IwanofF and Arnold.) .... 568 xxiv LIST OF ILLUSTRATIONS. FIG. 912. 913. 914. 915. 916. 917. 918. 919. 920. 921. 922. 923, 925. 926, 928. 929. 930. 931. 932. 933. 934. 935. 936. 937. 938. 93a. 940- 941. 942. 943. 944. 945. 946. 947. 948, 950. 95L 952. 953. 954. 955. 956. 957. 958. 959. 960. 961. 962. Equatorial section of eyeball, posterior segment. (After Merkel ) Diagrammatic section of retina. (After Shultze and Schwalbe ) Diagrammatic horizontal section of eye. (After Merkel ) Eye in normal situation in orbit, seen from in front. (After Merkel ) Eyehds closed ; skin removed to show tarsal glands. (After Merkel ) Orbicularis and neighboring muscles. (After Merkel.) Fibro-sarcoma of orbit causing exophthalmus . Spud for removing foreign bodies from cornea '. Broad needle for removing foreign bodies from cornea Liebreich's spring-stop speculum for separating eyelids Fixation forceps . 924 Bowman's stop-needles, curved and straight Grooved needle for fluid cataract . 927 Jaeger's keratomes . . • Cystotome Paracentesis needle and curette . Graefe's cataract knives . Graefe's tortoise-shell spoon Different forms of iris forceps Iris scissors Wecker's scissors, modified by Keyser Strabismus hooks Strabismus scissors Sands's needle-holder Ring-forceps for tumors of eyelid . Weber's probe-knife Bowman's probes . Williams's bulb-pointed probes Section of eyeball showing intra-ocular tumor Wilde's ear-speculum Forehead-mirror . Forehead-mirror ; profile view Forehead-mirror in actual use Angular forceps . 949 Curette and slender probe . Auricle. (After Urbantschitsch.) Politzer's apparatus Hard-rubber curved nose-piece Eustachian catheter Ear-douche • • Hard-rubber pronged ear-nozzle . Middle-ear pipette Blake's snare Proper method of holding Blake's snare Mastoid process of ciiild . Mastoid process of adult . Extensive distribution of mastoid cells Relations of facial canal to middle-ear and mastoid cells LIST OF ILLUSTRATIONS. XXV 963. Henle's diagram showing relations of parts of temporal bone 964. Strong periosteum knife . . • • • 965. Mastoid drills 966. Forehead-reflector . . - • • 967. Illwminating apparatus for rhinoscopy 968. Robert and Collin's nasal speculum 969. Fraenkel's nasal speculum . . . - 970. Nasal speculum 971. Elsberg's nasal speculum , . . - • 972. Thudichum's nasal speculum . . - - 973. Rhinoscopic mirror . . • ' - 974. Turck's tongue-spatula . - - ' • 975. Anterior rhinoscopy . • - - - 976. Posterior rhinoscopy . . . • - 977. The rhinoscopic image . . - • - 978. The rhinoscopic image . • • • ' 979. Vault of pharynx as seen by posterior rhinoscopy . 980. ■ Nasal douche 981. Nasal spray -apparatus . . • • ' 982. Posterior nasal syringe . . • - • 983*. Posterior nasal tube fitted to Davidson's syringe . 984. Compressed-air atomizer or spray-producer 985. Spray-tube with patent cut-off . . - - 986. Atomizer throwing spray downward 987. Another form of atomizer . . - - - 988. Insufflator for anterior nares . . . - 089. Insufflator for posterior nares . * - - 990. Robinson's tube for insufflation of nares . 991. Smith's guarded canula for applying nitric acid to nasal passages 992. 993 Nasal electrodes . . . . • 994. Jarvis's wire ecraseur . . . • • 995. Nasal curette 996. Double lip. (After Agnew.) . . • 997. 998 Operation for harelip with divergent margins 999, 1000. Malgaigne's operation for harelip 1001, 1002. Operation for harelip with marked irregularity of sides 1003. Telangeiectasis of lip strangulated with pins and ligature . 1004. Application of subcutaneous Hgature 1005. " Telangeiectasis of lip strangulated by ligatures crossing each other angles 1006. 1007. Dieffenbach's operation for restoration of upper lip . 1008, 1009. Sedillot's operation for restoration of upper lip 1010, 1011. Buchanan's operation for restoration of louver lip . 1012, 1013. Buck's operation for restoration of lower lip. 1014, 1015, 1016. Buck's operation for restoration of upper lip . 1017, 1018. Cheiloplasty of lower lip. (After Serre.) . 1019, 1020. Cheiloplasty of loAver lip and angle of mouth. (After Serre.) 1021, 1022. Cheiloplasty of lower lip and angle of mouth. (After Serre.) at rl.Z^ P^'^^jfo'". study in regard to these injuries are: their causes; the mechanism of their production; their varieties ; the phenomena and symptoms attending them their diagnosis; their consequences; their complications; the mode of their repair and deficiencies in this process; their prognosis; and the principles of their treatment. All these topics will be first taken up 111 a general way, and they will subsequently be considered in reference to the severa hones. Causes op Fkacture. Fractures are always caused by force, and by adequate force ; althouo-h under certain circumstances it may and does seem as if the bones gave wav as It were of themselves Hence the term "spontaneous" has been used! out, as will be hereafter shown, it is not strictly correct. The causes of fracture may be divided into immediate and predisposing. Under the former head are embraced the various forms of violence under which bones give way while under the latter belong all conditions, whether of the body at large, of the skeleton, or of the individual bones, which expose tne latter to fracturing forces, or make them more ready to yield. i,erv!.''!^o,'r« "i *''",f °f ^'■'''^■■^ '° 8«n«™lly attended with lesions of the great interest hat tl---^^^ "« 'V'T''''""' ^""'^ magnitude and such special interest, ttiat these subjects will be hereafter dealt with in separate articles. CAUSES OF FRACTURE. 3 Immediate Causes.— It would be vain to try to enumerate all the special forms of violence by which, in the complicated conditions of human life, bones are broken. But they may be classilied under four general heads : direct and indirect violence, muscular action, and avulsion. Direct violence is that wdiich is inflicted upon the bone at the point where the fracture occurs ; such as a blow with a stick or a stone, the passage of a wheel over a limb, or the fall of a heavy body upon it. Here the momentum of the impinging mass is expended in overcoming the resistance of a portion of the bony tissue. . , , i x- ^-u Indirect violence is that which is transmitted through some length ot the bone, which becomes an overtaxed lever ; as, for example, when a man falls from' a height, alighting upon his feet, and the femur gives way at some por- tion of its shaft. Here the resistance of the ground, acting through the loot and leo-, fixes the low^er end of the femur, while the momentum of the body continues to drive the upper end of this bone downward ; and the natural curve of the shaft is increased until its texture gives way. ^ ^ As will presently be further shown, there is often also an element of twisting added to the leverage. . -, , ^ - ^ ^ Muscular action, when it causes fracture, must either be extremely violent and sudden, as in cases of convulsion or very powerful effort, or the bone must be taken at a disadvantage, as wdll be further explained in speaking of the mechanism of fractures generally, as well as of those of special bones. _ Fractures by avulsion are those in which a small fragment of bone is torn away by the stress put upon ligamentous structures attached to it. They are more generally known at present as "sprain-fractures," and^ the observations to be made concerning them will be found in connection with fractures close to the joints, especially of the knee and ankle. ^ So many illustrations of the foregoing statements will be given m dis- cussing the mechanism of fractures, as well as in describing these injuries as affecting special bones, that I shall dwell no further upon them here ; only sayins: that in very many cases the agency of indirect force is greatly aided by the occurrence of muscular contraction at the moment of its application. Predisposing Causes.— Among the general diseases which have been thus ranked by authors, there are some which admit of much doubt. Thus, in regard to gout, rheumatism, and scurvy, there seems to be no evidence that they render the bones more fragile ; although they may possibly, by crippling or weakening the limbs, make their victims clumsy, and less able to avoid falls or escape violence. Yet it must be remembered that persons so diseased are obliged to take care of themselves, and to abstain from the active pursuits which would involve exposure to the usual fracturing forces. Scrofula has been placed by some writers in this category, but there is really no evidence that it belongs here. Its subjects are sometimes ill-nourished and feeble, and very probably their bones, like their tissues generally, are weak in texture. But many of the scrofulous are strong and active, and in these there is no sign of fragility of the bones unless they are actually affected with caries, and not alwavs then. After healing has taken place, the osseous tissue hceras to be condensed and peculiarly firm, although the constitutional disorder may be still progressing. Syphilis has been assigned by some as a cause of fragility of the bones, and many cases are on record in support of their views. Berkeley Hill^ mentions a case in which a child six weeks old, already affected with snuffles and pem- phigus, sustained a fracture of the left humerus by the mother " catching the 1 Syphilis and Local Contagious Disorders, 2d ed. London, 1881. 4 INJURIES OF BONES. arm in a hole in the towel with which the child was being dried. When the child was examined, the right clavicle was bent and thickened with callus near its middle, where it had been broken at some time unknown to its mother. The fractured bone united in the usual manner." He also speaks ot fractures occurring in syphilitic children during their birth, quoting a case recorded by Porak ;i and says that " in adults the bones occasionally give way under a trifling strain." Gross^ mentions the case of a man aged 31, whose humerus gave way as he threw a small chip at a dog. He had had syphilis seven years before, and was at the time subject to nocturnal pains in the arm and forearm. Prof Chiari, of Prague,^ maintains that the occurrence of "gummous osteomyelitis," or central gummata, in the medullary structure of the long bones, is not rare, and may afi:brd an explanation of these cases of apparently spontaneous fracture. But when we consider, first, the immense number of syphilitic patients constantly under observation, and the rarity of Iractures among them, and secondly, the fact that in many persons presumably free from any such taint the bones give way to seemingly inadequate force it must be admitted that the basis of the theory that syphilis weakens the bony structures is but a slight one. Only a very few instances have been reported m which fractures have taken place at the seat of the so-called tertiary lesions.* Cancer is another malady which has lons^ had the reputation of affecting: the strength of the osseous system. But here also the fact would seem to be that It IS only when local manifestations of the constitutional taint occur in the bones, that these organs show any unusual fragility. At least we may say, as m the case of syphilis, that in view of the great number of cases of cancer constantly under the eyes of the profession, it is strange that fractures without local deposit should so seldom occur, if the pathological change in the bones were really an element in the natural history of the disease. It is otherwise with regard to certain disorders of the nervous system, which are attended with such degeneration of the nerve centres as to affect the trophic innervation of many organs, and especially of the skeleton. Perhaps the bones betray this influence the more readilv by reason of their low grade of organic activity. Attention seems to have been first drawn to this subject by Davey,^ who reported the case of an insane person, an autopsy upon whom disclosed six so-called "spontaneous" fractures— three in the two femora, and three in the humerus, radius, and clavicle respectively. At a later period, the frequency with which fractures of the ribs were found in patients dying in lunatic asylums, attracted notice; it was thought that these lesions were due to maltreatment by attendants, until the publication of numerous observations by Pedlar ,6 Hearder,^ and others, showed softening of the bones to be one of the elements of a tabetic condition apt to occur in the later stages of insanity. The bones of two insane persons dying with frac- tured ribs, are said by Ormerod^ to have been dark, wet, greasy, easily decomposed, enlarged, and with thin outer walls ; under the mfcroscope they showed much fatty matter, and a granular condition like ossifying cartilage. According to T. L. Eogers,^ the organic constituents of the bones in a ' (raz. Med. de Paris, 1877, p. 538. « System of Surgery, vol. i. p. 898, 6th ed., 1882. 3 Phila. Med. Times, Feb. 10, 1883, from Vierteljahrsschr. fur Dermatoloffie uiid Syphilis. * Arnott, London Med. Gazette, June 5, 1840. 6 Medical Times, Dec. 24, 1842. 6 West Riding Lunatic Asylum Report, 1871. 7 .Journal of Mental Science, .Tan. 1871. ^ i- > ' St. Bartholomew's Hospital Reports, vol. vi. 1870. » Liverpool Med. and Surg. Reports, vol. iv. 1870. CAUSES OF FRACTURE. 5 similar case were in larger amount, and the proportion of lime to phosphoric acid less, than normal ; the bones resembling those of the fcetus. Moore^ placed upon record a case of " osteo-malacia" in a woman, aged 70, the sub- feet of acute mania, who had had at different times four fractures, and who died soon after the fourth. He does not appear, however, to have recog- nized this "breaking down of the bone-tissue" as dependent upon the disease of the central nervous system. In 1867 I made an autopsy in the case of the late Dr. Pennock,^ who had been long a paralytic ; the bones were all so soft as to be easily cut with a knife, and presented much the same appearance as those above mentioned, although no fracture had taken place. Dr. Weir Mitchell, in 1873,^ in an article on "Rest in Locomotor Ataxia," said : " It naturallv occurs to ask why so many ataxies have chanced to break limbs ? and as to this I should answer, first, that no people are so awkward or fall so much ; and, next, that in some of the cases it seemed to me that the habitual abruptness of the muscular acts had a share in the calamity, and that I have suspected, what has not yet been proved, that the bones in ataxics may suffer some impairment of their nutrition, and hence of their strength." Charcot^ reported a very remarkable case, in which several fractures occurred in the person of an ataxic woman ; and referred, with assent, to the suo:gestion of Mitchell, just quoted. Further observations were communicated to "the Pathological Society of London, in 1880, by Buzzard,^ and the subject was discussed by Hutchinson and others. A lady, about 60 years of age, was under my care in 1879, who had long been paraplegic, and who, by catching her foot against a cushion as she was lifted into a carriage, sustained a fracture of both bones of the right leg ; just about a year pre- viously siie had broken the other leg from an equally slight cause. A very similar case, in a man of 65, was placed on record by Mr. Busk.*' Professor Bruns, of Tubingen, has published a very interesting paper,^ based upon the case of an ataxic" woman, set. 57, who had sustained fractures, at different times, of both forearms ; the right without known cause, the left in lifting a plate. He gives a long list of references to articles, by various authors, bearing upon the subject, and defines the change which occurs in the bones as an eccentric atrophy, with rarefaction of the compact substance, and filling of the widened marrow-spaces with fat. Eoss,^ speaking of tropho-neuroses, says : — " Spontaneous fractures have attracted the attention of surgeons from a remote period, but these accidents were attributed to the influence of certain diatheses, such as gout, rheumatism, scrofula, and cancer. Larrey drew special attention to the fact that a cer- tain form of paralysis of the lower extremities was associated with a strong predisposi- tion to fractures of their bones. In the record of this case, however, it is mentioned that the so-called paralytic symptoms were associated with amaurosis and great exalta- tion of the sensibility of the lower extremities, which renders it almost certain that the symptoms were not due to paralysis, but to ataxia. In 1873, Weir Mitchell drew attention to the frequency of spontaneous fractures in locomotor ataxia, and suggested » St. George's Hospital Reports, 1871-2. « See American Journal of the Medical Sciences, July, 1868. » Ibid., July, 1873. * Arch, de Physiologic, Janvier, 1874. 5 Brit. Med. Journal, Feb. 14, 1880. The reader may refer with advantage to another article by Buzzard, "On the Affection of the Bones and Joints in Locomotor Ataxy," in the British Medical Journal for March 5, 1881. 6 London Medical Gazette, April 10, 1840. ' Spontan-fracturen bei Tabes. Berl. klin. Wochenschr., March 13, 1882. 8 Treatise on Diseases of the Nervous System, 1881, vol. i. p. 224. 6 INJURIES OF BONES. that during the progress of the disease the bones had undergone nutritive changes which greatly diminished their resistance. This subject was subsequently investigated by Charcot and his followers, with their usual thoroughness and success. The period of fracture is usually preceded by two or three paroxysms of lancinating pain ot" unusual severity ; and at the same time the limb is found swollen, and with all the symptoms of osteo-periostitis, and fracture occurs on the slightest movement of the limb, or in "the entire absence of any movement or other external cause. The femur is more frequently fractured than any other bone, the seat of fracture being frequently the neck of the ormer ; but the bones of the leg, arm, forearm, and, indeed, almost every bone of the hmb and trunk, have been found fractured, including the vertebral column. Multiple fractures in the same patient are by no means uncommon, and in a case published by Charcot, the patient, towards the close of life, could scarcely move in bed without frac- turing some one or other of the few bones which had not been already fractured. Damaschino has drawn attention to the fact that the spontaneous fractures of ataxics reunite very readily and rapidly, with an enormous formation of callus." Dr. Debove, in a communication to the Paris Hospital Society, observed that m his practice at the Bicetre, he had frequent occasion to see fractures in the subjects of hemiplegia, these fractures always occurring: on the hemi- plegic side, there bemg every reason to believe that changes took place in such cases m the osseous tissue, rendering it more fragile. In one case of chronic hemiplegia he found that not only the fractured bone itself, but all the bones on the same side, had undergone such change. They were less heavy than on the sound side, the medullary canal was larger, and the sub- stance of the diaphysis was less compact. Examined histologically, the Haversian canals were found much dilated, and the bone porous. Chemical examination also showed that the diaphysis contained a larger quantity of fat ihese fractures usually consolidated rapidly, the callus'' bein^ somewhat voluminous.^ It would seem clear, from the foregoing, that there is in many forms of cen- tral nervous disease, including hemiplegia, paraplegia, locomotor ataxia, gen- eral paralysis of the insane, and perhaps other allied conditions, a state of detective nutrition brought about in the bones, whereby they are rendered either softer or more brittle, and which causes them to yield very readily to slight fracturing forces. Very possibly, further study of the subject may throw additional liglit^ upon the whole series of changes ; but the statement just made is an embodiment of what is now known with regard to it. Rachitis, or rickets, a disease supposed by most w^riters to be almost wholly unknown m this country ,2 has been not unfrequently observed as a predispos- ing cause of fracture by British and Continental surgeons. It affects children chiefly, and is manifested by softening and distortion of the bones, with en- largement of their articular extremities. It may be that such cases often occur among the lower classes of our negroes, the parents being ill-fed, poorly clothed, and often strumous or syphilitic ; and that the deformed limbs so commonly seen in that race among us, are the traces of con2:enital rickets. Hamilton^ mentions a case seen by him in 1853, in which, in an infant four days old, born of a healthy mother and at full time, "nearly all of the 1 Medical Times and Gazette, Oct. 29, 1881 ; from Gaz. des Hopitaux, 20 Oct. 1881 ^i^cP^.*" I^achitis, by Dr. J. Lewis Smith, Vol. I. p. 251. In the American Journal of the Medical Sciences for January and April, 1872, the reader may find an admirable discussion of this disease by the late Dr. John S. Parry, who says he ''has been irresistibly forced to the conclusion that rachitis is scarcely less frequent in Philadelphia than it is in the large cities of Great Britain and the continent of Europe, and that it should occupy just as important a place in our mortuary lists as Hillier conceives that it should in those of ' the registrar-general of Practical Treatise on Fractures and Dislocations, 6'th ed., 1880, p. 33. CAUSES OF FRACTURE. i lono- bones were separated and movable at their epiphyses, the motion being o-enerally accompanied with a distinct crepitus. The bones were also much enlaro-ed in their circumference ; the bones of the forearm and the temur were greatly curved; the fontanelles were unusually open; and the clavicles were entirely wanting. The child was of full size, hut looked teeble. It died in a condition of marasnms six months after birth ; at which time some deo-ree of union had taken place at several of the i)oints of separation, the limbs havino- been supported constantly with pasteboard splints and rollei-s." A case was reported by Collins to the Manchester Medical Society m which a condition allied to rickets seemed to have been brought about m a child by the deficiency of casein in the mother's milk. The child was born January 2, 1882 ; when first seen, January 13, the left femur presented every appearance of having been fractured and recently united. On the 30th, the left humerus was found to be broken; on February 20, the right humerus,, and on February 24, the right femur. Each fracture was at the centre of the shaft, and there was in no i'nstance any evidence of violence or injury. There was no history of syphilis ; the child's bones were curved. All the fractures united readily. As illustrative of the more pronounced cases of rickets, 1 may quote trom Malgaigne^ a case recorded by Jacquemille: •• The patient was " born of healthy parents, but affected from his first year with gene- ral rachitis, which liad flattened his ribs, distorted his spine, and curved all the long bones except tlie humerus. He could not walk till five years old, and remained always excessively small and feeble. Toward the age of twelve, in climbing a wood-pile, he fell and broke the right arm at the middle. The fracture was simple, and united per- fectly. At fifteen, trying to get up behind a carriage, he lost his footing, and fractured both thighs ; which uniting with deformity, he was permanently crippled on the right side. At seventeen, he broke the left arm. At twenty-eight, he broke the left thigh, at a different point from before. Finally, at thirty-two, he again broke the right thigh, likewise at a new point. The case was now lost sight of." Mr. R. Barwell^ lately showed to the Pathological Society of London— A f^irl, aged 17, but apparently very much younger, who presented a most extraordi- nary "series" of deformities. Her family history threw no light on her condition, which was not congenital. In her mental development she was juvenile rather than weak, and she had not reached puberty. Very few of her bones were free from deform- ity. Both humeri were much bent, but especially the right ; so that, on that side, whereas the humerus measured seven inches and a half, the length of the arm from acromion to olecranon was only four inches and a quarter ; again, the right tibia meas- ured nine inches and a half, but the length of leg was only four inches and a half. This was owing to the bone, at about the lower fourth, being bent back on itself, so that it ran upwards and parallel to the rest of the bone. The left olecranon process was greatly lengthened, and placed at an obtuse angle to the shaft of the bone The bones, a few years ago, had been remarkably brittle, and still remained so, but to a less degree. Between the ages of 9 and 13, she had broken her arms four times, and her lower limbs on several occasions. There was no bending of the ribs, nor any enlarge- ment of the epiphyses.' Mr. Barwell did not think that the case could be classed either with rickets or with osteo-malacia. He had had under his care, some years ago, a boy who presented similar deformities, but less marked, and he had endeavored to straighten the femur. On cutting down to it, however, he found that on the slightest force the chisel sank through the whole structure of the bone, 1 Brit. Med. Journ., May 13, 1882. 8 Traite des Fractures et des Luxations, tome i. p. 20 ; Translation, p. 33. » Brit. Med. Journ., Dec. 9, 1882. 8 INJURIES OF BONES. and about five fluidounces of liquid fat flowed out. Both of these patients suttered from pam referred to the convex side of the distorted boiie He thought that there was hypertrophy of the medulla at the expense of the bone proper. J. Cloquet^ says: "M. Esquirol possesses, in his anatomical collection, the skeleton of a rachitic female, in whom nearly all the bones of the limbs and trunk are covered with the traces of fractures more or less well united • seve- ral of them are broken in two, three, or four points of their length These fractures, more than two hundred in number, appear to have occurred at different times, judging from the varying states of the callus." It is not easy to say what was the real nature of this remarkable case, but it is scarcely likely that it was one of ordinary rachitis ; more probably it belonged among- the now recognized tropho-neuroses. * As a general rule, when rachitic children survive the period of the second dentition, the skeleton acquires firmness, and even becomes remarkably dense and strong. Hence it might be questioned whether the adult cases iust quoted should fairly be regarded as belonging under this head.. But the condition known as moUities ossium, malacosteon, or osteo-malacia—'' mitQiim^ of the bones, in plain English— would seem really to differ very little from that which m children goes by the name of rickets ; and Jacquemille's patient may have simply passed from one into the other. Rickets, then, would be the mol- lifies ossium of children, mollifies ossium the rickets of adults ; an idea lon^ aero suggested. But this view must not be too implicitly accepted, since in rickets, although the pathological changes noted in the bones are more those of sub- acute inflammation, there is little or no pain ; while in the mollifies ossium of adults, a disorder m which fatty degeneration seems to be a very important element, the pains are excessive. The tendency of the former, under anything like favorable circumstances, is toward spontaneous cure ; recovery from the latter ha^ never yet been recorded. Of the published cases of mollifies, the subjects have been for the most part females. In some, large amounts of phos- phates and of "animal matters" are said to have been excreted with the urme. ^ Further reference need hardly be made to mollifies ossium, especially as it is highly probable that the cases hitherto ranged under this head may be found to belong properly among the trepho-neuroses before spoken of the changes connected with the bony skeleton being altogether subordinate to. those affecting the central nervous system. Such would seem to be the ex- planation, in the light of the science of our day, of the classical cases recorded by Curling, Solly ,3 Saviard,^ and others. ^ I ought, however, to remark that in some instances the softening is limited m extent ; thus in a case reported by the late Dr. is'eill,* one femur only seemed to be affected. The theory of the neurotic origin of the disease is not here set aside, but we have simply to suppose that a portion only of the central nervous system has undergone pathological change, and that as a re- sult there is degeneration of that part of the skeleton which is dependent upon the tract so involved. ^ Fragilitasossmm, or brittleness of the bones, differs from the already men- tioned predisposing causes of fracture in being not as much a disease as a > Article "Fractures," Diet, de Medecine. Paris, 1824. 2 Solly, Med.-Chir. Trans., vol. xxvii. p. 443 ; Maclntyre, ibid., vol. xxxiii. ; Chambers, ibid., v01« XXXVll. ! H"""^^"^' Transactions, vol. xx. ; Solly, ibid., vol. xxvii. * Malgaigne, op. cit., tome i. p. 21 ; Translation, p. 33. ^ Am. Journal of the Med. Sciences, July, 1874. CAUSES OF FRACTURE. 9 peculiarity. Sometimes it is seen in old people, as one of the changes inci- dent to their time of life ; but it has also been observed as a congenital con- dition, and in rare instances as a matter of heredity, so that many members of a family, and even several generations, may manifest it. From the published accounts, it does not appear that the bones of persons affected with fragility are always, or even generally, small or slight, and their muscular develop- ment would seem to be quite equal to the average stanciard. A few instances only need be here quoted at length. Dr. F. J. Shepherd reported to the Medico-Chirurgical Society of Montreal a case of senile atrophy of the bones, with very remarkable fragility, in a woman aged between 80 'and 90. TyrrelP thus reports a remarkable case of brittleness of bone in a man whose age is not given : — He had been the subject, at the time he was last under my hands, of seventeen frac- tures ; and when I last saw him, tliree or lour years ago, he had liad five more frac- tures, making in all twenty-two. These fractures affected the femur, the tibia and fibula, the upper arm, and the forearm — scarcely a cylindrical bone of any size had escaped. In consequence of these fractures he had lost in height from seven to eight inches. The first time I had him under my care was in consequence of fracture of the thigh-bone, and the other had been fractured once or twice previously. In consequence of indifferent surgery, that limb was shorter by three inches than that for which he came under my care. He had worn an iron to make up for the difference in the length of the two limbs, and it enabled him to make progression with some inconvenience. Finding this, I stated that it was possible to set the recently broken limb to the same length as the one formerly broken, and at his wish I did so. I made an angular union of the second limb, reduced it to the same length as the other, and he was enabled after- wards to make progression more easily and rapidly. Hence I was the instrument of taking off three or four inches from his height, by shortening the limb to that extent. It may not be anticipating too much to say here that it is difficult to see how walking could have been facilitated by making the leg crooked ; and the experiment is certainly one which surgeons of the present day would hesitate to try. Gibson^ gives the following case of his own : — A patient of mine, a Mr. Green, residing near Trenton, J., has a son now nine- teen years of age, who, from infancy up to the present period, has been subject to frac- tures from the slightest causes, owing to an extraordinary brittleness of the bones. The bones of the arm, forearm, thigh, and leg, have all been broken repeatedly, even from so trivial an accident as catching the foot in a fold of carpet whilst walking across the room. The clavicles have suffered more than any other bone, having been fractured eiglit times. What is remarkable, the boy has always enjoyed excellent health, and the bones have united without much difficulty or much deformity. The above was pub- lished in 1824 ; since then this patient died, in the twenty-third year of his age. . . . Altogether he had experienced twenty -four fractures. Stanley^ speaks of a boy aged ten, under the care of Mr. Earle, in St. Bar- tholomew's Hospital, " who had suffered eight fractures, six in one tibia, and two in the femur. Each fracture of the tibia occurred in a different part of the bone, and had united within the usual period." In a case reported by Arnott,^ a girl aged fourteen years was under treat- ment for her thirty-first fracture ; the right thigh having been broken seven ' Medical News, Nov. 18, 1882. 2 St. Thomas's Hosp. Reports, vol. i. 1836. 3 Institutes and Practice of Surgery, 8th ed. (1850), vol. i. p. 234. * A Treatise on Diseases of the Bones. London, 1849. s London Med. Gazette, June 15, 1833. ' INJURIES OF BONES. t mes, the eft six ; the right leg nine times, the left once ; the right arm four times, the left three; and the left forearm once. Her sister six veare oM had had nine fractures since the age of eight months. NeTer of her pare.S z£:':£^^i^i:;z^ ^-^'^ '^--^''^^ ^^^^^ Agnew' mentions a child seen by him who had twice broken the same thigh ; he was one of a family of six children, every one of whom had sut fered from fracture two of these three times eack The f^thei had had TnS':k:Xg '° '''' of the bones Gurlt^quotes from Axmann another case, in which three brothers showed this tendency to the occurrence of fracture oioiners snowea Of fragility affecting the bones in several generations, a very few instances have been given, but they are beyond doubt.^ Goddard' saV a ^0^8" ed twelve, who had had fourteen fractures, all from slight violence • his moXr had broken her right rtiigh once, and her left five times; and her brother at thirteen years, had suftered two fractures of one thigh, and nine of the other as well as two of the arm. " These people," says the record " are of vevv short stature, and have small bones." ^ ' ^ wl^^^'T ^/r' ^^'^ ^''^'"'^ ^""."^'^y t'^e parish of Offenbach, " three of whom had twice, and one thrice, broken an arm and a leg, while one had five times sutfered fractures of one or another limb, slight force only having been as a rule sufficient o produce the lesions. Both the father and ^-Indfether had had bones broken. The family were otherwise healthy, and presented no discoverable dyscrasia. It is remarkable that none of them sustafned frac tures before they were eight years of age. The fractures united very quickly so that the callus was generally perfectly firm by the end of three weeks But If the same bone was broken a second time, union did not take place." ' in a case reported by Greenish,^ a boy aged 18 had himself had thirteen fractures; his grandfather had had "numlrous" fractures; his fether one his uncle two ; his five cousins (children of his uncle), eight four, fouT fbur' ters Slcaped '''^ ^' ' ''^^ ''=^5' [The editor has recorded a case in which, without apparent reason, seven- teen fractures had been sustained by the bones of the right lower extremity-. Soped ^n ^Cr^J^l^r '''''''' ""^''^^^^ -^hondromata had beJn the Ji<*Hty of individuals to fracture; they are so closely connected in this respect that they may be considered together and ii,!lfr,-!\*''' °i! P"^^-^^''il^e habits, plays, and occupations of boys and gills are veiy much alike, and one might naturally suppose that their bones would be broken with about equal frequency, /et according to Ma^l- gaigne, from two to five years of age, " the number of girls attected lith frac- ture was nearly double that of the boys ;" while Gurlt^ gives the proport on from one to four years IJ times as many, and from five to eight yea^S times ' Principles and Practice of Surgery, vol. i. p. 718. 2 Ekraann's case, quoted by Gurlt from Acrplin« fA n i^qq\ «.« present catego.;,\„t to Lre Uen^lr^^Z' I^J^'^l^^^^^^^^^ be ■„ vagueness of the account enables one to judf^e. ^euiiary racniiis, as lar as the * Gibson, op. cit., vol. i. p. 23G. * Untersuchungen und Erfahrungen im Gebiete der Chirurc^ie 1844 • nnotf^d W Pi^.u Wo v. der Lehre von den Knochenbruchen, Bd. i. S. 149 ' ^ ^ Handbuch 6 Brit. Med. Jouru., June 26, 1880. " e Or^ u * ' " Op. cit., table on p. 9. CAUSES OF FRACTURE. 11 as many boys as girls. The two authors just quoted agree in saying that be- tween the fifteenth and twentieth years of life about eight times as many frac- tures occur in males as in females. Malgaigne thinks that the disproportion then steadily diminishes, until " beyond seventy-five years there are nearly twice as many fractures in women as in men ;" but Gurlt makes the propor- tion between twenty-one and thirty 10 times, and between thirty-one and forty llj times as many male as female cases. Then, according to the latter author, a decrease does occur, and from seventy-one to eighty the women are 2J times, and from eighty-one to ninety 7 times, as often affected with frac- tures as men. I shall make no attempt to reconcile or explain the differences between these estimates, coming from such distinguished sources. Children sustain fractures mainly as the result of falls ; but they are very liable to be hurt in this way, partly from their lack of muscular strength, partly from their heedlessness and love of adventure. Occasionally they put themselves in danger from the kicks of horses, or from being run over ; I once had to amputate the arm of a little fellow, only seventeen months old, for compound fracture caused by the wheel of a passenger railway car. After puberty, the rougher sports of boys render them much more liable than girls, not only to falls, but to other forms of violence ; and during adult life, many of the occupations followed by men are attended with numerous exposures from which women are almost wholly exempt. Our hospital wards attbrd daily evidence of the liability to fracture among painters, carpenters, masons, drivers, and laborers of all kinds. With the advent of old age, the habits of the two sexes become again much more nearly alike, and the accidents to which both are exposed resemble those which are apt to happen to children. Senile feebleness, and the timi- dity which comes wdtli it, is curiously similar in its effect, in this way, to the ignorant and heedless weakness of childhood. And the slighter frames of women yield more readily to sudden strains, so that the excess in the number of their fractures is not a matter of wonder. i^ot only is the frequency of fractures influenced by the causes just dis- cussed, but their character also. In children and in the youth of both sexes, we have to deal mainl}^ with fractures (sometimes incomplete) of the shafts of the long bones, and with epiphyseal disjunctions. In adults we meet with injuries of the former class, and (chiefly in the male sex) with fractures by crushing, as in mining, railroad, and machinery accidents, and falls from heights. Among old people, the bones are more apt to give way, from slight force, at weak points ; thus in them fractures of the neck of the femur are very common. But these points will be again referred to more particularly. Drunkenness has been spoken of by some authors as a source of immunity from fracture ; and in proof of this idea cases are adduced in which persons have fallen from considerable heights, while under the influence of liquor, without sustaining any injuries beyond contusions. But there are very many instances known in which sober people have likewise escaped fractures ; and on the other hand, a large proportion of the patients admitted into hospitals, or treated in private, for this class of hurts, have received them while drunk. The only way in which intoxication can prevent fracture is by relaxing the muscles, and thus rendering the limbs flaccid. Under such circumstances one of the conditions of indirect force as a cause of fracture is set aside, and the bones, if broken, yield to direct violence or crushing. The influence of season, and especially of cold weather, as a predisposing cause of fracture, was insisted on by some of the older writers, who main- tained that the bones were more brittle in winter. This idea need hardly be gravely refuted. When the ground is frozen hard, and rendered slippery by 1^ INJURIES OF BONES. ice and snow falls upon it are perhaps more apt to result in fracture of bones- but on the otner hand in milder weather, out-door occupations are more ex' tensively carried on, whether in the way of work or of sport, and a ^reat many accidents occur to those engaged in them. ^ Something may now be said of the local predisposing causes of fracture Ihe exposed situations of certain bones, and of certain portions of those bones render them especially liable to breakage. Tables are ^iven by sys- tematic authors, derived mainly from hospital records, showino; with more or less accuracy the relative distribution of fractures over the skeleton from a comparison of large numbers of cases. Such tables, as far as I have been able to hnd and compare them, agree in sustaining the following general statement of the comparative liability to fracture of the different portions of the skekton: The greatest number of fractures occur in the bones of the leg ; then follow the thigh, the arm, the forearm, the clavicle, the ribs the lacial bones (including of course the lower jaw), and the patella. A iore detailed exhibit would scarcely be of practical value here, but can be found m the writings of Malgaigne, Gurlt,^orris, and others, by those who may be interested m the matter. - Inflammation of a bone has been assigned as a cause of such weakening of Its texture as to render it apt to give way. Mcod's two cases, quoted by Malgaigne,! seem to bear this explanation ; in each the patient had had pains lor about a month m the humerus, which broke under very slight stress and necrosis, by depriving a bone of a portion of its thickness, may lead to the snapping of the remainder. Tubercle of bone may so alter it as to make it unequal to the resisting of iracturing lorces ; and m a very few instances the same result has been re- corded ol cystic or hydatid tumors. For details of five such cases, the reader IS referred to Gurlt.^ With regard to the development and natural history oi sarcomata of the long bones, by which they have sometimes been similarly attected, much information may be found in a paper by Dr. S W Gross ^ The central sarcomata would seem to be those most apt to weaken the bony structures so as to predispose them to fracture. Spontaneous Yractvk^^.— Spontaneous fractures, so called, are such as oc- cur without any apparently adequate cause. Thus Erichsen* says that he knew a gentleman a little over fifty years of age, seemingly in perfect health, whose thigh gave way with a loud snap as he turned in bed. .Gross^ nientions the case of a gentleman aged 54, who broke his femur in pulling oil a boot. Other like instances are on record. In a larger class of cases, there is evidence more or less clear of a precedent diseased condition of the bones ; and to designate these. Prof. Broca^ sug- gested " pathological" as a more accurate term. Thus there may have been previous complaint of pain at or near the seat of fracture ; and in some cases malignant disease has been present at the time, as in those recorded by Saltier and S. Cooper? Sometimes there is a local development of the disease in the bone, i)revious to its giving way, as in the case quoted from Petit by Malgaigne f or again, the fracture is the first sign of the bone becoming ' Op. cit., tome i. p. 23 ; Translation, p. 34, 2 Qp. cit. S. 193. ' American Journal of the Medical Sciences, July and October, 1879. * *' ' * Science and Art of Surgery, 1873 (Am. ed.), vol. i. p. 303 5 Op. cit., vol. i. p. 899. 6 Oaz. des Hopitaux, 15 Avril, 1876 ; Med. Times and Gazette, May 13, 1876. ^ Salter, Med.-Chir. Transactions, vol. xv.; Cooper, ibid. vol. xvii. ^ Op. cit., tome i. p. 13 ; Translation, p. 26. MECHANISM OF THE PRODUCTION OF FRACTURES. 13 affected, as in an instance recorded by myself.^ Hydatids (cysticercus cellu- losse) are sometimes found in bone, and the first indication of the disease has sometimes been the occurrence of fracture without apparent cause.* Still another set of cases are thus known, in which the bones give way un- der abnormal muscular action, as in epileptic or other convulsions. Lente^ has recorded an instance in which both femora were so fractured. Van Oven* reported a fracture of the femur, by cramp coming on during sleep, in his own person. Many other cases have been published, some of which will be hereafter referred to in connection with the special bones involved. As a general rule, if the muscular action be not clearly pathological, such as that exerted in epileptic states, it is sudden and forcible ; and the fact can often be demonstrated that the bones thus broken are taken at a mechanical dis- advantage. Sometimes, as I shall point out in regard to certain parts of the skeleton^ there is a probability of leverage being the true explanation of these apparently causeless yieldings. It will therefore be seen that the term " spontaneous," if used at all, should be clearly understood either to refer only to the first of the classes of cases just enumerated, or to have a simply conventional meaning, namely, that the force producing the fracture is not obviously adequate to the breaking of a sound bone. For it cannot be imagined that turning in bed, for instance, or throwing a chip, should involve sufiicient strain upon the structure of a normal femur or humerus to cause the fibres to give way. Indeed, in the first class of cases, it may be regarded as almost certain that some pathological change had taken place in the bones, although undetected ; the accounts do not state whether or not there was any further evidence of disease, but such a thing is quite possible. As to the third class, any one familiar with the fearful force of muscular action often manifested by patients afiected with epilepsy or tetanus, will see the absurdity of applying the word " spontaneous" to fractures occurring under such circumstances. ^^"othing ever occurs spontaneously, either in normal or in pathological phenomena ; although it may be that the chain is not traceable without closer observation or clearer insight than is brought to bear upon it. Mechanism of the Production of Fractures. It has already been remarked that the main function of the bony skeleton, and of each of its component parts, is mechanical, and is carried on in accord- ance with the known laws of mechanics. Further than this, each bone is a member of a system, made up of two or more bones, united together by ligaments, and moved upon one another more or less freely by the action of muscles, so that the mechanical conditions involved are somewhat complex, and can only be arrived at by the study of the structure, form, and connec- tions of the members of each system. When the strain put upon a bone is beyond its power of resistance, its fracture takes place in obedience to the same laws, and under the influence of the same conditions. Hence, if any one studies a large number of fractures, placing them in series according to the portion of the skeleton involved, he may readily note a certain uniformity which prevails among the difierent members of each series. Variations do indeed exist, but they are traceable to differences, perhaps slight, in the char- ' Malgaigue, Translation, p. 26. 2 Stanley, op. cit., pp. 190, 194 ; Wickham's case, from London Medical and Physical Journal, vol. Ivii. 3 Amer. Med. Times, July 21, 1860. * Med. Times and Gazette, Dec. 25, 1852. 14 INJURIES OF BONES. Fig. 802 Diagram supposed to represent extra-capsular fracture of the cervix femoris. An impossible line of fractui-e. acter, direction, or exact mode of application of the fracturino- force or In the conditions of resistance, or perhaps in the shape of the bones 'them- selves. Ihe dominant lines of breakage are singularly constant; and although they have been pointed out in regard to certain special fractures they have been overlooked in the general study of these injuries ' m such uniformity exists in the case of china, marble, or plaster. A bowl or statue, struck or thrown down, may be shattered into fragments of the most fantastic and apparently- capricious shapes. Or if several exact models of a femur were made in plaster, and force ap- plied to them, they would be cracked, shivered, or broken off short, in the most ir- regular way. The annexed outline (Fig. 802) is taken from a cut which has been used by eminent authors as a representation of ex- tracapsular fracture of the cervix femoris ; but I Avill venture to say that no one ever saw such a fracture, and that any one will be convinced of its impossibility who will look at a vertical section of the head and neck of the femur. What the dominant lines really are, will be shown when the discussion of fractures of this part comes in order. Only a brief review can be sfiven here of t,,,^ +1 1 • • 1 , . . mechanical conditions of the skeleton ; but the genera principles laid down will be found to be verified in the case of special bones and their fractures. Upon an exterior survey, it is at once seen that the long bones are narrow n their shafts, and expanded at either end for the purpos^e of strengthening the articulations It will be also noted that they are almost without excep" tion curved, and that many of them are twisted in a marked degree. These irregularities of form are-more pronounced in some skeletons than in others, borne of the bones, notably the lower jaw and the femur, are strongly bent. Upon making sections-of the femur for instance, this bone affbrdin- the most striking example-it will be seen that the shaft consists of a tubc^vith 1 "^r^ "^V"'^ gradually pass toward either end into a thin shell, filled with a network of cancellous bony tissue, of which more will be saic presently The aggregate of osseous substance is the same throughout ; so that an inch of the length, taken from the middle of the shaft of the femur will weigh about the same as an inch of the length cut near either end. Sec- tions ot the pelvis and scapula will show a very analogous arrangement be- tween their flat and their spongy portions ; and the same may be^said of the yertebrf^ In other words, the structure of all bones is adapted to the bear- ing ot either strain or pressure, or both. Where, as in the shafts of the long bones, strain is to be provided for, the material is massed in tubes of ade- quate thickness of wall ; and it will always be found that this thickness is greatest on the concavity of curves. On the other hand, where, as at the articulating ends, pressure is io be sustained, the bony substance is spread out so as to give surface. Allusion was just made to the backing up of the thm shell thus formed, by reticular tissue ; and this deserves special notice. J^.verywhcre in the spongy bones, as well as in the articular ends of the ong bones the lamellae forming this network run at right angles to the sur- face, so as to receive the pressure directly upon their extremitfes, and thus to MECHANISM OF THE PRODUCTION OF FRACTURES. 15 afford the greatest possible strength. Sections, vertical or transverse, of the bodies of the vertebrae, of the astragalus, of the carpal or tarsal bones, or even of the articular ends of the phalanges, will show this law ; aud it will be fur- ther-noticed that, in any of these cases, if the surface to receive pressure is concave, the shell of bone is thickened accordingly.^ If now the lines of muscular traction be considered, the further fact will appear that it is invariably exerted so as to bear in the length of these columns of bony tissue, whether of the shafts or of the extremities of the long bones, or of the mass of those more or less cubical in shape. The ribs, pulled upon by the intercostal muscles at their upper and lower margins, are tilled from end to end with cancellous tissue, so arranged as to take the strain thus imposed, while other lamellae, placed transversely, meet the effect of pressure ; hence these bones, although long in shape, are analogous to the so-called thick or round bones in structure. In looking at the relations of the ribs to muscles, it must not be forgotten that very powerful strain is brought upon these bones by some of the muscles acting on the upper extremity ; but it will be found that in this respect also the same law as to the distribution of stress is carried out, so as to reduce it to a minimum for each portion of each bone. The lines of tension of the muscles always form more or less acute angles with the axes of strength of the bones acted upon by them ; and this rule is more close and definite in proportion to the length and power of the muscu- lar masses concerned. From what has now been said, it will probably be apparent that the arrange- ment of the bony material is such as to adequately provide for meeting all the stress to which it is normally exposed. Let it be recalled, however, that each bone is but a member of a mechanical system of levers, and hence that the force brought to bear upon it may be vastly increased, as well as changed in direction, so as to take it at a disadvantage. Under these circumstances, its texture gives way to what is called in mechanics a " cross-breaking strain." The obliquity of most fractures with regard to the long axis of the portion of bone involved, to be presently noticed as almost if not altogether univer- sal, is an additional proof of the correctness of this view. '^o\Y the prevalence of this mechanism, together with the systemic rela- tion of each bone, above recalled, may serve to explain in great degree the existence of the dominant lines of breakage to which reference has been made, and which will be further spoken of in connection w^ith special fractures. A bone being broken across, it will easily be seen how^ in very many in- stances one of its fragments may engage in the other, and act as a w^edge to split it into two or more smaller fragments. The natural curves of the long bones, and the slight twist which is pre- sented by the longitudinal axes of many of them, although of advantage in their normal function, may render their fracture easier under certain circum- stances. Of all these mechanical conditions, instances will present themselves in connection with special fractures ; and the general statements now made may suffice for the present. 1 The reader will find this subject well set forth and illustrated in WagstaflFe's Student's Guide to Haman Osteology, London, 1875 ; and by Wyman, Trans. Am. Med. Assoc. for 1850. It has been almost wholly overlooked by systematic writers on anatomy. 16 INJURIES OF BONES. Varieties of Fracture. A good many terms have from time to time been suggested with a view to the designation of peculiarities presented by these injuries, but only a few are or need be retained. Confusion has arisen from the employment of some of these terms in different senses by different authors ; it is therefore especially necessary to define them as they will be used in the following pages. With regard to some of the varieties, the mere definition will sufiice; but of others I shall have to speak more at length, and will do so here for the sake of con- venience. Simple and Compound Fractures. — A sim.ple fracture is one to which the atmosphere does not find access, the soft parts remaining so far intact as to exclude it. _ There may be very extensive injury of all the tissues, and the skin not divided ; or there may be a gaping wound of the skin, and the mus- cles and fasciae untorn; but in either case, the fracture is still a simple one. When the external air is admitted to the broken portion of bone, whether by the action of the fracturing force wounding the soft parts from without, or by the thrusting of the fragments through the skin, the injury is called a compound fracture. A fracture, at first simple, may become compound by a process of slough- ing or ulceration, or by suppuration ; and conversely, a fracture, compound either primarily or secondarily, may become simple by the healing of the external wound and the consequent exclusion of the air. Compound fractures, as would naturally be supposed, vary extremely in severity ; but they are always more serious than the same amount of bone- injury would be if not exposed to the air. Sometimes the opening in the skin is but small, yet the bone is very extensively crushed and splintered, and the other soft parts have been torn and bruised beyond repair ; sometimes the bone suffers very largely, while the soft parts are very little injured ; some- times the wounding of the tissues about the bone is greatly in excess, the bone itself being merely broken across ; and in some cases a formidable lace- ration of the skin may attend upon comparatively trifling hurts to the deeper soft parts and to the bone itself. Railroad, machinery, and mining accidents, and falls from heights, are the most frequent causes of compound fractures, which may, however, be produced by much less formidable forces. I have several times seen these injuries, so grave as to require amputation, the result of slight falls. An attempt to rise and walk will sometimes convert a simple fracture of the leg into a compound one, by the ends of the fragments penetrating the skin. Occasionally the seat of fracture is laid bare secondarily by the occurrence of suppuration or by sloughing of the superjacent soft parts ; but here the gravity of the condition is not dependent upon the mere exposure of the bone. Compound fractures are more serious than simple, because they involve as a general thing more severe injury to the bone itself; because in them the tearing of the periosteum, an almost invariable accompaniment of any break- ing of the bone, is apt to be greater, whence there is more risk of impair- ment of nutrition — recovery, as will presently be further shown, being thus hindered, rendered more dififtcult, or prevented ; because the violence done to the surrounding soft parts is greater ; and because, independently of any sep- tic influence exerted by the atmosphere, subcutaneous injuries of all kinds are repaired more readily than those which are deprived of the protection of the skin. Suppuration is almost sure to follow upon compound fracture : it VARIETIES OF FRACTURE. 17 is only in very rare instances that the immediate closure of the wound can be effected. . ^ ^ j- It is in compound fractures, more frequently than m any other class ot injuries, that the question of amputation is raised. For the discussion of the conditions requiring it, the reader is referred to the article on Amputation.^ The treatment of compound fractures not calling for the removal of the limb, will be considered iu con- nection with that of fractures .generally. Multiple, Comminuted, and Impacted Fractures. When there are two or more distinct breakages, whether of the same bone or of different bones, the case is said to be one of multiple fracture. When there are several fragments, the fracture ia said to be comminuted. (Fig. 803.) Sometimes there is one main line of breakage, and the end of one or of both fragments is split or shattered into several smaller ones. (See Fig. 804, d.) Impacted fracture is said to exist when one of the fragments penetrates the other, and is so wedged into it as to limit or prevent their mobility upon one another. Usually there is first a partial separation, and then either by external force or by muscular contraction the wall of one fragment is driven into the cancellous structure of the other. Comminuted fracture. Multiple fractures are generally produced by very great violence, such as railroad or machinery accidents, or falls from heights ; forces being exerted either at the same moment, or successively, upon different portions of a limb or of the body. They derive their gravity either from the amount of injury inflicted, and the consequent shock to the system, or from the difiiculty involved in the application of proper dressings. Some years ago a man was brought to the Episcopal Hospital, who, while drunk, had been run over by a "dummy" engine as he was stooping down to hunt for his pipe on the ground. Almost all the bones in his body seemed to be broken, except those of the head ; his ribs were smashed ; his pelvis ground up so that it felt like a mass of loose stones, and his extremities could be twisted about in any direction. He died about an hour after the alleged time of the accident. In December, 1881, a colored man, aged 32, was brought to the Episcopal Hospital, having been injured by a derrick falling upon him. He presented but slight symptoms of shock, but died in about two hours.' On examination it was found that eight ribs on the left side were broken, and seven on the right ; on the left side the pleura was wounded, and the eighth intercostal artery was divided by a spiculum of bone ; on the right side four of the ribs had injured the pleura, and two had penetrated the lung also. In each pleural cavity there were a number of spicula of bone. Fractures of the spinous and transverse processes of the second, third, fourth, and fifth lumbar vertebra?, and on the left side division of two lumbar arteries by spicula, causing large hemorrhage into the areolar tissue, were noted. There were also oblique fractures of the right femur in its lower third, and of the left fibula in its upper third, with rupture of the internal lateral ligament of the knee. Gross^ speaks of an old woman, w^ho, by a fall from a third story window, sustained no less than eighty-three fractures. » Vol. I. p. 560. VOL. IV. — 2 2 Op. cit., vol. i. p. 898. 18 INJURIES OF BOXES, Less interest attaches, however, to eases such as tho>e just o-iven (the list ot which might he almost indefinitely extended), which are inevitably fatal than to those in which only two or three fractures are sustained, and in which the treatment presents points of much ditficulty. In April, 1882, a boy, aged 14, was brought to St. Joseph's Hospital, havintr been carried ten times around a revolving shaft. He had fractures of the ric^ht humerus radius and ulna, and temur, and of the left radius and ulna ; also dislocation of the hip and elbow on the right side. There was marked shock ; but he ultimately made a good recovery. I was called, in 1881, by Dr. Downs, of Germantown, to a young man, ao'ed 22, who had had his right arm caught around a shaft, and had sustained fracturel of the humerus, radius and ulna, and metacarpus. The swelling of the whole limb and shoul- der was so great as to mask the injuries somewhat, and "to interfere with the manage- ment of the case ; but, as it subsided, we succeeded in getting the bones into good position, and an almost perfect restoration of all the functions of the part was effected. When a part contains two bones, and a fracture of both is caused by the same violence, although at such difl:'erent levels that the two lesions are quite separate, the case is not said to be one of multiple fracture •} nor is the term applied to cases where several ribs are broken, unless the injur\' should afiect both sides, or be not only at different points, but due to forces acting distinctly" only on those points. Two or more separate fractures"^ each requiring special attention in the way of treatment, must exist in order to brhig the case properly under the present head. Of course, very various combinations of fractures may present themselves, and must be dealt with accord- ing to the best judgment of the surgeon. Some of these combinations will be referred to more in detail in speak- ing of fractures of special reo'ions. Traxsverse, Oblique, axd Loxgitudixal Fractures. —Fractures are further divided according to their direc- tion, into transverse, oblique, and longitudinal ; these terms having reference to the relation of the line of fracture to the longitudinal axis of the portion of bone involved. (Fig. 804; r/, transverse : oblique; r-, mixed oblique and longitudinal.) Transverse fractures, strictly speaking, are extremely rare. Occasionally they are met with In the succuleiit bones of the very young, and sometimes as the result of extreme violence, f once saw a thigh-bone broken directly across by the impact of a heavy chai'o-e of shot at very close range. But as an almost universal rule, a greater or less amount of obliquity may be looked for in fractures; a fact which has already been alluded to in support of the leverage theory of "the mechanism of the production of these injuries. " Lono-itudinal fractures are also very rare, except as subordinate to other lines of breakage. Fio-. 805 copied from Holmes's "System of Surgery," represents 1 Non-professional people often say that a man had his leg "broken in two place* *" when they merely mean that both bones were broken. VARIETIES OF FRACTURE. 19 a remarkable instance of a tibia split for a considerable portion of its length. Generally, the fractures called longitudinal are merely extremely oblique, so as to be nearly parallel to the axis of the bone. It almost always liappens that the fragments are serrated along their margins, by the irregularity with w^hich the fibres o-ive way. Sometimes the serrations are fine and close, but oftener the line of fracture is extremely jagged, and presents several strongly marked, tooth-like processes. The proper coaptation of these edges may be very difii- cult, by reason of their interlocking ; but if it be once eftected, they serve to prevent the reproduction of the displacement. It will readily be perceived that project- ini>; portions of the fragments are apt to be broken off, an^l that they may occasionally give rise to much trou- ble by acting as foreign bodies. Varieties of Incomplete Fracture. — So far, refer- ence has been made only to complete fractures, in which the whole thickness of the bone is broken through. It remains to say something of incomjjlete fractures — a term which embraces a variety of forms of injury. Fissures or cracks need hardly be formally defined here. They occur mostly as accessory to complete fractures, from which they branch off", fre- quently in a spiral course. In the flat bones, and especially^ in those of the cranium, they are often met with, and may be stellate, radiating, or caine- rated. Very rarely, they exist alone in the long bones, as the result of vio- lence not quite sufficient to break the wdiole thi^ckness of the shaft ; in such cases they may be unsuspected until much and long-continued mischief has been caused. Some of the recorded instances will be referred to in connec- tion with the special bones concerned. Splintered fractures are such as consist in the detachment of a small por- tion, generally an edge, of a bone, the main body of which is left intact. They are seen occasionally at the brim of the pelvis, or at the spine of the tibia ; but for obvious reasons they may readily pass unrecognized unless attended with a wound making them compound. Perforations of bone are ahvays compound fractures, and almost invariably the result of gunshot injury ; the reader is therefore referred, for information concerning them, to the article on Gunshot Wounds.^ Sprain fractures have been already briefly mentioned under the head of fractures by avulsion," as those in which small fragments of bone are pulled away by excessive stress put upon the ligamentous fibres attached to them. Thus Bruce ^ has published a case in wdiich, by a fall from a second story window, a boy aged 12, had a piece torn out of the right tibia, and one out of the left femur, in each instance by the anterior crucial ligament. And DitteP is reported to have met with an instance in Avhich the spine of the tibia was tlius wrenched away in a man who w^as violently kicked in the ham. Cases are referred to as observed by Poncet, and one at the University College Hospital, in London, in a boy aged 11, who had been run over by a cart. Dittel failed to produce this lesion experimental!}^ on the dead subject. Shepherd* has described a fracture of the portion of the astragalus into 1 Vol. II. pp. 121 et seq. 2 Trans, of the Pathological Society of London, vol. xviii. 1867. » Med. Times and Gazette, Sept. 30, 1876 (from Centralblatt fur Chirurgie). 4 Med. News, June 10, 1882. Fig. 805. Longitudinal fracture of tibia. 20 INJURIES OF BONES. which the posterior fascicukis of the external lateral ligament of the ankle joint is inserted, which probably belongs in this class. He exhibited four specimens, all however taken from bodies in the dissecting-room, and with^ out history. Callender, who I believe first gave the name of " sprain-fractures" to these injuries,! suggests that the bit of detached bone may remain held by its liga- mentous connection, but, failing to unite, may act as a foreio;n body, occa- sionally getting caught in the joint. Of this, however, there is no known instance. I have recently seen a case in which the tip of the inner malleolus was torn off in a fall on the ice ; whether it united or not I cannot say, but the injury was followed by very intractable lameness. Yery little is as yet known in regard to this form of fracture, to which special attention has only re- cently been attracted ; but the injury to the bone adds to the gravity of the case, renders recovery much slower, and may even cause permanent*^ impair- ment of the functions of the limb. Such cases, there can be no doubt, have often^ been unrecognized. Crepitus may sometimes be detected, but may be wanting by reason of effusion into the joint or into the tissues, or because the small fragment is separated from the main portion of the bone. Any case of sprain or other injury about a joint should be carefully ex- amined with reference to the existence or non-existence of this form of frac- ture, and its possibility, or proof of its presence, should influence the surgeon in making and expressing a prognosis. _ Partial fractures are those in which a bone is so acted upon, either by direct or by indirect violence, that some of its fibres are broken, while the rest are only bent. Sticks are often broken in this way, especially when they are green and tough ; hence the name " green-stick" 2 or willow" frac- ture has been given to this form of injury. And fractures of this kind are especially apt to be met with in the tough and resilient bones of the young, in whom, moreover, the periosteum is proportionately thicker and less apt to he torn through than in later life. Otto^ says that he has seen incomplete frac- ture in the radius of a lion, as also in the bones of animals of the deer kind. Reference may be best made here to the subject of bending of hones, about which there has been much discussion, some surgeons maintaining that it is common, and others that it is impossible. Without going into the history of the question, I may say that cases were long since observed, in which, generally in the forearm, distortion, or rather angular deformity , was noticed, but without any of the other signs of fracture to be presently described. Sometimes, indeed, there was pain, and always more or less loss of power ; but not the helpless dangling of the limb usual in fracture. Hence it was claimed that the affected bones were not broken, but only bent. Experience, however, showed that whenever dissections were made in such cases, the lesion was found to be incomplete or partial fracture, as above described. It must be admitted that Hamilton^ succeeded in bending experimentally the bones of young animals ; but this does not prove the possibility of such a thing in the human subject ; and for practical purposes it is better to regard and treat cases of apparent bending as partial fractures. I believe, indeed, that this would be the true view of bending, if that were shown to exist ; that is, that * St. Bartholomew's Hospital Reports, vol. vi. 1870. * " There is also a curvedness which may be reduced to a fracture. I have seen it in children often It is as it were when you break a green stick ; it breaks, but separates not." — Wiseman, " Chirurgical Treatises," vol. ii. book vii. p. 239, 6th ed. 1734. ' Compendium of Human and Comparative Pathological Anatomy, translated by South. Lon- don, 1831. ^ Op. cit., p. 85. VARIETIES OF FRACTURE. 21 the crumpling up of the bony tissue of the wall on the concavity, would amount to a solution of continuity equivalent to the rupture of the bony fibres of the wall on the convexity in the usual form of partial fracture, and that the difference would be simply that in the former case the convex wall, and in the latter the concave, remained unsevered. Such a result is often produced in the attempt to bend metallic tubes, and may have existed in the really tubular bones which were experimented upon by Hamilton, as above mentioned. Partial or " willow" fractures are generally produced by moderate force, or by great force acting slowly. Thus in many of the recorded cases they have been the result of slight falls; and Hodge ^ and Parkman^ have seen them in young men carried around revolving shafts. Farquharson^ published one in a young man of 18, sustained in a foot-ball match. Two very remarkable cases, due to gunshot, were observed during our late war.* They affected the right ninth rib and the left fourth rib, and the patients were aged respec- tively 21 and 28 years. The restoration of the shape of the limb is apt to be very difficult, and in its accomplishment the fracture is often rendered complete. Sometimes, however, it has been gradually brought about by nature, apparently as the result of the continuous action of the surrounding muscles. Epiphyseal separations or disjunctions, met with only in the young, be- fore consolidation by bone has taken place between the diaphyses and the epiphyses, do not differ materially from fractures, although the tissue which gives way is not true bone, but the cartilage-like, osteogenetic matrix. Some- times in these cases the line of separation seems to be very nearly if not quite transverse. Union generally takes place readily, but the subsequent growth and development of the whole bone has seemed in some instances to have been interfered with. Hutchinson^ gives instances of deficient growth in bones which have been the seat of such injuries, and Holmes^ says that he has several times noted this after fractures in the neighborhood of the wrist. In all cases the child's friends should be informed of the probability of impaired development as a result. Holmes, from a study of the specimens contained in the Museum of St. George's Hospital, is inclined to agree with some of the French sur- geons^ in the opinion that "the line of fracture seldom runs accurately through the epiphyseal cartilage in its whole course." I shall have occasion to refer to these injuries again in speaking of ordi- nary fractures affecting special bones in the neighborhood of their articular extremities. Complicated Fractures. — This term has a special significance in surgery. According to ordinary speech, any coincident condition, such as delirium tremens, tetanus, or disease of the liver or kidney — rendering the treatment more difficult and the prognosis more grave — might be said to complicate a fracture; and so also would the existence of other fractures or injuries, even in distant regions of the body. But, in surgical language, a complicated frac- 1 Proceedings of the Pathological Society of Philadelphia, vol. i. p. 232. * Am. Journal of Med. Sciences, Oct. 1853. 3 British Med. Journal, Dec. 4, 1869. ♦ Med. and Surg. History of the War of the Rebellion. First Surgical Volume, pp. 567 and 568. 5 Transactions of the Pathological Society of London, vols. xiii. and xvii. ^ Surgical Treatment of the Diseases of Infancy and Childhood, 1868, p. 240. Grazette des Hopitaux, 1865. 22 INJURIES OF BONES. ture is one along with which there is some serious surgical lesion of neigh boring structures. Thus there may be extensive wounding of the soft parts, but not admitting the air to the broken ends. (Such admission of air would, as before said, make the fracture compound ; and while the fact of its being compound really constitutes a complication, there is a propriety, as well as convenience, in limiting the use of these terms.) Again, the original violence may have not only broken the bone, but also ruptured the adjacent artery or a vein of considerable size, or lacerated a large nerve-trunk. Such rupture or laceration may also be caused by contact with the sharp or jagged edge of one of the fragments. Or, besides the fracture, there may be luxation of the neighboring joint; or, without dislocation, the joint may have been seriously damaged. Or, in certain positions, important viscera may have been lacerated or penetrated by the fragments ; thus the bladder is apt to be ruptured in frac- tures of the pelvis, and the lungs, or even the heart, may be wounded in frac- tures of the ribs. The amount and character of the influence exerted by these other lesions upon the course of a case of fracture, vary, as might be supposed, very greatly. Some, as wounds of the soft parts, merely embarrass the surgeon in his treat- ment ; others, like luxations, require special measures for their relief; or, if uncorrected, will, in a marked degree, vitiate the ultimate usefulness of the hmb. Injuries of vessels or nerves, superadded to fracture, may necessitate amjDutation. But there is a large class of complicated fractures— those in which the vis- cera are wounded— in which the gravity of the complication is apt to be such as to altogether overshadow that of the fracture. These cases may be ame- nable to surgical treatment, as, for example, when the bladder is ruptured in fracture of the pelvis, and success depends upon preventing the escape of urine, either into the surrounding areolar tissue or into the peritoneal cavity; or they may come within the province of the physician, as when a pleurisy is set up by a broken rib. Sometimes the lesion complicating the fracture is neces- sarily fatal, as in the case of a wound of the heart. Further reference to these various complications will be made in connection with fractures affecting special bones. There is still another class of complications of fracture — those, namely, which arise secondarily, from the occurrence of inflammation in neighboring: parts. Thus it occasionally, though rarely, happens that an abscess is formed either about the fragments, in the soft jDarts close by, or in a joint. Under such circumstances, the treatment of the fmcture itself maybe seriously inter- fered with, and the prospect of restoration of usefulness to the limb much impaired. Intra-uterine Fractures. — ITotwithstanding the mobility of the foetus, and its protection by the amniotic liquid and by the maternal body, its bones are occasionally broken. These injuries are generally due either to blows or to other violence inflicted from without through the belly of the mother, or to abnormal contraction of the muscles of the child itself. In one or two in- stances, one of twins has sustained fracture apparently from entanglement of its limbs with those of its fellow. When external violence is the cause of these fractures, the effect is, of course, limited to those bones on which it falls. Of this many instances have been published, and are quoted by Malgaigne and other systematic writers. Only a few points need be noted here. VARIETIES OF FRACTURE. 23 Sometimes union has already taken place at the time of hirth ; as in the case reported by De Luna.^ A woman aged 32, at the middle of the nmth month of pregnancy, fell down stairs, striking her belly against a wooden tub. Pain, not very severe, and faintness followed. The cliild, when seen by the reporter, was four weeks old, and had "fracture of the clavicle near the acro- mial extremity, united by bony callus, with considerable overlapping." In one case recorded by Rodrigue,^ the humerus was dislocated, and both bones of the forearm of the same side were broken and firmly united at an angle of about 45°. Sometimes the fragments have projected, and have heen felt by the mother irritating the walls of the womb. Although the bones in many instances have become solidly united before birth, it occasionally happens that no union takes place. Thus, a case is recorded by Mr. II. Smith^ in which the tibia and fibula, broken within the Avomb, w^ere still ununited when the child was seven years old. One curious instance is quoted by Gurlt,-* from Maeder, in wdiich a woman seven months pregnant fell from the top of a ladder, and subsequently lost, at first blood, afterward blood and water, from the vagina ; she had also persistent pains in the belly, but no loss of general health, and her confinement was normal. Her child, a strong boy, was born wanting the left upper extremity from the mid- dle of the arm, where the white bone protruded through a reddish-brown, moist, but not bleeding or suppurating wound, which soon healed up. The separated limb came away with the after-birth ; it seemed to have undergone maceration. This case, which stands alone, as far as I can ascertain, admits of only one explanation, which suggests itself. It is scarcely worth wdiile to dwell here upon the cases in which very nume- rous fractures have been seen in the foetus, as in most of them there is no ques- tion that they were the result of diseased conditions of the skeleton, and it is probable that this was the true explanation in all. Sometimes it is clearly from deficient ossification between the diaphyses and epiphyses. Thus, Barker^ reported a case in which all the long bones of the extremities were broken, and the frontal, parietal, upper part of the occipital, and squa- mous portion of the temporal were absent. On examination, the skeleton was found deficient in inorganic matter, except in certain enlarged portions which contained an excess. Brodhurst,^ in a paper read before the Royal Medico-Chirurgical Society, suggested the connection between these lesions and other congenital defects, such as distortions of the feet and hands. In the discussion which followed, Messrs. Little and Pollock spoke of cases which they had seen with defi- ciencies of fingers and toes ; and Mr. Adams said that the limbs in such cases did not grow normally. Davies^ has reported a case in which a man, grow^n up when seen by him, had had an intra-uterine fracture of the leg, in which this defect of growth was very marked. Of fractures sustained during birth, very little need be said. They are some- times' caused by the powerful expulsive contractions of the uterus ; as in a case reported by Vanderveer.^ But they are for the most part due to the ' Am. Journal of the Med. Sciences, .July, 1873. 2 Am. Journal of the Med. Sciences, January, 1854. 3 Trans, of the Pathological Society of London, vol. xviii. 1867. 4 Op. cit., Bd. i. S. 222. 5 British Medical Journal. Sept. 26, 1857. ° Med. Times and Grazette, April 7, 1860 ; Med.-Chir. Transactions, vol. xliii. ' British Medical Journal, Oct. 17, 1857. 8 Am. Journal of the Med. Sciences, May, 1847. 24 INJURIES OF BONES. operations of the accoucheur. Gibson^ says that he has seen the clavicle give way from an ignorant midwife pulling at the arm. Malgaigne mentions a number of cases of epiphyseal disjunctions thus produced ; in one, the lower epiphysis of the femur and the upper epiphysis of the tibia were separated at the same time by traction on the foot. In the use of the blunt hook such accidents sometimes occur, and cannot always be avoided even by the most dexterous and careful Operators.^ Phenomena and Symptoms of Fracture. When a bone is broken, it loses more or less completely its value as a lever, and the muscles of the part, instead of acting upon it as a whole, act upon the fragments separately. The periosteum is torn, or, in rare cases, stretched. The surrounding soft parts, including capillary and other vessels and nerve fibres, are ruptured and lacerated to a greater or less degree, and pressed upon by the ends, jagged or pointed, of the fragments. Hence, the injury gives rise to a series of phenomena, or symptoms, which are now to be described. Sound. — Occasionally, but very rarely, the patient hears a distinct sound attending the giving way of a bone ; and sometimes it is even perceived by the bystanders. But under the circumstances of excitement usually attending an accident, a momentary and unlooked-for noise may readily escape notice, even if it were one which would, if expected, be plainly audible. Loss OF Function. — Almost always there is immediate loss of power in the part where the fracture is situated. This does not mean that the muscles are paralyzed, although we often hear non-professional persons assert that an arm, for instance, cannot be broken, because the patient can move his fingers. But the value of the aftected bone, as a lever, is destroyed ; and hence the system of which it forms a part is useless. When, however, there are two bones, only one of which is broken, or when the injured bone is braced by tissues around it, there is sometimes so little disability, for a time at least, as to cast doubt upon the reality of the fracture. Thus, Hunt^ records the case of a man aged 26, struck by a falling girder, who walked next morning to a steam-train, got off at Philadelphia, and into a street-car at the station ; from the car he walked with a stick some two hundred and fifty yards to the Pennsylvania Hospital gate, and thence up into the ward in the third story. He died on the twenty-third day, from pelvic abscess and pysemia, and it was found that " the neck of the femur, immediately behind the head, was broken directly across," the line of fracture being immediately within the capsule of the joint." In 1877, I saw an elderly lady who broke the neck of the femur by tripping in the carpet, and who yet walked up and down a flight of stairs several times a day during the following week. She died exhausted about two weeks subsequently, and there was found extensive fracture of the bone referred to. 1 Op. cit., vol. i. p. 255. 2 'Jlie reader, should he wish to pursue this subject further, will find valuable information in Bouchut's Traite Pratique des Maladies des Nouveaux-Nes, etc., Paris ; also, in Delore's article on Fractures in the Foetus, in tlie Dictionnaire Encyclopedique des Sciences Medicales; in Kuest- iier, Die typischen Verletzungen des Extrem.-knochen des Kindes durch den Grebtirtshelfen, Ilalhi, 1877. He may also consult with advantage an article by Dr. Alex. Russell Simpson, "On Diastases in the Bones of the Lower Extremity of the Foetus, produced by the Accoucheur," in the Edinburgli Med. Journal for June, 1880 ; and one by Ruge, in the Zeitschrift fiir Geblirtsh. und Frauenkrankheiten, Berlin, 1876. ^ Philadelphia Medical Times, Oct. 26, 1872. PHENOMENA AND SYMPTOMS OF FRACTURE. 25 In 1876, one of my own children had his arm broken by an accidental blow ; tliere was no displacement, and no sign of fracture except pain and loss of power, until two weeks later, when he had a fall, and tlie fragments at once became freely movable. Deformity of the affected part ia almost always one of the results of frac- ture ; not invariably, because it may be that the periosteum remains suffi- ciently intact to hold the fragments in place. The kind and degree of deformity vary greatly in difierent bones, and in difterent portions of the same bone ; it is apt to be less where the fracturing force has not been very violent, where only one of two parallel bones is broken, and where the bone, if single, is surrounded by a large mass of muscle. Deformity may be owing either to the original violence, to muscular con- traction, to the weight of the distal part of the limb, or to incidental causes, such as, in case of the femur, the pressure of the bed-clothes on the foot. When the fracturing violence is direct, it simply forces the fragments apart after breaking them ; and they may be held thus by the entanglement of their serrations, by muscular contraction, or by both combined ; when it is indirect, the leverage afforded by one or both fragments will be readily un- derstood. Muscular contraction may drag the fragments apart, as in the case of the patella or olecranon ; or may pull one fragment past the other, as when the shaft of the femur is broken obliquely ; or may rotate one fragment, as in fracture of the cervix femoris. In case of fracture of the thigh or leg, the slight weight of the foot, perhaps with the addition of that of the bed-clothes, is sufficient, acting through a long bent lever, such as is formed by the distal part of the limb, to produce great twisting. We often meet with expressions such as "the fragments being uncon- trolled," and "the fragments assuming bad positions;" but these are incorrect, as they imply that the fragments are not, as they really are, absolutely passive. It is not generally at the seat of injury that we must look for the causes of deformity or of its continuance. However produced, deformity consists in a change in the relation of the axes of the fragments. This change may consist either in their forming an angle with each^other — angular deformity ; or in the rotation of the distal one — rotary deformity ; or in the end of one passing by the end of the other — lateral deformity, over-riding, over-lapping, or shortening. Obviously these may all be presented together in fracture of a long bone — the femur, for example — or they may exist singly. And either of them may, in either case, be very slight or very pronounced ; but their significance does not depend upon their degree. Of all the phenomena attending fractures, the deformity is the most im- portant, not as much on account of appearances (although in women this may sometimes be a matter of great moment), as by reason of the disability which it is apt to involve if it is uncorrected. Even a slight degree of angular or rotary displacement may, in the upper extremity, interfere seriously with the complicated movements upon which the free use of the hand depends, or, in the lower extremity, may give rise to awkward lameness. Hence the great end and aim of the innumerable appliances which have been, constantly are, and probably will always continue to be, proposed for the treatment of frac- tures, is the keeping of the fragments in their normal relation until they have become fixed tlius by the process of repair. The degree of the deformity is not always, or indeed generally, an index of the difficulty of^its correction ; -for often a very slight displacement can scarcely be overcome, while it may be that a very great one will yield at once. But, on the other hand, detcrmity which is easily corrected is apt to 26 INJURIES OF BONES. be reproduced with equal readiness, and under such circumstances all the re- sources of the surgeon may be taxed to keep the fragments in proper place. A point which should always be borne in mind, is that the pain suffered by the patient may be very slight, although the bones are in very bad position. Hence the surgeon should by no means be satisfied that all is going on well because no complaint is made. iTothing but actual inspection of the injured part can assure him of its safety. This remark, however, does not apply to fractures of the ribs, or to such other fractures as are serious only because of the involvement of contained viscera. Pain is an almost invariable attendant upon fracture. It is due in part to the tearing of the soft parts, and to the inflammatory condition immediately set up thereby; in part to the irritation of the soft parts by the ends of the frag- ments; and perhaps in part to the sensitiveness of the fragments themselves, or at least of the medulla. A peculiar, thrilling, numb pain, extending down along the limb to the fingers, is often complained of in fracture of the arm, from pressure of the lower end of the upper fragment against the nerve- trunks; and occasionally, but much more rarely, an analogous pain accom- panies fracture of the leg. I have once or twice seen cases in which the persistent pain was out of all proportion to the severity of the injury, in persons of very sensitive nervous systems, and liable previously to attacks of neuralgia; but generally the pain is not very violent, and subsides steadily with the redaction of inflammation. It is only apt to remain, under proper treatment, when the fracture is in a part such as the lower third of the forearm, where there are extensive thecal serous membranes ; here there may be set up a sort of rheumatoid irritation, diflScult to overcome, and productive of much suffering. A notion prevails extensively among the laity that fractures are most painful when they are " knitting," and that the ninth day is the time when this process is at its acme; I need hardly say that this opinion is wholly without foundation in fact. Persistent pain, or rather tenderness, over one part of a bone may become an important symptom in case of mere fissure. Mobility.— A greater or less degree of mobility at the seat of fracture is nearly always observable, and is more distinct the nearer the lesion is to the middle of a long bone. Of course the mobility referred to is passive, and may be detected either upon an attempt of the patient to use the part, or by grasping the two portions of the limb, one in each hand, and then placing them at an angle with one another, or rotating them in contrary directions. It is upon this mobility that the loss of pow'er after fractures is chiefly de- pendent. Crepitus.— Along with the mobility, if the ends of the fragments be in contact, there is developed a peculiar, rough, crackling or clicking sound, partly heard and partly felt, known as crejpitus or crepitatioi} . It is not always equally distinct, being sometimes masked, either by effusion of liquid or by the entanglement of soft parts between the fragments, sometimes les- sened by impaction. It is not present, for obvious reasons, in incomplete fractures. Bony crepitus should be carefully distinguished from what is known as soft crepitus— the crackling of dry tendon-sheaths— and from a very similar but smoother sound due to the rubbing of the^islocated head of a bone over the surface of another bone covered by periosteum. When clearly heard and felt, true crepitus is proof positive of fracture. Yet it does not always indicate accurately the degree of mobility. It may be quite loud, PHENOMENA AND SYMPTOMS OF FRACTURE. 27 and give the impression of loose grating, and yet the fragments may be closefy held together. I recently saw an instance of this in an old lady of eighty-five, who died some weeks after sustaining a fracture of the cervix femoris ; during life and after death, the crepitus was so distinct as to lead to the belief that the fragments were very movable, yet, when the bone was re- moved they were found in accurate apposition, and hardly any sound could be elicited. Crepitus is of course wanting when the fragments are not m contact, as m fractures of the patella and olecranon, if one portion of the bone is drawn up so as to leave a wide gap, and in some cases of overlapping. I feel constrained here to enter a protest against the employment of undue efforts to obtain crepitus. Should it not be readily felt, the surgeon should fall back upon the other means of diagnosis ; as by persisting'in the attempt to move the fragments upon one another, he not only gives present pain to the patient, but may do harm by producing or increasing displacement. When once the surgeon in charge has perceived it, he ought not to unneces- sarily elicit it, again and again, as I have sometimes seen done, to satisfy either himself or others. Swelling is very apt to follow upon the occurrence of fracture, especially in superficial bones, and in the neighborhood of joints. It is due to inflam- matory effusion, and takes place very rapidly, sometimes almost immediately. EccHYMOSis nearly always shows itself in the vicinity of a fracture, and is often owing to the rupture of small vessels in the soft parts, just as in any other bruise. But when a bone is broken, its vascular medulla is torn across ; and hence there comes on gradually an extravasation of blood, sometimes stainins: the skin a deep mottled purple, almost black, and extending along the limb for a great distance. This secondary effusion of blood is much m^ore significant than that which shows itself within the first few hours after the injury. It is usually very slowly absorbed, and may often be still percepti- ble as a o-reen and yellow discoloration, even after the fracture has been alto- gether repaired. At the same time with this extravasation, there may appear upon the sur- face of the skin, especially in weakly patients, hlehs or bullcE of various size, sometimes very large, distended with serum more or less stained with blood. These are often a source of great alarm to the patient, and even to the inex- perienced surgeon ; but if carefully let alone, they wdll shrink away in time, and the cuticle either becomes re-attached, or a new cuticle forms before the old one is cast off'. It is a bad practice to open them, as they may then give rise to troublesome and intractable sores, interfering with the treatment of the fracture itself. ISTuTRiTivE Changes. — Certain local, atrophic changes have been observed in cases of fracture, and may be mentioned among the phenomena attending injuries of this class, although they are by no means constant Curling^ speaks of atrophy of one fragment as not uncommon, and gives a list of twenty- four specimens illustrating this condition, which, however, is certainly not often present in such a degree as to attract attention. Guenther^ claimed that the growth of the nails on the affected limb was arrested during the pro- cess of union; but his observation has not been substantiated by the expe- rience of others. I have myself reported^ two cases, one in the leg and one ' Med.-Chir. Transactions, vol. xx. 2 Grazette des Hopitaux, Nov. 24, 1842. (Malgaigne.) 8 Am. Journal of the Med. Sciences, April, 1874. V 28 INJURIES OF BONES. in the ring-finger, in which the nails did not grow on the injured members ; but, in spite of careful w^atching for other similar cases, I have failed to meet with them. Muscular wasting, from confinement and disease, is very frequently seen in fractured limbs ; but in general it speedily disappears upon the re- sumption of the normal functions of the part, as does also the oedema which ^ often accompanies it, From what has now been said of the general phenomena attending frac- tures, the symptoms may be readily learned. These are divided into two classes, — the rational, and the physical or sensible. The former are such as give rise to a reasonable suspicion of the existence of fracture; they are pain, loss of power, swelling, and ecchymosis. To these may be added, when it is present, the audible crack caused by the snap- ping of the bone ; but this would not be conclusive, because very much the same sound niight accompany the rupture of tendon, muscle, or ligament. The physical or sensible signs are conclusive: deformity, preternatural mobility, and crepitus. Sometimes the first named, striking the eye of the surgeon, will at once reveal the nature of the case. But for the most part it is from the combination of all that he is enabled to frame his opinion. Constitutional Symptoms AccoMPANYma Fracture. Perhaps it will have been noticed that nothing has as yet been said about the constitutional symptoms attending fracture. In very many cases these are very slight, and might readily be overlooked by an inattentive observer. Yet they always occur, and are in proportion to the severity of the local injury ; modified, however, by the idiosyncrasies of the patients, by their condition at the time of sustaining the hurt, and by incidental circumstances. Thus, in some individuals, the nervous system is very sensitive, and even a simple fracture, produced by slight violence, may give rise to marked shock. Such shock may be the more severe from the fact of previous fatigue, of fright at the time of the accident, or from other transient circumstances. Wagstafi:e,i in an article on temperature in shock, in surgical cases, notes a decided lower- ing as attendant upon compound fractures ; and it is probable that a propor- tionate degree of reduction would be detected in less serious cases by careful observation. Following upon this state of depression, a more or less decided febrile rise is often noted, especially in private practice, where patients are apt to demand and receive more attention than in hospitals. But Stickler^ has proved, by a series of carefully tabulated observations, that there is, as a rule, a tempo- rary febrile rise after fractures ; it reaches its maximum during the first three days, when the local inflammation is at its height. Upon the subsidence of this febrile movement, the system at large generally ceases to manifest any disturbance, and the whole period of local repair may be passed through without any other trouble than perhaps constipation, and it may be indigestion, if the patient is prevented from taking exercise, and yet indulges his appetite. But in old and feeble persons, the powers may be unequal to the tax upon them, and a condition of debility may ensue, from which recovery is impossible. I have seen a simple fracture of the hume- rus prove fatal on the seventh day, in a lady of eighty-one ; yet Hender- son^ has recorded the case of a woman, eighty-nine years old, whose femur, ' St. Thomas's Hosp. Reports, 1870. 2 New York Med. Record, Feb. 11, 1882. 8 London Med. Gazette, Jan. 13, 1843. DIAGNOSIS OF FRACTUKE. 29 broken near the middle, was found firmly united on the forty-fourth day ; Meachem* one, in which, in a woman of ninety, a fracture of the lower third of the leg was united in twenty-eight days ; and Lee^ one of union of a frac- tured femur in a man of ninety-eight. These cases are exceptional, and do not set aside the fact that old age makes every injury more formidable. Diagnosis of Fracture. This ipattcr has, of course, been to a certain degree dealt with in speaking of the symptoms of these injuries, and it must be considered again in refer- ence to each special fracture ; but there are some general points which may be made here, and some rules laid down, in order to save repetition. The earlier an examination can be made to determine whether or not frac- ture exist, and its seat, if present, the better ; since swelling often conies on very rapidly, and the muscles become rigid, so as to mask the condition of the bone. Hence, if the surgeon be called to a patient who must be moved a long distance to his home, or to a hospital, he should, if possible, ascertain at once the character of the injury, by as careful an examination as the circum- stances will allow. ^ . n . In cases of injury in the neighborhood of joints, this rule is especially im- perative ; since here the question is apt to be between fracture and luxation, and, if the latter be overlooked, the delay involved may add seriously to the difficulty of reduction. Of mistakes of this kind, instances will be given hereafter. . . As a o-eneral rule, in the comparison of fractures and luxations,^ it will ^ be found tlfat, in the former class of injuries, the degree of possible passive motion is increased beyond the normal, while in the latter it is, in certain directions at least, materially diminished. On the other hand, in luxation, the power of rnovino- the limb to some extent is apt to be retained, the lever affected not beino- broken, but having merely changed its bearing point ; while in frac- tures, as before stated, the limb is usually altogether disabled. From the study of normal anatomy certain test lines have been derived, by which the displacement consequent upon fractures, as well as luxations, may be detected. With these lines, and with the relation of the normal skeleton to them, the surgeon ought to render himself perfectly familiar, so that they may serve as landmarks in his examination of injured parts. They will be detailed in speaking of fractures in the several regions. ^ The diao-nosis of fracture has reference not merely to its existence, but also to its exact seat and direction. The latter points are, indeed, in many cases by far the most difficult to determine, and may have to be arrived at by ex- clusion only. The general symptoms already detailed may be clear enough, and the fact of fracture be absolutely established, yet the surgeon may be in doubt as to the precise line of breakage, or even, when a joint is involved, as to which of the bones entering into it has suffered. These questions can only be settled by careful exploration, with a skill acquired by experience ; in other words, with the educated hand. Occasionally, the observation of the effect of certain passive motions will go far to solve the doubt ; or gentle and dexterous pressure with the tips of the fingers, perhaps with the nail, may reveal the line of breakage. In the diagnosis of compoiind fracture, as to its extent and severity, the finger is always better than any other probe ; hut even this should be used 1 Am. Med. Times. 1861. 2 St. George's Hospital Reports, vol. iv. 1869. 30 INJURIES OF BONES. with caution, and onlj for the purpose of determining such points as the sur- geon really needs to know. All poking about to satisfy mere curiosity, at the risk of disturbing or tearing tissues not already damaged, and all wrench- ing of the fragments to get at the deeper parts of the wound, should be abstained from. The amount of injuiy to vessels and nerves can be better ascertained in other ways, and may be increased by meddlesome and indiscreet handling. Consequences of Fracture. While it is quite true that, in general, simple fractures progress steadily toward recovery, it is also true that they sometimes give rise to very grave and even fatal symptoms. These symptoms may be general or local, imme- diate or remote. 5lurray^ mentions a case in which a simple comminuted fracture of the thigh was folloAved by trauraatic delirhim ; Hammick,^ one in which tetanus ensued upon simple fracture of the thigh. Pycemia^ not a very uncommon sequence of compound fracture, has been seen by Hewett^ as the result of simple fracture of the leg. The occurrence of wounds of arteries veins ^ and nerves^ has been already mentioned {complicated fractures)^ and will be again referred to in connection with fractures of special bones. Occasionally, when vessels of some size are \u]\xve^, gangrene comes on, or the hemorrhage challenges immediate attention, and either ligation or amputation must- be performed ; but sometimes the symptoms are only perceived at a later period, Avhen aneurism., true or false, has developed itself^ AVith regard to nei^ves also, the signs of the lesion 'may appear immediately, or may be postponed until they show themselves in the altered nutrition or sensation of the distal parts. In several instances to be hereafter quoted, it was to the callus that the trouble was to be attributed, either from exuberance of this formation, or from entanglement of nerve- trunks within it. is'erves may also be caught and pinched between the fragments ; a case is mentioned by Callender^ in which the ulnar nerve was thus entangled in a fracture separating the styloid process and triangular ligament from the rest of the ulna. The same author saw a case in which a compound fracture at the wrist was followed by gangrene by reason of stretching of the ulnar and median nerves. Pre-existing disease may become fatal when complicated with fracture ; thus Hunt' has placed upon record a case in which a man, aged 29, who from the age of four years had had chorea and partial hemiplegia, lost his life from the incessant movement of his arm, broken by an accident. There are some instances in which untoward results take place without any apparent reason. In one of his clinical lectures. Prof. Yerneuil referred to the case of a man, 60 years of age, strong, robust, and tall, who had been in hospital for two months and a half for a fracture of both bones of the leg. He was treated as usual, had^ exhibited no bad symptoms whatever, and, in fact, was just about to be sent to a convalescent hospital prior to dismissal, when (the only thing that had excited attention having been some alteration in his features) he suddenly died, his face havhig a violaceous aspect. Prof Verneuil believed that this must have occurred from embolism., which is not very rare after fracture. It is produced by tkrombosis of some of the veins • Edinb. Med. Journ., Feb. 1882. 2 On Amputations, Fractures, etc., p. 74. ' Lancet, 1867, vol. i. p. (J28. * For much valuable information on this subject, with details of 27 cases, the reader is referred to a pamphlet entitled " Des Anevrysmes compliquant les Fractures. Par Gerard Laurent, Doc- teur en Aledecine, etc." Paris, 1875. ^ St. Bartholomew's Hosp. Reports, 1870. s Pennsylvania Hosp. Reports, vol. ii. 18G9. CONSEQUENCES OF FRACTURE. 31 in the vicinity of the fractured bone, which is the cause of the oedema that so commonly accompanies fracture of the leg. Through a sudden movement or muscular effort, one of the clots which have thus formed in the inferior veins, and whicli are not usually very adherent, may become detached, and, cnterino- the femoral and iliac veins, and eventually reaching and obstructing one or more of the branches of the pulmonary artery, may give rise to sudden death, as in asphyxia. However, in thi-s case the diagnosis was erro- neous, for the most careful examination of all the veins and of the pulmonary arteries failed to show the existence of any clot. The heart was absolutely empty, and the brain, minutely examined, exhibited no disease.^ Again, Hammick^ describes the case of a man with simple fracture of the leg, who was very despondent; on the third morning he "became ill, grew very feeble, and in four hours was dead. We examined with the minutest dissec- tion every part of the body, but were not able to detect anything in the remotest degree to account for his death." It seems not improbable "that this may have been an instance of fat emholisya. Thrombosis and Embolism. — These sometimes ensue upon the breaking of a bone. Southam^ has recorded two cases, one in a man aged 60, with Pott's fracture of the libula, in whom thrombosis appeared on the 17th day, and proved fatal, and the other in a woman aged 65, also with fracture of the libula, who had like symptoms on the 16th day, and died. In the former case the diagnosis was verified by an autopsy. A case is reported by Tyrrell, in which a man aged 49, had his left leg fractured for the sixth time, the other leg having been broken once. On the twelfth day he had symptoms of cerebraf disturbance, followed by partial paratysis of motion on the left side of the face and in the left arm. These symptoms were ascribed by Tyrrell to the withdrawal of his accustomed stimulus, but should rather, perhaps, be referred to embolism. Fat-embolism^ is a condition first observed as a sequence of fracture by Wagner and Zenker, in 1862. It consists essentially in the passage into the veins of liquefied fat, which is carried into the lungs, brain, and spinal cord, blocking up the capillaries of those organs. The occurrence of free oil in the blood had been pointed out by E,. W. Smith, as early as 1836 f and in 1856 a case was reported by Macgibbon,'^ in which a woman, aged 35, affected with delirum tremens, died suddenly, the immediate symptoms having been dyspnoea, with coma and marked pallor ; the autopsy disclosed fatty degeneration of the heart and other organs, and a great deal of free oil in the blood. Wagner, in 1865, Busch, in 1866, Bergmann, in 1873,^ and Czerny, in 1875,^ made important investigations on the subject, which has been further studied by Scriba.^^ Flournoy, in 1878,^^ showed that three conditions were needful for the development of fatty em- bolism after fractures : large openings in the veins ; free fluid fat ; and a vis ^ Med. Times and Gaz., Oct. 22, 1881, p. 486 ; from Gaz. des Hopitaux, No. 86. « Op. cit., p. 74. 3 Lancet, March 1, 1879. * St. Thomas's Hospital Reports, voL i. 1836. ^ See also the article on Shock, Vol. II. p. 268. 6 Stokes, The Diseases of the Heart and the Aorta, p. 308. Dublin, 1854. 7 Am. Journal of the Med. Sciences, Jan. 1856. 8 Berliner klin. Wochenschr., Aug. 18, 1873. 9 Ibid., Nov. 1 und 8, 1875. '0 See London Med. Record, Oct. 22, 1873 ; Med. Times and Gazette, Jan. 8, 1876, and British Med. Journal, May 22, 1880. These articles were reproduced in the Am. Journal of the Med. {Sciences, Jan. 1874, and July, 1880. Contrib. a I'etude de I'embolie graisseuse. Strasbourg, 1878. 32 INJURIES OF BONES. a iergo^ generally found in a copious extravasation of blood. Drs. Sainidby and Barling, in a recent article,^ quote papers by Boettcher and D. J. Hamil- ton, in 1877, Dejerine, in 1878-9, Buret, Sinclair, and Jolly, in 1879, and Mansell-Moullin, in 1881. Bejerine is said to have seen ten cases, and to have produced fat-embolism experimentally upon animals by means of sponge-tents or laminaria-tents introduced into the bones. Sinclair is quoted as authority for the statement that fatty embola ^vere found in 10 per cent, of the bodies examined at the Pathological Institute at Strasbourg ; but it should be remembered that post-mortem clots containing fat-globules may readily be mistaken for true fatty embola. The former have been repeatedly met with in autopsies upon diabetics with " milky blood." Symptoms of Fat-embolism. — From the accounts given by Scriba and others, who have had opportunities of studying this subject clinically, it would seem that fat-embolism comes on as a sort of secondary shock, within two or three days of the receipt of the fracture, and therefore earlier than venous throm- bosis usually appears. Bs onset is marked by transient attacks of dyspnoea, with irregular action of the heart, slight haemoptysis, and at first shallow respiration, at times interrupted by deep sighing inspirations ; subsequently the peculiar form of breathing known as " Cheyne- Stokes" respiration,^ manifests itself. Collapse, with marked pallor of the skin and mucous membranes, soon ensues ; spasms of various kinds, or paralyses, generally bilateral, and dimi- nution of reflex irritability, have been noted. The chest is free from dulness or rales. Fat has been detected occasionally in the urine. As to the tem- perature in this disorder, the accounts of observers vary. According to Scriba, it is low^ered ; but Skirving^ records a case in which it was a-t first noted at 100°, but increased to 104°, and after death reached 105°. In another case seen by Saundby and Barling, in 1881, the temperature w^as 101.8°. Secondary abscesses do not form in fat-embolism. Czerny thinks that this condition is a constant attendant uj)on cases of fracture, but mostly in very slight degree, and Avithout inducing any distinct symptoms. Minich* says that it occurs in all cases of fracture except in chil- dren, who are exempt from it by reason of the small amount of fat contained in their skeletons. Scriba is of opinion that it may go through several cycles, and that its injurious efi:ect is due solely to the blocking of the vessels of the brain, since this w^as observed in all the fatal cases. Minich shares this view^ as to the cause of death ; but it seems as if the interference with the function of the lungs must be at least contributory, if it has not a large share, in inducing the fatal result. The diagnosis of this pathological condition can hardly be very obscure in any case in wdiich the symptoms as described are well pronounced ; and the prognosis, under such circumstances, must obviously be extremely grave. As to the treatment of this afi:ection, the intra-venous injection of sulphuric ether would seem to be clearly indicated ; and diff'usible stimulants might be given by the mouth. I am not aware, however, that any definite line of medication has yet been pointed out. Stiffening of neighboring joints is a very common sequence of fractures, and may be attributed to various causes. In some cases, violence is inflicted 1 Journal of Anat. and Physiology, July, 1882. 2 " It consists in the occurrence of a series of inspirations increasing to a maximum, and then declining in force and length, until a state of apparent apnoea is established. In this condition the patient may remain for such a length of time as to make his attendants believe that he is dead, when a low inspiration, followed by one more decided, marks the commencement of a new ascending and then descending series of inspirations." (Stokes, op. cit., p. 324.) 3 Lancet, Oct. 7, 1882. < Lo Sperimentale, Marzo ed Aprile, 1882 (quoted in Medical News, Nov. 11). CONSEQUENCES OF FRACTURE. 33 upon the joints as well as upon the bone at the time of the accident, and ar- thritis is set up, with etiusion into the periarticular tissues. Or the circula- tion in the limb or its innervation, may be disturbed, so that the nutrition of all the tissues is impaired, and the movement of the joints is thus inter- fered with. By some authors, the long-continued immobilization of the joints required by treatment is thought to render them stiff; but this idea is rendered untenable by the fact that experience in other cases gives no such result ; and it is more likely that ill-advised pressure by apparatus, or the inflammatory condition above alluded to, is at fault. As a general rule, this stiffening is only transient, and either gradually disappears with use, or yields to proper local medication. Atrophy of a broken limb sometimes takes place, and may affect all its tissues, or the bone only. A very curious instance of the latter kind is re- corded by Drs. Jackson and Dwight,i in which a humerus, broken for the second time, was almost wholly absorbed ; and another by Gross,^ in which the fracture was originally double. In both these cases the arm retained very considerable muscular power. "When all the tissues of the limb are atrophied, the bone also may shrink, but this is not apt to be the case. The muscles become small, stiff, and weak, and the foot or hand, as the case may be, contracted and twisted, much as in cases of paralysis from lesions of the central nervous system. Pointed foot" is not unusually due to atrophic contraction of the muscles of the calf. Prevention, it need hardly be said, is in these cases far better, and certainly far easier, than cure. Often, indeed, the latter proves to be impossible. The measures to be adopted are very simple, and their efficiency depends rnuch upon the regularity and perseverance with which they are applied. Frictions, with or without medicated liniments, bathing, shampooing, or massage, and sometimes faradization, may occasionally restore the tone of mus- cles which seemed at first hopelessly damaged. But no discreet surgeon will venture in a case of this kind to hold out hopes which may utterly +ail to be realized, i^ECROSis, after simple fracture, is extremely rare, if it ever occur at all. Possibly in some of the cases in which blows or other injuries are followed by the death of a portion of the bone, there has really been a separation of the part thus mortified ; but I have never seen an instance in which this could be proved. After compound fractures, however, it is very common to find one or more splinters loosened and dead ; their presence may interfere with the process of union, which is apt to take place promptly upon their removal. DeveloPxMent of Morbid Growths.— Among the remoter local conse- quences of fracture may be mentioned the development of tumors at the seat of the old injury. Virchow,^ after stating that enchondroma, more frequently than any other tumor, is clearly to be ascribed to trauma.tic causes, says : " Among these, fractures seem to be of great interest. Nelaton (Gaz. des Hop., 1855) mentions a man who, having broken his leg, was completely cured in two months ; but six months afterward had severe attacks of pain in the part. Re-fracture occurred from slight violence, and union again took place in two months, but the part remained painful. A tumor began to develop itself, increased more and more, and at length i Boston Med. and Surg. Journal, July, 1838, and Oct. 10 1872. « Op. cit., vol. i. p. 929 ' Die krankhaften Geschwiilste, Band 1. S. 482. VOL. IV. — 3 34 INJURIES OF BONES. burst. The patient died exhausted five years from the date of the first fracture ; the autopsy disclosed an enchondroma. Otto (Seltene Beobachtungen zur Anatomic, etc.) speaks of a woman who, two years before her death, sustained a fracture of the humerus, which united, but remained painful and became greatly misshapen ; there was de- veloped a tumor (clearly an osteoid chondroma) which acquired a colossal size. Ducluzeau (Lebert, Traite d'Anat. Pathol.) removed from the rib of a man an enchondroma, which had taken its origin from a fracture of the bone several years previously. Lan- genbeck (Deutsche Klinik, 1860) disarticulated the shoulder of a man aged 23, on account of a tumor which I recognized as an osteoid chondroma, and which began a year and a half after a fracture caused by a fall." Adams^ has recorded the history of a man who twenty-five years before his death broke his humerus ; nineteen years afterward he strained it, and it remained weak ; four years after this a swelling was perceived, which grew rapidly, so that amputation was thought of, but declined. The tumor ulcerated and discharged a glairy fluid; at the time of death its circum- ference was equal to that of the body. It was composed of enchondromatous, colloid, and compound cystic elements. It is perhaps scarcely proper to include among the cases now under con- sideration those in which, fracture occurring in a person already affected with malignant tumor, the constitutional disease manifests itself afresh at the point of local injury. Here the fracture merely serves as a nucleus, as it were, around which deposit takes place, precisely as may be observed in other cases of hurts. Sometimes, indeed, it may be questioned whether the bone may not give way because its texture is already impaired by the de- velopment of disease ; as in one instance recorded by Morton,^ in which the woman having already a mammary tumor, the left humerus gave way as she turned in bed, and " shortly afterwards the tumor was noticed at the seat of fracture death occurred within three months. The symptoms and diagnosis in these cases need hardly be discussed,. and the prognosis is unfortunately but too clear. As to treatment, it must be based upon general principles ; often there is no chance for anything but palliative measures. Amputation may sometimes save suffering, and delay the fatal issue.^ (a-ENERAL Prognosis of Fractures. Various circumstances must be taken into the account in forming a prog- nosis in any case of fracture. Among these are : the character and amount of the injury to the bone, its simple or compound character, its extent, the presence or absence of comminution, the nearness of the lesion to a joint, the amount of damage done to the soft parts. The age and previous history of the patient are also to be regarded. From a consideration of all these points, some idea may be formed as to the chances of saving the patient's life, as well as of preserving a useful and sightly limb. With regard^to the influence of the local conditions of the injury on the prognosis of fractures, it scarcely needs to be enlarged upon here, as it has been already set forth in the discussion of the phenomena and varieties of those injuries. As to age, it may be said that the fractures of children gene- rally unite with FRACTURES OF THE BONES OF THE FACE. 67 venient hamperino: of its laovenients, not remediable, as mere shortening is, by the weariiio' of a^boot with a thick cork sole, or with a metallic stirrup to nnke up the want of leui^tb ; and for such a condition the surgeon is justihed in' ad()i)ting severer measures, and running greater risks, than tor one less ^^^OnTorTvvo instances are upon record in which surgeons have shortened a sound limb in order to obviate the limp due to a badly healed fracture m the other. I mention the fact only to enter a protest against any such pro- cedure, which, in my opinion, could never be otherwise than rash and un- suro-ical, and the result of which could not be satisfactory. Reference will be again made to the subject of union with detormity in connection with certain special fractures. FRACTURES OF SPECIAL BOJSTES. Fractures of the Bones of the Face. From the size, shape, and arrangement of the bones constituting the skele- ton of the face, they are, with the exception of the lower jaw, unapt to be broken sino-ly. By crushing forces, such as a fall from a height on the tace, the kick of a horse, or the passage of a wheel, very extensive injury may be inflicted. These fractures are generally compound, and often comminuted. Cottinc^ has reported^ the case of a man ran over by a cart, who had " a fracture of the lower jaw on one side, and a dislocation on the other ; and a separation ot the whole face from the base of the skull. The patient recovered without much deformity. A man was brought to the Pennsylvania Hospital in 1855, who had had his head caught between the platform of a steam hoisting-machine and a floor. The face was sepitrated— bones, soft parts and all— from the cranium, as far back as the sphenoid ; a crhastly American Journal of the Medical Sciences, Jan. 1850. 2 Diseases and Injuries of the Jaws, p. 55. London, 1868. 68 INJURIES OF BONES. ments which seem hopelessly detached will adhere and live, perhaps helping materially to preserve the contour of the face. Generally the attention of the surgeon is confined to the prevention of de- formity after these injuries ; but sometimes other bad consequences may ensue. Thus, Martin reports^ a case in Avhich amaurosis followed a fracture of the nasal portion of the superior maxilla, as well as of the palate bone, and most probably of the lachrymal; the patient, a man aged sixty, had been struck with a stone. Sight was ultimately restored. A numl)er of instances are on record in which foreign bodies have been forcibly thrust into the orbit, producing fracture of its bony walls, and in- juring the eye, or even the brain itself; but these will be more appropriately discussed elsewhere. The treatment of fractures of the facial bones must be directed to the re- placement, as already said, of the fragments. This may often be done (after the careful removal of all foreign bodies, if the fracture be compound) by simply moulding with the fingers. Compresses should then be applied, ex- actly adapted to the size of the part over which pressure is to be made, and fastened in place by means of strips of fine isinglass plaster, or of rubber adhesive plaster. Of course the eyebrows, moustache, or any hair that may interfere with the dressing, should be carefully shaved. A light ice-bag, not filled so full as to prevent its taking the shape of the part, should be lard on, to keep down inflammation ; the patient should be placed in bed ; and liquid diet only should be allowed. If the efitbrt of swallowing even this be pro- ductive of pain, or disturb the fracture, nutritive enemata may be employed. It is rarely necessary to confine the lower jaw ; but this may readily be done in case of need by means of a broad strip of rubber plaster applied under the shaven chin, and brought up with the ends crossed above the forehead. ^^hen the fracture involves the alveolar margin of the upper maxilla, it may become necessary to have a cast taken of the teeth, and on this a vulcanized rubber mould, to serve as a splint. (In large cities it is generally easier to have this done by a dentist, to whom the process is thoroughl}-*^ familiar.) Having put the splint in place, the surgeon brings up the lower jaw against it, and applies the broad strip of plaster above mentioned. A roller may be employed, in the form known as "Barton's bandage,"' ^ if there be any objec- tion to shaving the chin, or, in the case of females, to shaving the front hair." Fractures of the Zygoma. — Fractures of the zygomatic arch are very rare, and can only be caused by great violence. Malgaigne quotes from Duvemey an account of " a young child, who, having in his^ mouth the end of a lace- bobbin, fell headforemost, so that the end of the bobbin, piercing the soft parts, broke the zygomatic apophysis from within outwards ;'' and another, in which Duverney says that he detected the fracture by passing his finger through the patient's mouth. But since, as Malgaigne "^justly remarks, the zygomatic arch cannot be reached in this way, there is good reason to doubt both these stories. I have seen one case of fracture of the zygomatic arch, firmly united with deformity outward. It had occurred sevei^al months previously, by the fall- ing of some chains on the head and left shoulder of the maii, who was a sailor. When the deformity is outward, which may perhaps result from the jam- ming backward of the malar bone, simple pressure inward may, in a recent case, overcome it. When it is inward, resort may be had to incision, and the ^ Medical Press and Circular, Sept. 23, 1874. 2 See Vol. I. p. 499. FRACTURES OF THE BONES OF THE FACE. 69 introduction of an instrument to i>ry the fragnients up. Malgaigne quotes a case thus operated upon by Ferrier, with a good result. Muhlenberg' has recorded a case of fracture of the zygomatic process by the kick of a'horse, followed by very troublesome false anchylosis of the tem- poro-maxillary joint. Malar Bone. — Fractures of the malar bone are exceedingly rare, as might be expected from its great strength, and from its attachments. A few instances are on record in which it has been separated from the adjoining bones, by very great force. In one, recorded by Malgaigne, there was depres- sion, especially marked posteriorly, where the malar bone had been driven inward away from the zygomatic process of the temporal, and injury was done to the infra-orbital nerve, paralyzing the area sup[)lied by it. Replacement may be difficult, or even impossible ; but the resulting defor- mitv is not very great, unless from some such lesion of nerves as that just mentioned. There would be no valid objection to making a slight incision so as to introduce an elevator for the purpose of prying the bone up, as in Ferrier's case of depression of the zygomatic arch. In any such case, by making the section of the skin obliquely, the resulting scar would be materially lessened. Upper Jaw. — Fracture of one upper maxillary bone is very rare, except in the alveolar portion. This is sometimes broken off by blows or falls; thus I have seen a semicircular piece detached in front, carrying with it the incisor teeth, in a man, who, having fallen from a wagon on his face, had a heavy box come down on his head as he lay ; his lower jaw was also broken in two places. I have seen a much smaller piece knocked loose in a boy of six, by a fall against a step ; he bled profusely for a time, but a good result ensued. Occasionally the wall of the antrum is pierced by a thrust \vith a stick or sharp instrument ; and in such a case the bone may be more or less splintered in various directions. In most cases, the force fracturing the upper jaw-bone is exerted at the same time upon adjacent bones, and a more complex injury is produced. Thus the kick of a horse may crush and drive back both upper maxillae, with the palate bones and vomer ; or the same effect may be produced by a fall on the face from a height. Wiseman"^ relates a curious instance, in which, a boy, aged 8, liaving had a kick from a horse, which drove the bones backward, he " caused an instrument to be made, whereby the great fractured body was more easily brought into its natural place, and also kept there by the hand of the cliild, liis mother and my servants helping him some while." The result is said to have been " better than could have been hoped for from such a distortion in that place." Hayes' reports the case of a man, who, being thrown from a carriage and striking upon the end of a fence-rail, sustained com})Ound comminuted fractures of the right upper maxilla and right malar bone, with simple fractures of the left upper maxilla and the lower maxilla on tlie right side. There was a good deal of cerebral commo- tion, and very severe hemorrhage ; but the patient ultimately did well. A man, aged 40, was brought to the Episcopal Hospital, in December, 1876, having been injured by the caving in of a culvert. He had a compound fracture of both nasal bones, the greater part of the left one being crushed off; and a laceration of the right lower eyelid, tlie ball being partially torn away and falling forward in the orbit. The whole face was enormously swollen, and there was continuous and free bleeding from the 1 Phila. Med. Times, May 15, 1871. 8 South. Med. Record, 1882, p. 281. 2 Op. cit., vol. ii. p. 253. 70 INJURIES OF BONES. nose. On the next day, the swelling having subsided, a fracture was discovered begin- ning near the zygomatic arch on the right side, and extending across the upper jaw to the left side in front of the molar teeth. The fractured portion was very freely movable. Plugging of the posterior nares was resorted to, but the patient persisted in pulling the tampons away, and the hemorrhage was finally arrested by means of astringent injec- tions. About the fourteenth day an abscess formed below the right eye, although the swelling and ecchymosis had almost wholly disappeared ; this continued to discharge for some weeks, but no dead bone could at any time be felt. Union of the fracture took place readily, and on January 1, when I gave up the wards to Dr. John Ashhurst, Jr., there only remained a condition of ptosis due to tearing of the muscles above the right eyeball. This was remedied by Dr. Ashhurst by operation, January 11, and on tlie 20th the man went out cured. Occasionally these injuries are productive of most ghastly deformity. Thus Malgaigne mentions a case seen by him a long time after the injury, which the patient had sustained, when a child, by the kick of a horse, comminuting the nasal, upper maxillary, and palate bones, and tearing and bruising the soft parts. The nasal bones were destroyed ; the anterior portion of the alveolar arch, and most, if not all, of the vault of the palate, had likewise disappeared. He had no nose nor mouth ; the two lips being fastened together by a thick and firm cicatrix, the chin was continued up to an oval opening, formed between the two ascending processes of the maxillary bones as high as the frontal. By this one opening the patient breathed, spoke, ate and drank ; when a piece of bread was put into it, the tongue was seen to come up, and to carry it down to the molar teeth, which performed their functions very well. Concerning the symptoms and diagnosis of these cases, there is very little to be said ; the nature of the injury is generally clear enough. As to the treatment^ the indications are to restore the fragments to their place as nearly as this can be done, and to keep them so until union, which generally takes place very readily, has occurred. In compound fractures, no splinters should be removed by the surgeon ; they may unite, and if they do not, they will be thrown off". By the older surgeons, very complex appliances were devised, with head-bands, curved steel bars, and plates to press against the fragments. Bat the improved resources of modern dentistry render such apparatus, for the most part, needless ; and in the great majority of cases the retention of the fragments can be effected by means of well-fitted vulcanite splints made to fit the dental arches. When these are arranged, a bandage is put on so as to restrain the movements of the jaws. In some cases, after the first day or two, there is no difiiculty in the admin- istration of liquid food by the mouth, the patient learning to take it with- out deranging the fragments or the apparatus. But should there be any awkwardness in this, rectal alimentation may be resorted to. Fractures of the ITasal Bones. — The bones of the nose are so thick, at their upper part, and so well supported, that they are not often broken except in their lower portions. Sometimes the septum sufters also ; perhaps this is more generally the case than is suspected. It is not always easy to tell how far the injury consists also in separation of the cartilages from the edges of the bones ; but this certainly does occur in some instances. The mucous membrane is often ruptured, and thus the fracture is rendered compound. I have seen the nose broken by a cricket-ball, by a blow with the fist, by a blow received in boxing with the gloves, by a fall from a horse ; the vio- lence is always great and direct. Oftentimes it falls a little to one side or the other, so as to drive the nose crooked ; and if this deformity is not corrected, it is very disfiguring. FRACTURES OF THE BONES OF THE FACE. 71 Concussion of the bniin is sometimes produced by the severity of the blow, but it seems very unlikclv that tlie force can be transmitted tlirough the nasal bones; it is more prol)abfe that it bears also upon the neighboring portions of tlie walls of the cranium. . , , • i • i Hamilton gives several cases of injury of tlie nose in cliildren, m wliieli tiie na^al ])rocesS?s of the upper maxillary bones were spread outwards ; one of these was in a child only three weeks old, upon whose face a block ot wood fell as she lay asleep. Such an occurrence could hardly take place in an '^'^^The history of the injury, and the deformity, generally point to the diag- nosis, which is nearly always rendered certain by the detection ot crepitus. Other symptoms apt to be present are : severe pain and headache, hemorrhage from one or both nostrils, and sometimes emphysema in the surrounding areolar tissue. Swelling takes place so rapidly as often not only to make the exact seat and direction of the fracture obscure, but to interfere seriously with attempts to correct the displacement. . , , i In many of these cases, especially if the violence inflicted has been very o-reat, the bones are comminuted ; and this adds notably to the dithculty of exact diao'uosis as well as of treatment. The mere detection is easier, as well as the reduction, but the latter is hard to maintain. IWatmcnL—Frnctwves of the nasal bones usually unite very readily, and this fact makes it very desirable that the displacement should be carefully corrected at the earliest possible moment. Hence the surgeon^ should at once press the frao-ments into their proper relation by means of an inliexible probe or director luissed into the nostril, first on the one side and then on the other, mouldino; them at the same time with the fingers of his other hand applied on the outside. Another good plan is to use a pair of forceps. In many cases this will be sufiicient ; the deformity, once reduced, does not recur, and all that is needful is to keep down infiammation. Hemorrhage may be arrested by o-ently introducing a slender bit of ice, or by making the patient snufi" up into the nose, water as hot as he can bear. Emphysema will subside of itself. Should the fragments be so loose as to foil out of place, the attenipt may be made to support them from within by means of pieces of thick soft-rubber catheters, with adhesive plaster externally; or the plan suggested by Dr. L. D, Mason^ may be adopted. This consists in pushing through the base of the nose a strong pin (gilt or nickel-plated), and bringing a strip of rubber or adhesive plaster across from one end to the other so" as to support and compress the parts. For the treatment of deflections of the septnm it is impossible to give any rules which shall apply to the more diflicult cases, since they may require judicious modifications of operative procedures. Usually, in the simpler cases, properly applied pressure will sufiice to overcome them. Sometimes, when the nasal process of the upper maxillary bone is involved, there may be violence infiicted on the lachrymal duct. From this may arise stoppage of the duct and flstula. lachrymalis ; it is obvious that such a case would present unusual diflficulties. Malgaigne quotes from Duverney a case in which the ultimate result of an injury of this kind was a cancer, which destroyed the patient's life. Fractures of the Lower Jaw. — The lower jaw presents the figure of a more or less pointed arch, bent upward neiu' each buttress. Its bod}^ com- prising all in front of the angles, is thick and strong, and especially dense at ' Annals of Anatomy and Surgery. Brooklyn, 1880. 72 INJURIES OF BONES. the symphysis. The rami are flat and comparatively thin, widening out transversely above and posteriorly to form the condyles, while above and an- teriorly they run up into the thin points known as the coronoid processes. Without a careful study of the anatomy thus briefly sketched, a proper com- prehension of the fractures of this bone is impossible ; and such study must embrace the relations of the condyles to the base of the skull, as well as of the arrangements of the osseous structure as seen in sections. As to the latter, it aftbrds a very striking illustration of the law before stated, that the lamell8e always run perpendicularly to the planes of pressure, and as nearly as possible parallel with the lines of muscular action. If a line be drawn from the symphysis to the centre of either condyle, it will be found to represent the resultant of all the normal forces to which the corresponding half of the bone is subjected. As might be inferred from its complicated shape, the fractures of this bone present great varieties. They may result from direct violence at almost any point, or from indirect violence at one or even at a number of points. A force from without may tend to crush down the whole arch, in which case it may give way at its apex, at two or Fig- ^^4. more weak points, or, if the force be exerted somewhat obliquely, at some point on the opposite side of the arch. Occasionally there is a distinct lever- age, and sometimes a j)ressure on one side of the arch, with a counterpressure on the other. The annexed diagram (Fig. 814) will serve to show the portions of the bone at which fractures are most apt to oc- cur. The body is the part oftenest involved ; it may be broken just at the symphysis (although on the autho- Fractures of the lower jaw. rity of BoyCr this WaS loug tllOUght to be impossible), or at a variable distance from it. Double fractures, the body being broken through at two points, are by no means rare. The angle may give way, probably ahvays to leverage across it. Occasionally the neck of the condyle has been broken, and very rarely the coronoid process. Fractures of the lower jaw are rarely met with in children, by reason of the small size of the bone at their age ;^ and they are infrequent also in women and old people, whose habits of life exempt them in great measure from the kind and degree of violence by which these injuries are produced. Blows of all kinds— with the fist, with weapons, by the kicks of horses, by flying masses in mining accidents — falls on the face, and crushing forces, such as the passage of a wagon-wheel, are the chief causes of fractures of the lower jaw. Hamilton states that he has seen the bone broken on both sides by the vio- lent grasp of a hand. Gross^ mentions the case of a man of 70, who sustained a fracture of the neck of the bone during a violent paroxysm of coughing ; this case I believe to be unique. The amount of injury done to the bone varies greatly, l^o other single bone is so apt to be broken in several places ; a fact which is readily ex- plained by its complex shape, and its double articulation, giving two points I Bouchut (op. cit. p. 759), says that fractures of the lower jaw are sometimes caused by the accoucheur in aiding delivery ; but he cites no cases in proof of the statement. Two are quoted, however, byClurlt (op. cit., Bd. ii. S. 409). « Op. cit., vol. i. p. 940. FRACTURES OF THE BONES OF THE FACE. 73 of resistance. Malgaigne quotes from Ilouzelot a case in which, the patient bavin"- been killed by a fall from a height, it was found that he had sustained fractures of the symphysis, of the neck of each condyle, and of both coronoid processes. Sir W. Fergusson^ mentions an almost similar case, in which, however,* only one coronoid process was broken. Ileath^ describes a speci- men in tiie Museum of King's College, in which the body of the bone is frac- tured on either side, with the necks of both condyles. The probability is that in all these cases the force was received on the symphysis, and that the frac- tures were produced sinmltaneously, the bone yielding at all its weakest ^^Another specimen mentioned by Heath will serve to illustrate multiple fracture, due, it may be supposed, to lateral compression :— " One fracture runs obhquely forward in front of the first molar tootli into the men- tal foramen. A second fracture runs vertically between the right incisor teeth. A third fracture runs very obliquely from the hist molar on the right side down to the lower border of the bone opposite the canine tooth. This is met by a fourth fracture running obliquely backward in front of the first molar tooth of tlie same side. The lower border of the bone in the mental region is broken off and comminuted into numer- ous fragments, one of which contains the mental foramen of the right side. The left condyle is also broken off obliquely." Still another is described by Heath as follows : — A fracture extends obliquely backward between the second and third molar teeth of the left side, the external and internal plates of the bone being equally involved. There is also an oblique (downward and backward) fracture of the neck of the right condyle." Fractures of the body of the jaw-bone are almost always compound, by lace- ration or rupture of the mucous membrane and underlying tissues, so that the air within the mouth gets access to the broken ends. Hence there is very apt to Fig. 8i5. be suppuration, and the breath and secre- tions of the mouth are generally offensive from the decomposition which ensues. The annexed sketch (Fig. 815) from a specimen in the Mutter Museum of the Philadelphia College of Physicians, shows a comminuted fracture, one portion of which, extending backward, is a mere fis- sure. Malgaigne quotes from Gariel an instance in which he " proved by an autopsy the existence of a fissure on a level with the dental canal, involving but part of the thickness of the bone ;" the patient had fallen from a height. When there is double fracture of the body of the jaw, the two lines of separation may be on the same side, or on opposite sides, of the symphysis. In the former case the intermediate fragment will not be as greatly displaced, or as hard to control, as in the latter. Peirson^ has recorded an instance of double fracture of the jaw by the passage of a wagon-wheel, in which the middle fragment of bone, with the tongue, " was forced down the throat, so as nearly to occasion suffocation. Tlie accident occurred in the night, but fortunately near a house whose inliabitants were awake ; and the patient obtained the loan of an iron spoon, with whicii he contrived to drag the tongue for- ward, and prevent the impending suffocation, till I was enabled to secure tlie fragments Comminuted and fissured fracture of lower jaw. > System of Practical Surgery, p. 457. London, 1870. 3 Remarks on Fractures. Boston, 1840. Op. cit,, p. 5. 74 INJURIES OF BONES. by wiring the teeth. Great swelling followed, preventing deglutition for many days ; but the patient, being supported through an oesophagus tube, eventually recovered." Here it was the unopposed action of the muscles of the floor of the mouth' that dragged back the fragment. Indeed, the effect of muscular action in causing or keeping up displacement is generally as clearly demonstrable in frac- tures of the lower jaw as in those of any other bone. In one case, in 1877, I was obliged to divide the muscles behind the symphysis, in a fracture close to that point, in order to reduce the fragment drawn back by them. Occasionally, however, the degree of displacement is curiously slight, per- haps because the actions of different muscles counterbalance one another, as is noticed in some other parts of the skeleton also. The signs of fracture of the body of the lower jaw are seldom very obscure, and sometimes very plain. Usually there is rapid swelling, which, when the bone is broken at one side, produces a curious twist of the face. Of course the motion of the part is limited, not only by the mere loss of continuity in the bone, but by the pain caused by it ; and there is apt besides to be at least a temporary paralysis of the lip, from the injury to the inferior dental nerve. Hence speech is impaired and chewing often impossible. Profuse salivation is an almost constant symptom, and is made more apparent by the loss of control of the mouth. Sometimes, especially if the fracture be compound, the saliva is offensive, even to the patient himself. When the finger is inserted into the mouth, and the other hand applied outside, the line of the teeth is found to be abruptly irregular, and the fragments maybe moved upon one another, with the production of pain, and of more or less distinct crepitus. It must be borne in mind that very few adults have perfectly regular teeth ; and that even very marked irregularities do not indicate frac- ture, unless there is pain on pressure, and a corresponding deviation at some point on the opposite margin of the bone. Abnormal mobility, also, is very rarely wanting, though it may be so slight as to require extreme care for its detection. The irregularity in the line of the teeth may be either transverse, one frag- ment being drawn down below the level of the other, or lateral, the anterior fragment generally slipping up within the posterior. This latter displace- ment is due partly to muscular action, but partly also to the fact noted by Malgaigne, that the plane of the fracture is apt to run inward and backward, the posterior fragment being beveled at the expense of its inner face ; and this again, it seems to me, may be accounted for by the pointed arch-shape of the whole bone. Although it would seem as if the dental nerve could never escape being torn or stretched in fractures of the body of the lower jaw, the occurrence of permanent trouble from this cause is very rare. Hamilton^ gives one case, and refers to another seen by Desirabode. Fractures at the angle of the jaw are generally oblique, in the direction shown in the annexed cut (Fig. 816), representing a specimen without history in the Mutter Museum. In this case there had been a false joint formed. Another case occurred in my ward at the Episcopal Hospital, in 1882, in the person of an elderly man who had fallen down, striking on a stone. A much rarer form of fracture, partly involving the angle, is shown in Fig. 817 ; it represents a specimen also in the Miitter Museum, and of unknown history. Besides a very old and firmly united fracture, almost exactly at the symphysis, there is a recent oblique one beginning at the angle and running downward and forward to near the middle of the lower margin of the right half of the body of the bone. • Op cit., p. 127. FRACTURES OF THE BONES OF THE FACE. 75 The coronoid process has very rarely been seen fractured ; never without other lesions. Besides the cases before quoted from J [ouzelot and Fergusson, Gurlt gives one other, from Middeldorpf, andTatum has reported ^ a fourth. Fig. 81(J. Fig. 817. Fracture of lower jaw at augle. Fracture of lower jaw at symphysis and augle. A number of instances are on record in which the condyloid process has been broken, either by itself or, as in cases already referred to, along with other i)()rti()n's of the bone. I have seen the former condition caused by a stone, in a man injured by the premature explosion of a blast. WilP has reported one observed by him in a patient hurt by a falling wall. Watson^ has recorded a case of fracture of the necks of both condyles, by a fall from a yard-arm, the iaw-bone being otherwise uninjured. Cockburn* gives a curious case in which 'bv a blow on the left side of the face, the neck of the right condyle was broken. Other instances are quoted by Malgaigne, who points out that the condyle itself remains in relation with the glenoid cavity; but the pterygoid muscle makes it execute a movement of rotation, carrying the fractured neck up- ward, forward, and imvaid, so that the fractured surface of the inferior frag- ment' is in relation only with the posterior surface of the neck and of the condvle." . i • i A "'case is reported ^ in udiich, along with fracture about an inch to the right of the symphysis, there was discovered after death, fifty-four days from the time of the accident (a fall from a horse), a fracture "situated in the left condyle, and extendhig obliquely downward and inward." If this fracture involved the condyle itself, it was, as far as my knowledge goes, altogether unique. . The symptoms of fracture of the neck of the condyle may be readily in- ferred; they will be more clearly made out if the fracture is on one side only. Besides crepitus, pain, and inability to move the jaw, there will be a twisting of the chin toward the injured side, which, according to Malgaigne, is apt to be permanent in cases wdiich do not prove fatal. This t\yist has an obvious diagnostic significance, as in unilateral luxation the chin is directed away from the injured side. Fractures of the jaw vary greatly in their degree of gravity. Even when they are compound, healing often takes place with readiness, and in cases which look very unpromising a good result may be obtained by careful and well-directed treatment. Yet it must be remembered that injuries about the face are particularly liable to be followed by erysipelas ; and the interference with nutrition which necessarily attends the lesion in question, may be a source of serious debility, especially in persons previously broken down by > Lancet, Dec. 1, I860 ; see also Trans, of Path. Society of London for 1861, p. 159. * Lancet' .Jan. 21, 1882. ^ New York .Journal of Medicine, Oct. 1840. ■* British Medical .Journal. December 28, 1867. 6 Medical and Surgical History of the War of the Rebellion, Part III., Surgical Vol., p. 649. 76 INJURIES OF BONES. hard labor and bad habits. Hemorrhage very rarely ensues to a troublesome degree, unless in very bad compound fractures, in which the facial artery is wounded. Stephen Smith^ reports a case in which, on the twentieth day after fracture of the body and ramus, the patient lost a pint of blood, prob- ably from the inferior dental artery. Necrosis of detached fragments, with loss of teeth, is a common consequence of severe fractures of the lower jaw. Abscesses often form, and may even prove fatal. Thus Mr. Abraham^ exhibited to the Pathological Section of the Academy of Medicine in Ireland, a jaw fractured on the right side at the mental foramen, on the left side from behind the last molar tooth to the angle. The patient, a man aged 36, had been knocked down, and kicked while on the ground. " On the fourth day after the receipt of the injury he got out of bed, walked from his house a short distance, and returning fell dead at his own door. The fracture at the angle was found to be compound, communicating with the mouth ; and an abscess traced from the parotid region dow^n along the carotid artery into the pericardium, had formed in connection with it." Eichet,^ in 1865, called attention to the occasional occurrence of putrid infection (septiccemia) as the result of fractures of the jaw with laceration of the alveolar periosteum, and Chassaignac stated that he had seen and pub- lished similar cases. Salivary fistula is said to have sometimes occurred after compound fracture. Treatment. — This may be a very simple affair, or it may require great mechanical skill and ingenuity on the part of the surgeon. Sometimes reduc- tion is readily effected, and maintained with ease by bandaging; sometimes, although the fragments can be replaced without difficulty, they resume their faulty relation the moment they are left to themselves. Sometimes the obstacles to reduction are very great. One case is recorded by Lonsdale,* in which a woman had the jaw fractured by a blow with a poker ; " there was great difficulty in getting the two por- tions to lie in apposition, and the cause was not discovered till two or three days after the receipt of the injury, when, on passing a probe down, a tooth was felt jammed between the fractured surfaces; as soon as it was withdrawn, the ends of the bone came easily into contact." Sometimes splinters become wedged cross-wise between the fragments. I have already mentioned having had to divide the muscles just behind the symphysis in one case, in order to effect reduction ; and my belief is that in very many cases^ even with the best apparatus that can be devised, muscular contraction is not wholly overcome, but a certain degree — too slight it may be to produce obvious deformity — remains. The great object to be aimed at is, so to restore the form of the bone that the teeth shall come into proper apposition with those of the upper jaw, and thus to insure to the patient the ability to masticate food. It is by no means always easy to judge of the degree of accuracy of the reduction, during the progress of the treatment ; and the surgeon will do well as early as possible — say about the third week — to cautiously test the question by removing all apparatus, and, carefully supporting the broken bone below, bringing it up so that the line of the teeth, upper and lower, can be compared by means of the finger inserted into the mouth. Should there be any defect in the apposition, it may be much more readily corrected at this stage than at any later period. 1 New York Journal of Medicine and Surgery, January, 1857. 2 British Medical Journal, December 23, 1882. 3 (laz. des Mopitaux, 1865 ; Am. Journal of the Med. Sciences, July, 1866. '* Practical I'reatise on Fractures, p. 229. FRACTURES OF THE BONES OF THE FACE. 77 In effecting reduction, the surgeon should pass one or two fingers of one hand into tlfe patient's mouth, applying them to the teeth, while with the thumh and lingers of the other hand he endeavors to bring the bone itself, at its lower border, into proper shai)e. As a general rule, the greater the vio- lence which has caused the injury, the inova will the bone be likely to be shattered, and the soft parts to be torn. Fractures at or close to the sym[)hysis are more easily kept reduced than those of the middle of the body at either side. And fractures at the angle are but little liable to displacement, partly because they are at the widest part of the pointed arch before spoken of, partly because the disposition of the muscles is such that neither fragment is pulled upon more than the other; they are as it were balanced. The bandage most frequently employed in Philadelphia, in the retention of fractures of tlie lower jaw, is that known as Barton's.^ Hamilton describes an apparatus made with straps and buckles, on a very similar plan, which he has used with satisfaction. Before applying either, it is better, if the patient be a male adult, to have the face shaved^ or, at least, to have the beard clipped very short ; the hair, if long, should also be cut. If the fracture is at either side, it will readily be seen that the pressure of the bandage may be so exerted as simply to flatten out the broken bone, as it were ; a"n action which, carried to excess, would produce between the frag- ments an angle salient toward the mouth. Hence it is much better to use a 8j)ruit made of binder's board, felt, or gutta-percha, moulded to tit the chin, and smoothly lined with a thin sheet of raw cotton, or with Caution flannel. Greater security may be given to this apparatus, if, before applying the ban- dage, the outer splint be fastened in place by a strip of plaster about an inch and a ludf in width, passing well up on each cheek. What is known as " rubber adhesive plaster" is the best, but any well-made adhesive plaster, not too fresh, will answer. If the strip be made twice as wide, and doubled on itself so as to have an adhesive surface toward the splint and another toward the bandage, tlie latter will be still further prevented from slipping. Such a precaution is by no means needless in the cases of some very unruly or delirious patients. When the surgeon has any doubt as to the accurate retention of the frag- ments, a very siniple and easy expedient may be adopted to insure it, at least until a permanent apparatus can be made. A large vial-cork may be cut down so as to square it on two opposite sides, leaving it of sufiicient thickness for spaces to be cut out on these square sides, on one side for the upper and on tlie other side for the lower teeth. This shaping can be easily done with a sharp knife, by any one with ordinary dexterity in" such matters. When finished, this interdental splint can be fitted to the upper teeth, the lower jaw brought up to it, and the fragments properly placed in their groove, after which the outside splint and bandage may be put on. Another very ancient device is that of surrounding the adjacent teeth on the two fragments with a wire, which thus includes them in a loop, secured by twisting the ends of the wire. Such a loop need not be retained very long, and, indeed, ought not to be, lest it should injure the gums ; a week or ten days will generally be a sufficient time, as the process of union will then have begun, and the fragments will be apt to keep their place. In cities, or where vei" the services of a competent dentist can be had, the best plan is to have a mould taken of the patient's jaws, the fragments being held in place by the surgeon. From this an accurate cast may be made, and upon this again a vulca^iite plate, to fit above and below. When skilfully ^ See Vol. I. p. 500, Fig. 64. 78 INJURIES OF BONES. done, this gives the surgeon as absolute control of the fragments as it is pos- sible to obtain. By some, splints of this kind have been attached to steel arms or branches coming out at the corners of the mouth, and connected with an outside framework, a padded plate fitting underneath the chin ; when such an apparatus is employed, there is no need of the upper teeth being taken into the account at all, as the fragments are securely held between the mould above and the padded plate below. The arms connecting the two are arranged with screws and nuts, so that they can be tightened to the requisite degree. Rutenick, Lonsdale, Gunning, Bean, Kingsley, and many others, have exer- cised much ingenuity in devising modifications of apparatus based upon this idea. The appliances known by their names may be found described in detail in so many systematic works, that it seems hardly worth while to devote more space to them here. During the confinement of the jaw by any of the means now mentioned, it is obvious that the patient is debarred from the use of ordinary food ; and by some of the older writers it was advised that a front tooth should be drawn in order to allow of the introduction of milk, soups, etc. This, however, is unnecessary ; scarcely any one has the teeth so closely set together as to pre- vent liquids from finding their way to the back of the mouth. If from swel- Ihig or other cause deglutition be very much hindered, nourishment may be administered either by means of a tube passed along the floor of the nose, and so down into the stomach, or by enema. The difiiculty of swallowing rarely persists more than a few days. Suturing of the fragments has been practised with advantage in a few instances of very oblique fracture, where retention by ordinary means was found impossible. Kinloch's case,i the first of which I have any knowledge, was one of compound fracture, and the result was excellent. Thomas^ has reported two cases attended with like success. Fastening the fragments together, by means of silver pins, as recommended by Wheelhouse,3 appears to ofter no advantage over the ligature, while it multiplies the chance of irritation of the soft parts. Fractures of the lower jaw are sometimes, but very rarely, complicated with luxation of one condyle. Probably the dislocation occurs first, as other- wise there would scarcely be purchase enough to force the condyle out of its socket. Details of the reported cases are given by Heath.^ In one case only were both condyles displaced, and the necks fractured ; and in one, in which only one condyle was luxated, it was also broken oft' at the neck.^ Replacement of the condyle would, under such circumstances, be obviously impossible ; but when the fracture is far enough from the condyle to give sufticient purchase, the luxation may be reduced in the ordinary manner, and the treatment of the fracture then proceeded with. Non-union. — While, as a general rule, fractures of the lower jaw unite readily, there are not a few cases on record in which they have failed to do so. Malgaigne quotes from Berard a curious case of " a child whose fracture made no progress toward recovery until the apparatus, an ordinary bandage, was removed." On a previous page a specimen of false joint formed at the angle was depicted ; and Physick's case, in which union was brought about by the employment of a seton,is among the most widely-known instances ot success by that mode of treatment. But little need be said as to the course to be. adopted when union takes 1 American Journal of the Medical Sciences, July, 1859. 2 Lancet, Aujjnst 17, 1867. a Ibid. * 'Op. cit., p. 22. 6 Botli these cases are quoted from Bonn by Coote, in Holmes's System of Surgery, 2d ed. vol. ii. p. 429; Am. ed. vol. i. p. G80. FRACTURES OF THE LARYNGEAL APPARATUS. 79 place slowly, or when a false joint has formed, in fractures of the lower jaw, since the general principles already laid down are of particularly easy appli- cation here. In cases of slow consolidation, the surgeon should first have made a very accurately fitting interdental splint, and, after thoroughly rubbing the frag- ments together, he should apply it, so as to keep them at absolute i^est in good relative position. Failing in this, he should proceed at once to drill the frao:ments, and wire them together, confining the jaw subsequently with a moulded outside splint and a carefully applied bandage. When a false-joint has formed, the fragments may be at once scraped, drilled, and wired. It will, perhaps, seem as if so prompt a resort to the most heroic mea- sures, without a previous trial of milder means, were at variance with the accepted rules of surgery. But it must be remembered that this bone, though easily accessible, is very difiicult of control ; and that the interference with nutrition during the period required for such attempts, would be of itself a serious evil. Union with Deformity. — When a fracture of the jaw has united with the fragments in bad relative position, it is very seldom that any means of cor- rection are available ; only, in fact, when the bone has been broken some- where near the symphysis, as elsewhere interference would either endanger the vessel or nerve, or both, or would be useless by reason of the want of purchase for mechanical treatment. Yet it may be that in some few cases, even as far back as the angle, subcutaneous osteotomy might aftbrd a chance of dividing the uniting medium, as it would indeed be the best means of doing it at any point. Afterward, drilling, wiring, and a well made inter- dental splint, with a bandage externally, should be employed. Fractures of the Laryngeal Apparatus. Fractures of the IIyoid Bone. — From its position and connections, this bone is greatly protected, yet a number of instances are upon record in which it has been broken, either alone or along with severe injuries of neighboring parts. It is of the former class of cases only that I have now^ to speak, since this lesion is in the others a comparatively unimportant complication. Strange as it may seem, the hyoid bone is seldom fractured in cases of hanging, whether suicidal or judicial. Casper says^ that he has never seen it in any of the numerous bodies ofi&cially examined by him. Mackmurdo, for many years surgeon to the IS^ewgate Prison, in London, is quoted by Gibb^ as stating that he had only once seen the body of the bone broken in a hanged man, and that in three or four only had he seen one or other cornu (never both) fractured. In suicides, the body of the bone w^as seen broken by Orfila, and a cornu by Diefienbach and Cazauvieilh (two cases). In the body of Wirz, hanged at W^ashington, D. C, in 1865, " the hyoid bone had received six injuries ; separation of the greater and lesser processes on both sides from the body of the bone, and true fracture of the outer third of the greater process on either side."^ This'bone has been several times observed to be broken by throttling (Auberge, Diefl:enbach, Murchison, Lalesque, Devergie, Helwig), and by falls in which the front of the neck is struck against some resisting body (Harley, • Forensic Medicine, voL ii. p. 174. B On Diseiises of the Throat and Windpipe, etc. London, 1864. 3 Med. and Surg, Hist, of the War of the Rebellion, Part I., Surg. Vol., p. 400. 80 INJURIES OF BONES. Griinder, T. Wood), and in three cases the lesion was ascribed to muscular contraction (Ollivier d' Angers, Obre,^ La Roe^). Ollivier's case was that of a woman, aged 56, who made a false step and fell, her head being thrown forcibly backward. "At the same moment she heard a very distinct crack at the upper part of the left side of the neck ; there was a fracture of the greater cornu of the hyoid." La Roe's patient . sustained the injury in yawning. From the few recorded cases, the symptoms of this fracture would seem to be: sharp, sticking pain; sometimes spitting of blood ; swelling, and embarrassment in speaking or swallowing ; and, when the fragments remain in contact, crepitation. Upon examination with one linger in the mouth and one outside, the fragments can be felt, and perhaps pushed into place. In Grlinder's case, the only uncomplicated one which proved fatal, the broken cornu was found "jammed between the epiglottis and the rima glot- tidis." In all the other instances, there was union b}^ means of callus ; and this had taken place in two specimens, one without history,^ and the other taken from a woman who several years before her death had received a blow on the neck by a heavy boot falling on her as she lay asleep.* As to the treatment^ the first point must of course be to remedy any dis- placement of the fragments, by manipulation ; next to allay inflammation, by suitable local applications ; to enjoin upon the patient perfect quiet, and to provide for his due nourishment, should swallowing be difficult or impossi- ble, by means of nutrient enemata. A stomach-tube has been used in some cases, but at some risk of disturbing the fracture. Fractures of the Laryngeal Cartilages. — The laryngeal cartilages are from their situation exposed to the same causes of fracture as the hyoid bone — compression by hanging or throttling, falls, and blows — but they are less under the shelter of the lower jaw, and hence more frequently suffer. Casper^ says that he has never yet seen fractures of the larynx in cases of hanging ; but instances are recorded by Weiss and Cazauvieilh, and in the Warren Anatomical Museum, in Boston, there is a specimen of fracture of the right upper cornu of the thyroid cartilage from a Sandwich Islander, who took his own life in this way. A case in which the cricoid was broken by hangins: is also recorded by Porter.® (In the official report^ of the autopsy on the assassin Guiteau, it is stated that the thyro-hyoid membrane was ruptured, and that the hyoid bone and thyroid cartilage were widely separated.) Mor- gagni^ says: "That the larynx is sometimes broken from that cause [hanging], I have seen, together with Valsalva." ..." A hanged man had the sterno- thyroidei and hyo-thyroidei muscles torn, so that only a membranous sub- stance remained in their place about the annular cartilage. And this very cartilage was also broken asunder." . . . " The celebrated Professor Weissius found, in a soldier who had been hanged, the annular cartilage broken asunder into many pieces, and the inferior part of the trachea entirely torn away from the larynx." Malgaigne quotes cases of fracture of the thyroid cartilage, by the grasp of a hand, from Ladoz and Marjolin. Fractures of the cricoid cartilage alone, produced in the samcvway, have been reported by Fredet^ and Pemberton.^" • (xibb, op. cit. 2 Medical Record, April 15, 1882. 3 (libb, Trans, of the Pathol. Society of London, 1862. 4 Clurlt, op. cit., Bd. i. S. 327. ^ Op. cit. 6 Archives of Laryngology, June 30, 1880. ^ Medical News, July 8, 1882. ^ De Sedibus et Causis Morborum, Lib. ii. Epist. xix. 9 Brit, and For. Med.-Chir. Review, Jan. 1869. ^0 Lancet, May 22, 1869. Mr. Pemberton refers also to papers on Manual Strangulation, by Wilson and Keiller, in tlie Edinburgli Med. Journal for 1855 and 1856. FRACTURES OF THE LARYNGEAL APPARATUS. 81 Wales^ reports a case of fracture of the thyroid cartilage and lower jaw by a fragment of a shell ; Hamilton gives one case^ of fracture of the thyroid and cricoid by a kick from a man, and another^ by the kick of a horse. I have myself met with a case'' of supposed fracture of the larynx (probably of the thyroid cartilage only) by the kick of a man. Hunt records^ an instance in which both the thyroid and cricoid were broken by a blow from a piece of wood thrown off from a circular saw. Per- haps the most remarkable case, however, is that reported by Sawj'ei-,^ in which there was double fracture of the lower jaw, with fracture of the hyoid bone, thyroid cartilage, right radius, and left patella ; tracheotomy was per- formed on the fifth day, having become urgently necessary; the patient ulti- mately made a good recovery. Instances have been reported by Maclean^ and Roe,^ in which the thyroid cartilage alone was broken by falls against resisting objects — a stump and the edge of a table. Sometimes the hyoid bone also suffers, as in a case recorded by Koch,^ and in Sawyer's case above referred to ; and sometimes, again, the cricoid is involved, as in the instance quoted by Malgaigne from Plenck. Fractures of the cricoid alone by hanging and throttling have already been spoken of; Stokes records^^ an instance in which this lesion was the result of a kick. The mechanism of production of these lesions is sufficiently apparent." It does not seem that the rigidity of the cartilages has anything to do with their liability to fracture : Gibb^^ mentions a number of cases occurring in young children. As to the symptoms^ there is always more or less swelling of the parts, often increased by the occurrence of emphysema ; in the case observed by me, there was a curious limitation of the emphysematous condition to the cervical region both anteriorly and posteriorly. Pain, increased by efforts at coughing or swallowing, is generally present, and is sometimes marked ; there is always tenderness, and often the handling of the parts elicits crepitus. The voice is husky, perhaps almost extinct ; breathing is difficult, and the face generally more or less livid, with an anxious expression. A very con- stant symptom is the expectoration of bloody, frothy mucus, with or without cough. From the presence of all or most of these phenomena, and the his- tory of the case, a diagnosis may be arrived at without much difficulty. The prognosis is a matter open to more doubt. In Plenck's case death was instantaneous, as it was also in a case of throttling reported by Damonetta ;^^ but more frequently the patient dies gradually by suffocation, from hemor- rhage beneath the mucous membrane, inflammatory swelling, or oedema. Roe, in the article before quoted, speaks of fracture of the cricoid as " almost invariably" fatal ; and from the records it would seem as if he might have * Am. Journal of the Med. Sciences, Jan. 1867. 8 Medical Record, Jan. 1, 1867. 8 Fractures and Dislocations, 6th ed. p; 153. * Reported in Archives of Laryngology, March, 1880. 6 Am. Journal of the Medical Sciences, April, 1866. The reader may consult with advantage the table of 29 cases given at the close of Dr. Hunt's article. 6 Ibid., Jan. 1856. 7 Canada Med. Journal, Sept. 1865. ^ Trans, of Am. Laryngological Association, 1880, p. 99. ^ Quoted by Roe, loc. cit. Dublin Quarterly Journal of Medical Science, May, 1869. " In the Index Medicus for 1882 (p. 380), there is given a reference to a paper by R. Haume- der, " Uber den Entstehungs-mechanismus der Verletzuugen des Kehlkopfes und des Zungenbeins beim Erhangen," in the Wiener med. Blatt, 1882, S. 810. This pjobably embodies the latest views on the subject. '2 Diseases of the Throat and Windpipe, etc., p. 436. ^ Ann. des Mai. de I'Oreille et du Larynx, Mai, 1879. VOL. IV. — 6 82 INJURIES OF BONES. omitted tlie qualification. One case only has been reported^ in whicJi reco- very is claimed to have occurred after lesion of this part of the larynx ; I have seen a French translation^ of the account, which is too vague, and apparently too inaccurate, to weigh against the mass of testimony on the other side. (Possibly this gloomy condition of affairs might be changed by the very early performance of tracheotomy). Unfavorable indications are, in any case : great interference with breathing, severe cough, marked cya- nosis, and free spitting of blood. When recovery takes place, the voice is apt to be permanently altered. As to treatment, anodyne fomentations and poultices, the latter made of light materials, may be nsed locally, to allay irritation. No compresses, or other confining apparatus, should be employed, as they would only still further embarrass respiration. Opiates may be given by the mouth if swal- lowing is not verv difficult. Absolute silence and rest in bed should be enjoined, and a warm and moist atmosphere should be provided by the usual means. For a few days, at least, the patient should be ted by enemata. I think that the invariable rule should be to contemplate from the very first the probability that tracheotomy may become necessary, and to arrange for its immediate performance should the breathing become increasingly difiicult. case of this kind can be safely left unwatched ; and unless, as in a w^ell- ordered hospital, aid can be instantly rendered in case of need, it would be the best practice to open the trachea at once, in anticipation of trouble. Fractures of the Ribs, Costal Cartilages, and Sternum. For a reason already stated, fractures of the vertebrae are given considera- tion elsewhere ; and the subject now to be taken up embraces the fractures of the lateral and anterior portions of the Avail of the thorax. In order to a full understanding of these injuries, the anatomy should be carefully studied, not only of the separate bones, but of the framework as a whole, and as covered in great part by muscular and other structures. It will be seen that the seven upper ribs are attached, not rigidly, but nearly so, both posteriorly and anteriorly ; the next three have in front a greater degree of motion, by reason of the length of the cartilaginous branches which run up to give them an indirect connection with the sternum ; while the eleventh and twelfth are merely tipped with cartilage. Each rib has an angle, a curve, and a twist ; and the mobility of the walls of the chest is the aggregate of that of all the constituent ribs. The sternum has a mobility dependent chiefly on the elasticity of the ribs and their cartilages. Fractures of the Ribs. — The ribs may be broken by direct or indirect violence, or by muscular action. They are, in children, extremely elastic, and are not often fractured in them except by very great crushing force. Holmes 3 quotes the opinion of Coulon, that incomplete fractures of the ribs are very common in childhood. One case is mentioned by the latter author, in which a child, who died of rupture of the lung, was found to have sus- tained partial fracture of two or three ribs on each side. It is highly probable that in many cases in adults, supposed to be mere contusions, one or more ribs may have given w^ay in a part only of their thickness. Mention has 1 In tlie Index Medicus for Aug. 1882, the reference is given as foHows : " Masucci (P.) Su di 'Un caso di frattura della cricoide, seguito da guarigione. Arch. Ital. di LaringoL, Napoli, 1881-2." 2 In the Revue Mcnsuelle de Laryngologie, etc., 1 Nov. 1882. * Surgery, its Principles and Practice, p. 219, note. FRACTURES OF THE RIBS, COSTAL CARTILAGES, AND STERNUM. 83 already been made of two cases of " willow fracture" of tlie ribs from gun- shot, noticed during the late war. Direct violence, ma}^ affect only a limited area, and one rib only may be broken ; or it may crush a large portion of the chest-wall. Indirect violence generally acts in the latter way. Blows with the tist or with weapons, falls against resisting objects, etc., are the chief direct causes of fracture in this region. Of indirect causes, one of the most frequent is the passage of a wheel over the chest; the caving in of earth, crushing under heavy falling bodies, and the pressure of crowds, have also been noted. Double fractures are not unfrequent. An important difference obtains between the effects of these two forms of violence. Direct force is apt to drive the broken ends inward, so that the inner wall of the bone or bones gives way iirst, and is more extensively^ splintered; and, hence, injury to the pleura or lung is more apt to. ensue, either as a primary or secondary effect. By indirect violence, on the other hand, the arch of the thoracic wall is bowed outward, and the fragments are caused to project. For an obvious reason, when the ribs are broken by direct force, the line of separation is apt to be less oblique than when the fracture is due to indirect violence. Fractures of the ribs by forces acting from without, are much more com- mon in men than in women, the habits and occupations of the former involving more exposure to such causes of injury. Muscular action has been observed as a cause of fracture of the ribs in a large number of instances. It is not easy to understand the mechanism of such lesions, unless we suppose that they are the result of a sudden pull by the extra-thoracic muscles, as by the serratus magnus (its lower part), the shoulders being lixed. Coughing has been the action to which these accidents have been most frequently due ; the portion of the chest involved has been near or below the middle, and, whether from coincidence or not, almost always the left side. Thus Despres^ has recorded the case of a woman, aged 53, who broke "the eleventh left rib, four fingers' breadths from its junction with the car- tilage," in a fit of coughing. Doit^ reported a fracture of the sixth left rib in its anterior third, produced in the same way, the patient being a man, aged 59. Malgaigne mentions a case observed at the Hopital Xecker, in which " there took place in less than one month three successive fractures, aftecting first the tenth, then the ninth, and, lastly, the eleventh rib." One case is related by Castella,^ in which a fracture of the ninth rib on the left side, was caused by sneezing. Gurlt quotes from Groninger a case in which the seventh and eighth ribs gave way in a robust man of 45, as he made a great effort to save himself from falling. J^ancrede'' records the case of a robust Englishman, aged 44, who sustained a fracture of the second rib on the right side, in an effort to straighten a scythe-blade. Fractures of the ribs are rarely eitlier compound or comminuted ; they are very generally complicated with pleurisy, although this may be of very limited extent. The chief symptoms of fracture of a rib are pain and difiiculty of breathing, which are combined so as to constitute what is known as " a stitch in the side." The respiration is apt to be largely^ abdominal ; as a rule, the patient can lie indifferentl}- on either side. Cough, slight and suppressed, but con- stant, and troublesome from the pain caused by it, is very generally present; ' Gazette des Hopitaux, 28 Fev. 1882. 2 Med. Times and Gazette, May 6, 1882, from L'Union Medicale, 29 Avril. 8 Ibid., Jan. 25, 1862, from Gaz. des Hopitaux, 1861. 4 Philadelphia Med. Times, May 23, 1874. 84 INJURIES OF BONES. it has been suggested that it may be reflex, from the irritation of the inter- costal nerves, which can scarcely fail to exist. Crepitus may often be elicited by merely placing the hand flat on the seat of injury, or by making alternate pressure on either side of it ; or by placing the ear over the spot, and inducing the patient to take as long a breath as he can. Tenderness on pressure is a constant symptom. When the lung has been punctured by one of the fragments, emphysema is very generally the result, air escaping into the subcutaneous areolar tissue. Of this Hammick^ gives a very curious instance : — " A man was brought in for fractured ribs from the Glory, then lying in Cawsand Bay, and when the sailors uncovered him, it being night and very dark, they were aston- ished, for when they quitted the ship, immediately after he had fallen, he was a thin person, but* from the escape of air into the cellular membrane, he was blown up to a frightful size — the scrotum being as large as his head — the breathing so laborious, and the symptoms so urgent that, without waiting to put him into bed, with a scalpel I freely incised several parts, particularly the scrotum ; the escape of air was so great that it blew out a large candle held before it. By the next day there was only a little crackling feel in the neighborhood of the fractured ribs ; he recovered finally from the injury, though it was many months before he could be discharged from the hospital." The slight pleurisy, already mentioned as generally attendant upon frac- tured rib, may spread and assume such proportions as to endanger life ; and pneumonia may be superadded to it. The prognosis is, of course, grave, if the injury is very extensive ; yet Holmes^ says he has seen a young woman recover from fracture of every rib in the body, and comminuted fracture of the left clavicle involving such damage to the brachial plexus as to cause permanent paralysis of the arm. Injury to the vessels, or to the viscera, adds very greatly to the danger. Turner 3 has recorded an instance in which a robust man, fencing with another in sport, was struck with a light cane over the eighth rib on the right side, and died from rupture of the intercostal artery, five pints of blood being found in the pleura. Wounds of the heart are not infrequent. Lonsdale* gives an account of a man, aged 21, run over by a wagon-wheel, in whom the following condition was found after death : — " Eight ribs of the left side w^ere fractured at their posterior part, about an inch from their tubercles ; and the four middle ones were broken at the anterior part as well, causing a double fracture. The pericardium was filled with blood, and a large quantity had escaped into the chest as well. The left auricle was found to be torn by the frac- tured ends of the ribs having been thrust against it.'* Eve^ quotes from Lees a very singular case : — " A brewer's man had fallen under a dray, when it was heavily laden, which passed over his chest ; he was lifted up and complained of pain and weakness, but was able to continue sitting on the side of the dray, driving the horse for nearly an hour, when being in the vicinity of the hospital he thought he might as well get himself examined ; he w^alked in and lay on a bed, but on turning on his side he suddenly expired. On dissection it was found that the fifth rib was fractured, and that the extremity of one portion had penetrated the pericardium, but had freed itself from the heart ; and this, as Mr. Wilkin observes, accounts for the sudden death of the man. For it is probable that the portion of rib had filled up the wound of the heart, and thus prevented any hemorrhage until his arrival at the^hospital, when, on its coming out, the sudden effusion of blood into the pericardium caused death." 1 Op. cit., p. 163. 8 Med. Times and Gazette, Dec. 22, 1860. 6 Remarkable Cases in Surgery, p. 221. 2 Op. cit., p. 218. 4 Op. cit., p. 258. FRACTURES OF THE RIBS, COSTAL CARTILAGES, AND STERNUM. 85 Hammick^ mentions a case in Avhicli a man was struck on the side by the end of a flying rope, and died immediately : — The post-mortem showed that " one rib only had been broken, both ends of which bad been driven inward, piercing the very apex of the heart, penetrated both ventricles, and then had returned to their situation by their own elasticity ; the pericardium was full of blood, but none had escaped into the chest." Hammick suggests that death was due here to the shock to the diaphragm or to the heart ; but it seems as if the escape of blood into the pericardium might amply account for it. Still another case may be cited, reported by West:^ — A young man fell into a coal-pit, and was taken out dead. There was no wound on the surface ; but the sternum was broken into two fragments, and the third, fourth, fifth, sixtli, and seventh ribs on the left side were fractured also. The pericardium and pleura were full of black fluid blood, and both right and left ventricles of the heart extensively lacerated. Fractures of the ribs generally unite without difficulty, in the simpler cases; but from the unavoidable mobility of the parts there is apt to be some excess of callus. When several ribs are involved this condition is more marked, and sometimes — as in a specimen in the Wistar and Horner Museun* of the University of Pennsylvania — there are curious stalactitic prolongations from each bone at the fractured part, as if the plasma had been pulled upon and drawn out when soft. ]^on-union is sometimes met with : — Boardman^ found in a colored girl, aged 22, a fracture of the eighth right rib, of three or four months' standing, ununited, and the fragments carious ; a fistulous opening led into tlie pleura, which was coated with lymph and contained about two pints of pus. On the left side, the eighth rib was also broken, and there was an abscess between the in- tercostal muscle and the pleura, pointing within, and apparently ready to burst. This latter lesion was only discovered after death ; the other was attributed to a kick. The treatment of fractured ribs, when uncomplicated with lesions of the internal structures, consists simply in immobilizing the parts ; and this is best done by means of adhesive strips, as first recommended by Hannay.^ It had been previously effected by the application of bandages, either ordinary wide rollers, or broad strips of flannel or muslin pinned about the chest. At the present day, the adhesive plaster is in very general use ; it is cut into strips from eight to sixteen inches long, according to the size of the chest, and about an inch and a half in width. These are put on very firmly, parallel with the ribs, and overlapping one another from above downw^tird, each one covering about one-third or one-quarter of the width of the preceding one. By Erichsen and others it is advised that the strips should surround the whole body ; but this will be found to impede respiration and give trouble. It is better to let the strips extend no further than the median line in front and at the back. Before applying the plaster, any marked displacement of the fragments should be corrected by suitable pressure and manipulation, the patient being directed to fill the chest as much as possible during these attempts. My own practice is to apply the strips during expiration ; and the pain caused by the act of breathing ought to be rnarkedly relieved. When the fragments project outward, a compress of lint, not too thick, may be placed over the angle before the plaster is put on. When they are driven ' Op. cit., p. 165. 2 St. Thomas's Hospital Reports, N. S., vol. i. 1870. * Proceedings of the Pathological Society of Philadelphia, vol. ii. p. 130. < London Medical Gazette, November, 1845. gg INJURIES OF BONES. inward, two compresses may be employed, at such points as to tilt up the ends and take off the pressure upon the parts within. Operative interference for the purpose of prynig up a fragment by means of the linger, a lever, or a blunt hook, inserted through an incision of the skin, has been suggested. Malgaio-ne mentions " removal of a piece of rib" as having been resorted to by Soranus and by Eossi ; but these, I believe, are the only known cases of the kind. He proposes the use of a hook curved like a tenaculum, inserted over the upper border of the bone ; and if the hook were blunt this could readily be done without wounding the pleura. Such a procedure could, how- ever, very rarely be called for. Should the fracture involve several ribs, I believe advantage would be gained by the use of a short, thin slip of wood, properly covered, and applied across the posterior portions of the ribs, so as to act as a splmt as well as a compress, pushing the fragments outward, away from the pleura and lung. It might of course be held ni place by adhesive plaster, put on m the manner above directed. . When a bandage is used, it is best made of flannel, about three inches wide ; if cut obliquely, or " bias," it will be much more elastic than if torn lengthwise of the piece. One or two turns round the shoulders will prevent it slippiiig downward, and a few strips of adhesive plaster across it on either side (not In front), running down as far as the pelvis, will keep it from slip- ping upward. Emphysema generally disappears of itself, without treatment. As to com- plications from intra-thoracic inflammation, they must be dealt with on the principles laid down in works on the practice of medicine. I may, however, say that leeches, applied just at the seat of injury, or cups in its immediate neighborhood, have sometimes seemed to me to be of great service. General bleeding I have never had occasion to employ in cases of this kind. Internal hemorrhage, in the recorded cases, has usually been speedily fatal, and it is seldom, if ^ever, amenable to treatment. Should opportunity be given for the employment of remedies, ergot and acetate of lead would ^ be indicated, and advantage might be derived from the external application of cold. ^ - . lu any case of injury of the chest, when fracture of one or more ribs is suspected, but cannot be clearly made out, it is safer to adopt the same course that would be followed if the bone were proved to have given way. I he enforced rest will be beneficial if there is mere contusion, and still more so if there is really an undetected fracture. Fractures of the costal cartilages are very rare, and not always easily distiucruishable from separations at the junction of the cartilages with the ribs. "^They are apt to be nearly ti^ansverse, and are generally due to direct violence. Reed ' has reported the case of a man, kicked by a mule, in whom there was separa- tion of the sternum at the junction of the first and second pieces, with fractures ot the cartilages of the second, third, fourth, and fifth ribs on the right side, as well as of those of the second, third, and fourth ribs of the left side. The pleural cavities were filled with blood. The right clavicle was also fractured. This extensive injury produced no sign until tympany came on (from rupture of the spleen), and the respiration became of necessity thoracic, with crepitus and displacement of the fragments. A man was brought to the Pennsylvania Hospital in 1855, who had fallen from a wharf, strikincT his chest on the edge of a boat. After his death from peritonitis (the colon having been ruptured), it was found that the sixtli and seventh cartilages I Proceedings of Path. Society of Philadelphia, vol. ii. p. 47. FRACTURES OF THE RIBS, COSTAL CARTILAGES, AND STERNUM. 87 on the right side were fractured about an inch from tlie sternum ; the perichondrium was entire in the sixth, but torn anteriorly in the seventh. M. Broca^ is reported to have mentioned to the Societe Anatomique a case in which tlie sixth, seventh, and eighth cartilages on the right side were fractured by muscular action. The patient, a porter, had a sack of peas on his shoulder, when another sack was suddenly laid ui)on him. Tlie weight bore him forward, and in raising himself against it he sustained the injury, the result of which is not stated. Gurlt quotes from Chaussier the case of an officer, aged 48, who had a diastasis of the cartilage of the left upper false rib, produced by a fit of coughing ; there was a hernia of thelung as large as a hen's egg. He cites also Monteggia's account of a very thin man, aged^TO, in whom the cartilages of the second and third (true) ribs had been separated from the ribs themselves, also by coughing. When these fractures do not prove immediately fatal by reason of the damao:e involved to the thoracic viscera, they may heal like other lesions of the same kind in other parts. Sometimes, however, they result in serious impairment of respiration, and consequently of the j_^eneial health. Ot this the following case aflbrds a good example : — A cavalry officer'^ was injured in the right side by a fall from his horse, in July, 1864. Three months later his case was reported as "fracture of the ribs, which have not yet united." In 1870, he was examined by a pension surgeon, who certified that the sixth and seventh ribs on the right side were fractured and dislocated from the sternum, and, not being properly adjusted, an imperfect cure was the result. There is a projection of two inches outward from the chest at the ends of those two fractured ribs, which are not joined to the sternum. The muscles which move the arm are weakened, and exercise causes pain." Seven years afterwards, it was noted by an ex- amining board that the pensioner had " an anxious expression of countenance ; dis- tended "nasal alie; respiration easily disturbed ; loud resonance and weak respiration in right lung, indicating emphysema." Macleod^ mentions the case of a man " hit by a round shot on the edge of the breast- plate, which was so turned inward as to fracture the cartilages of the fifth, sixth, and seventh ribs on the left side, close to the sternum. The skin was not wounded. He walked to the rear, and complained but little for two hours, when he was seized with an acute pain in the region of the heart. His pulse became much accelerated, and he grew faint and collapsed. A distinct and sharp bellows-sound accompanied the heart's action. He died in seventy-two hours from the receipt of the injury, the pain and dyspnoea, which had been so urgent at first, having abated for some hours before death. The heart was found to have been ruptured to an extent sufficient to allow of the finger being thrust into the left ventricle. The obHquity of the openinor had prevented the blood escaping into the pericardium, which contained about two ounces of dark-colored serum." From the cases now quoted, it w^ill be perceived that the injuries in ques- tion have much in common with fractures of the ribs. Union takes place, according to Gurlt. by the formation of spongy bone around both fragments, or in the interspace between their outer walls, the broken ends remaining quite passive.' A number of specimens exist in various museums illustrating this. Gurlt says, on the authority of Mal- gaigne and Klopsch, that in dogs and rabbits the divided cartilages unite by fibrous or .fibro-cartilaginous substances ; but that in large animals, as in the horse, the rule is the same as in man. The treatment must be immobilization by means of adhesive plaster. Mal- ' Brit, and For. Med.-Cliir. Review, Oct. 1856. « Med. and Surg. Hist, of the War of the Rebellion, Part III. Surg. Vol., p. 649. ' Notes on the Surgery of the War in the Crimea, etc.; Am. ed., p. 204. ^ Interesting and instructive articles on this subject, by Prof. Bennett, may be found in the Dublin Journal of Medical Science for March, 1876, and for October, 1877. 88 INJURIES OF BONES. gaigiie recommends an instrument like a trass, having a spring carrying two pads, one to be applied over any projecting fragment, the other at the back, and mentions a case in which he employed this apparatus with success. Fractures of the Sternum. — From the spongy structure and exposed situation of this bone, one might expect that it would be very readily broken. Yet such is not the case ; it is not often fractured, and very rarely by direct violence. When this does happen, other bones in the neighbor- hood are apt also to be involved. A good many instances, however, are upon record in which this bone has given way to indirect force, and to muscular action. A longitudinal fracture of the sternum, produced in a mason who was buried under some heavy stones, was recorded by Barrau, and is quoted by Malgaigne and Gurlt ; it is the only undoubted case of the kind, as far as is known. Gurlt quotes two instances of partial fracture of this bone, the pos- terior surface alone having suffered ; hemorrhage had taken place into the mediastinum in each. One, seen by Senator, was from the kick of a horse ; the other, by Brotherston, from a fall of about ten feet upon the head. The following curious case is mentioned by Malgaigne : — " A man of sixty-three was knocked down by a dray, the wheel of which went up on the left side of the chest, but not getting over the trunk, passed off on to the left arm, which, however, was uninjured. Tlie next day the man came to the hospital ; a quite notable swelling occupied the upper sternal region ; and the first piece of this bone, with the cartilage of the second rib on each side, made so marked a prominence in front that I thought 1 had to deal with a luxation, or with a transverse fracture with overlapping. I tried various manoeuvres to accomplish reduction, but in vain ; effusion occurred in the pleura; an abscess formed above the fracture, and the patient succumbed on the thirty-third day. At the autopsy^ fractures were found in the semi-ossified cartilage of the first rib on the left side, as well as in the second, third, and fifth ribs of the same side ; these had not been suspected at all. The sternum was broken transversely at the level of the third intercostal space, the upper fragment being slightly inclined backward; this fracture also had escaped notice. Lastly, a fracture, situated above and to the left, detached from the bone, as if with a knife, a sort of scale, the base of which reached from the fourchette to the level of the second costal cartilage, comprising all the left sterno-clavicular articulation, and the cutting edge of which was at the anterior face of the bone ; the abscess had formed at the seat of this fracture." Malgaigne quotes from Duverney a case in which a ten-pin player, who bent forward to watch his ball, fell, striking a large stone ; he was taken up dead, with a fracture of the sternum. I must say that this account is ' not full enough to be satisfactory, as some other lesion must have been pre- sent. Gibson^ says that, in 1839, he saw^ in the museum of the London LTni- versify a heart, the right ventricle of which had been lacerated by a fractured sternum ; and he cites a like case from Sanson. A number of instances are on record in which fracture of the sternum would seem to have been caused by the impact of the chin, the vertebrae giving way and allowing the head to be forced forward and downward. Four such cases were observed by Hodgen;^ in three of them the patients had fallen backward, striking on the shoulders. Eivington^ mentions a case in which — " An acrobat, aet. 30, in turning a double somersault, fell about ten feet on to the back - of his head. He came down on some tan, and his head was violently flexed on to his chest. The injury caused a separation between the sixth and seventh cervical vertebrae, 1 Op. cit., p. 253. ^ Holmes's System of Surgery, Am. ed., vol. i. p. 752. 8 British Medical Journal, January 31, 1874. FRACTURES OF THE RIBS, COSTAL CARTILAGES, AND STERNUM. 89 and ah oblique fracture of the sternum, sucli as might have been produced by the chin inclined to one side." MichaeP records the case of a seaman who fell into a hold, sustaining a dislocation of the fifth cervical vertebra on the sixth, with fracture of the sternum, the periosteum remainino- unruptured in front. Spontaneous reduction of the luxation took place. There was laceration of the lung, and the mediastinum became emphysematous. Death occurred on the third day. In all the foregoing cases the fracturing force acted directly. Indirect vio- lence may be exerted in either one of several ways : by the forcible bending backward of the trunk, or by falls on the buttocks or on the feet. Malgaigne suggests that some of the fractures ascribed to muscular contraction are really due to the first of these causes — a forcible separation of the upper and lower ribs, carrying with them their respective portions of the sternum. But in all cases, I think, we may exclude the direct pull of the muscles attached to the sternum as causes of its fracture. Gross' gives the following ac- count : — "In 1838 I attended, along with Dr. Rohrer, a case in a large, heavy, muscular man, forty-six years of age, who had received a transverse fracture of the upper |)art of this bone, from inordinate contraction of the sterno-cleido-mastoid muscles, in jump- ing, in a state of intoxication, off a shed eleven feet high. The heels striking the ground obliquely, threw the body violently backward, the head and neck coming in contact with the edge of a board. The fracture was, doubtless, occasioned by the effort which the man made* to regain his equilibrium." My own belief is that here there was sudden flexion of the body backward, and that the fracture was due to the mechanism before spoken of. A number of instances have been known in which the sternum has given .way to powerful muscular contraction in child-birth. In all of them, as far as I know, the trunk is stated to have been bent strongly backward. Analo- o;ous to these cases would be that often quoted from Faget, in which a mountebank, as a feat of strength, was leaning back and trying to raise a weight with his teeth. When the great extent of muscular struc- ture, connected with the ribs, which Avould thus be put into forcible play, is considered, it can scarcely be doubted that to this, and not to the mere contraction of the muscles attached to the sternum alone, should the production of the fracture be ascribed. It is not always an easy matter to determine whether the lesion is an actual fracture, or merely a diastasis between the pieces of the sternum ; but the question is not one of great practical importance. Occasionally, as in the specimen^ of which Fig. 818 is a representa- tion, the line of fracture clearly runs across one portion of the bone, with a marked degree of obliquity. Sometimes the displacement is very slight, but it may be considerable ; and, in the great majority of cases, the lower fragment projects in front of the upper. Malgaigne mentions one case seen by Sabatier, in which an old man had been subjected to great violence, and thrown into a hole thirty feet deep. He fell on his Fracture of sternum. ' Maryland Med. .Journal, Sept. 1, 1882. 2 Op. cit., p. 956. 3 In the Mutter Museum of the College of Physicians of Philadelphia ; the specimen has no known history. 90 INJURIES OF BONES. back ; the second piece of the sternum was broken away from the first, and driven in behind it. The symi:)toms of this injury are analogous to those of fractures of the ribs and their cartilages. Pain, tenderness, swelling, and ecchymosis have been noted in all the cases not immediately fatal. Cough almost always occurs, and emphysema may exist independently of injury to the lung. Displacement and crepitus have generally been more or less distinctly marked. Suppuration has occasionally taken place in the anterior mediastinum. Eiedinger^ says that repair, v/hen it ensues, is effected by means of a layer of fibro-cartilaginous material, placed between two other layers of hyaline cartilage. Very probably this statement may apply to cases of disruption occurring between two of the pieces ; but when a true fracture takes place in this bone, it is repaired in the ordinary manner, as may be seen in many museum specimens. The treatment of these injuries does not differ in any material respect from that of fractures of the costo-sternal cartilages. When displacement exists to any marked degree, it should be corrected as far as possible. But while it is eminently proper to make this attempt, it must be remembered that the dis- placement is not of itself a source of danger. Hammick^ says that " if the bone were allowed to remain depressed, it would extinguish life ;" but there is no ground for this statement. Hence operative interference, such as the introduction of gimlet-like screws, or of elevators or blunt hooks, for the pur- pose of pulling or prying up the depressed fragment, is unjustifiable. More- over, the texture of the' bone is too spongy to afford a good hold to such in- struments. The only available method of procedure is to act upon the lateral walls of the chest, by causing the patient to alternately fill and empty the lungs to the fullest extent possible to him, and by raising and lowering the arms, while the surgeon tries to push in the projecting fragment. The deformity having been thus rectified as far as may be ^Dracticable, the walls of the chest should be immobilized by means of adhesive strips, applied across their anterior portion, and covering in the whole sternal region. A flannel bandage surrounding the whole thorax may be put on in addition to the strips, and secured so that it shall not slip upward. Should inflamma- tory or other complications arise, they should be met by appropriate treat- ment. Absolute rest in bed should, be enjoined, and a concentrated diet. When an abscess formes behind the sternum, if its presence can be clearly, made out, there is no positive objection to penetrating the bone in the median line with the crown of a small trephine ; but it is almost certain that the pus will find its way to the surface, either at the seat of fracture or in one or more of the intercostal spaces, when vent can • be given to it by a simple puncture of the skin. Fractures of the Pelvis. Viewed as a whole, the pelvis constitutes a bony ring, interrupted ante- riorly by the pelvic synchondrosis, and posteriorly on either side by that between the sacrum and the ilium. These synchondroses, by the arrange- ment of the walls and cancellous structure on either side of them, are adapted to diminish the stress put upon the whole framework, either by ordinary or by extraordinary forces. It may further be said that the pelvis presents not only the bony ring just mentioned, which has no great depth below the brim of the lower or true pelvis, but also certain appendages — the iliac expansions I Gaz. Med. de Paris, 12 Aout, 1882. 2 Op. cit., p 167. FRACTURES OF THE PELVIS. 91 above the rami of the pubis and ischium below and on either side, and the downward prolongation of the sacrum and coccyx behind The ligaments which bridge across the gaps between these appendages add nothmg to the security of the bone against fracturing forces. Of the whole framework the strono-est part is that where, in the erect position, the weight ot the trunk is transmitted to the head of the femur ; the sacrum, although thick is com- posed in great measure of sponiry bone, further weakened by the pei-torations for the sacral nerves, as well as by the terminal portion ot the spinal canal. Fracture of the pelvis is not common in men, is rarely met with in women, and is almost unknown in children. The youngest patient I re- member to have treated for such an injury was sixteen years old. Bryant, however, mentions two cases seen by him in children, and a few others are upon record. I may mention here that, notwithstanding tlie rarity of frac- tures of the pelvic bones, three cases were under treatment at one time in my wards at the Episcopal Hospital, in 1882 ; a sort of coincidence not unfre- quently met with in practice. . Fractures of the appendages may occur without aftecting the continuity ot the pelvic o-irdle proper. They aVe generally due to direct violence. Thus the crest ot^the ilium may be broken off, in one or more pieces; the lower part of the sacrum may be fractured more or less transversely, or com- minuted ; or a portion of the ischium may be separated, this, however, being very rare. The lines of fracture vary almost indefinitely, as might naturally be expected. . . ^ n n r When a crushing force, such as the caving m of a mass ot earth, a tall ot rock or of coal in a mine, or the passage of a heavy wheel over the lower part of the body, is brought to bear upon the whole pelvis, the bone may give way at two or more different points. One or the other side of the ring may be especially acted upon, or the stress may be exerted directly across either antero-posteriorly or laterally. In any case, however, the pubis would seem to yield first, in its horizontal ramus, when there must be a fracture also somewhere between the symphysis pubis and the tuber ischii. IText, if the force acts antero-posteriorly, the tendency will be to open out the lateral arc of the bone, which may be broken at or near the sacro-ihac junction. Thus a portion of the sacrum may be torn away, or the lesion may be con- fined to the OS innominatum. Cases of the former kind have been very fully discussed by Voillemier, in two instructive jiapers.^ According to him, ver- tical fractures of the sacrum very generally belong m the category of " frac- tures par arrachement," or what we should now call " spram-fractures. That is, by the immense strain brought to bear upon the pelvic ring, the sacro-iliac' synchondrosis being too strong to yield, the spongy substance of the sacrum is actually torn across. The mechanism above described is regarded by Tillaux^ as that which uniformlv prevails in the production of tlfese fractures; and his view is sup- ported by the fact that in all cases of multiple fracture of the pelvis (and there is no portion of the skeleton so liable to this form of injury), the ante- rior seo:ment of the rins; suffers. The annexed cut (Fig. 819), taken from a specimen (without history) in the :\[utter Museum, will give a good idea of the usual characters of this fracture.^ i • i A few years ago I saw a case in which double fracture of the pelvis had been produced by lateral pressure in a somewhat curious way. The man * Clinique Chirurgicale, pp. 77 et 107. 2 Traite d'Anatomie Topograpliique, p. 829. » Kusmin, in an article to which I have not been able to obtain access (Ueber Beckenfrakturen Centralblatt fiir Chirurgie, Jan. 6, 1883: from Wiener med. Jahrb., 1882), gives the results of experimental researches on the mechanism of the production of these fractures. 92 INJURIES OF BONES. was sitting in the side window of the " cab " of a locomotive, leaning for- ward with his buttocks projecting, when it passed through the narrow door of an engine-house, and he was caught Fig. 819. and jammed. After his death, it was found that the bone had given way on each side. Occasionally, fractures of the pelvis have been seen as the result of falls on the feet, and even from much slighter accidents. Thus Bouvier^ recorded the case of a man, aged 71, who met with a slight fall out of bed, and fractured the left OS innominatum, from the ilio- pectineal eminence, down through the acetabulum to the spine of the ischium. Sometimes the force acts directly through the head of the femur upon Multiple fracture of the pelvis. the adjacent portiou of the OS innomi- natum. Hutchinson^ records an in- stance of starred fracture of the acetabulum, the head of the femur being driven through it by a fall on the trochanter. Gama^ reported the case of a man, aged 30, who fell eighteen feet, striking on the trochanter. Death occur- red from peritonitis on the tenth day. At the autopsy it was found that there was an abscess extending from the hip to the calf of the leg, and into the iliac region within the pelvis : the acetabulum had been broken into three pieces, the smallest of which was placed with the round ligament upon it, and unbroken, on the head of the bone ; the second was the horizontal ramus of the pubis, which was separated from the symphysis pubis and ischium ; and the third was the ischium, which was no longer connected with the ilium. Perhaps the most remarkable case is that recorded by Lendrick,*in which, by afi accident many years previous, the head of the femur was found to have been driven through the acetabulum, and to be covered in, partly by bone, partly by fibrous tissue ; the os pubis had been fractured and united with shortening, entangling a portion of intestine, which remained within a bony cavity as a sort of hernia ; the ischium also had been fractured and united. It not unfrequently happens that the anterior portion only of the pelvis suffers, perhaps at numerous points. Lodge ^ saw six fractures thus located, as the result of the caving in of a bank of earth upon the patient ; and Peaslee^ a case in which seven fractures had been caused by the patient being jammed in a narrow space between a railroad car and a platform. Rupture of the bladder had occurred in both cases. In one instance, reported by Letenneur,'^ it was claimed that fracture of the pubis had been caused by muscular action ; the patient, a woman, was lifting some large stones in unloading a boat, and felt something give way; but as it is expressly stated that, at that moment, she rested a stone, weighing over one hundred and fifty pounds, on the pubis, there must at least be some doubt whether the fracture might not be more justly attributed to the direct pressure thus exerted. Coates^ has recorded a case in which the os pubis was fractured in a very analogous way, a coach in which the patient was 1 Am. Journal of the Med. Sciences, February, 1839. 2 Med. Times and Gazette, February 24, 1866. ' American .Journal of the Medical Sciences, May, 1838, from Gaz. Med, de Paris. ^ Londcm Medical Gazette, March, 1839. 6 Am. .Journ. of the Med. Sciences, Oct. 1865. « Ibid., April. 1850. ' Medical Times and Gazette, November 28, 1868. ^ Med.-Clxir. Trans., vol. xi. FRACTURES OF THE PELVIS. 93 travelliiio- havins; been overturned, and the anterior part of her pelvis having been forced against the seat by the weight of several of the other passengers thrown over upon her. Fractures of the Acetabulum. — Fractures of the rbn of the acetabidum are by no means uncommon ; they owe their im})ortance chiefly to the fact that they are apt to allow the head of the femur to slip out of place, and, although it is easily reduced, it escapes again with equal readiness. A number ot instances of this kind are given ^by Sir A. Cooper,^ one of which, observed at St. Thomas's Hospital inlTOl, is, I think, the earliest on record. McTyer^ published several cases; R. W. Smith,^ one; Lonsdale, one; Holmes,4one; Eve,* two ; Gurlt^ gives a wood-cut, representing a fracture of the upper part of the rim of the acetabulum, which allowed of a very curious luxation— the trochanter major lying in the acetabulum, and the trochanter minor being applied to the outer edge of the tuber ischii. Favell, in an address before the British Medical Association,^ detailed a case which occurred under the care of Mr. Wheelhouse, in which a fracture of the rim of the acetabulum gave rise to subsequent dislocation of the femur upon the dorsum ilii— the symptoms of the latter lesion being manifested only some months after the accident, when the patient got up and bore his weio'ht on the limb. The case became the subject of legal proceedings, but the result is not stated. MorrisMjas reported an instance of unreduced dorsal dislocation of the femur, with fracture of the rim of the acetabulum, in a young and active man, the displacement coming on gradually during a period of about ten weeks. The mechanism ot this fracture must be sufficiently obvious. Fracture of the Sacrum. — Fracture of the sacrum by itself is not of com- mon occurrence, although the spongy character of this bone, before spoken of, renders it really the least resistant portion of the pelvis ; and occasionally violence is applied to it directly. Lee^ has recorded the case of a man in whom, by a fall from a height of forty feet, the sacrum was broken across ; the displacement of the lower fragment forward was corrected by means of a flnger in the rectum. At the autopsy, " the sacrum was found com- minuted, a large fragment of the left ala being broken off longitudinally and displaced to a considerable extent." In a very remarkable case reported by Burlingham./° the patient, a railroad conductor, was thrown into the air, fell on the top of a car, striking on his back, and then rolled down an embankment a distance of over eighty feet. He sustained a compound fracture of the sacrum, the posterior surface of the bone at least being comminuted ; and through the wound in the back, urine flowed for many months.^^ » Dislocations and Fractures of the Joints, 6tli ed. London, 1842. * Glasgow Medical Journal, February, 1831. 8 Archives Gen. de Mfedecine, 1838. < Transactions of Pathological Society of London, vol. xi., 1860. Med.-Chir. Transactions, vol. Ixiii., 1880. « Op. cit., Bd. i., S. 320. ^ British Medical Journal, August 5, 1876. ^ Lancet, February 18, 1882. 8 Proceedings of Pathological Society of Philadelphia, vol. ii. p. 116. ^0 American Journal of the Medical Sciences, April, 1868. " In the account of this case, it is stated that about three weeks after the accident " a probe could be passed from about an inch above the base of the coccyx, and about three-quarters of an inch to the right of the median line, across the pelvis, forward and slightly downward, a distance of five inches, until it was obstructed by bone, denuded or fractured." This fact, taken together with the injury to the bladder, seems to me to indicate that a fracture had occurred anteriorly also ; but, as the patient recovered, the diagnosis could not be placed beyond doubt. 94 INJURIES OF BONES. Fracture of the coccyx is spoken of bj authors ; but the consolidation of the several pieces takes place only in advanced age, and without this a true fracture could scarcely occur. No unquestionable cases are upon record in which this bone alone has been broken, and the probability is that the lesion involved to the surrounding soft parts w^ould be of far more importance. Should trouble arise in any such cases from inflammatory thickening and con- traction of the tissues, it would be proper to divide the latter with the knife ; and failing relief from this, excision of the bone might be practised, although the experience recorded by Mursick^ is not such as to warrant great expecta- tions of success. A case is reported^ in which the coccyx, " fractured and standing at a right gle with the sacrum," was removed by means of the " surgical engine," by Dr. Garretson. The history given of the case is simply that the patient, a lady, had suffered from coccygodynia for thirteen years. The periosteum was incised and laid open so as to expose the bone, which was then drilled away. The ultimate result is not stated. an Fracture of the Crista Ilii. — Fracture of the crest of the ilium is by no means uncommon. I have seen it caused by a fall from a horse, the patient striking on his hip against some railroad iron piled at the side of the street. At the Episcopal Hospital, in 1882, I had in the w^ards a man aged 21, who had fallen about twelve feet, striking on a rafter ; the left crista ilii, from near the sacrum to a point near the Fig. 820. anterior superior spinous process, was broken off. In this case there w^as, for some weeks, severe pain along the course of the anterior crural Dcrve ; and it seemed probable that its trunk had been pinched or torn. A rarer form of fracture of the ilium is shown in Fig. 820, taken from a specimen (without history) in the Miitter Museum. The bone has been separated nearly vertically, and transversely as well, the two lines of fracture representing an inverted y. Hamilton states that he has seen about three inches of the ilium, in- cluding the anterior superior spinous process, torn off by muscular action ; the patient, a man aged 70, having merely risen from his seat in a railroad car, when he felt "something wrong." Eiedinger^ claims that musculai action plays a much more important part in the production of fractures of the pelvis generally than has been ascribed to it by most writers. Fractures of the ischium alone are very rare, the six cases collected by Malgaigne being the only ones known. Three of them were due to violent falls on the buttocks, and all to direct violence. Malgaigne has devoted a special section to what he calls '^double vertical fracture of' the pelvis." This he defines as a combination of two vertical 1 American Journal of the Medical Sciences, January, 187G. 2 Philadelphia Med. Times, February 11, 1882. 3 Arch, fur klin. Chirurgie, Bd. xx. Heft 2 : American Journal of the Medical Sciences, April, 1877 X-fracture of the ilium FRACTURES OF THE PELVIS. 05 fractures, separating at one side of the pelvis a middle fragment comprising the hip-joint ; according as this fragment is carried upward or inward, the femur follows its movements, and hence result changes in the length and^ direction of the limb which have often misled practitioners." An injury of this kind might readily be mistaken, at iirst sight, for fracture of the ncc;k of the femur, as there would be crepitus, some degree of shortening— although in one case, according to Larrey, there was lengthening — of the limb, and very probably impairment of motion; certainly inability to walk or stand. Careful examination, however, into the precise seat of the crej)itus and diffi- culty of movement would, in most cases, be apt to reveal the true nature of the lesion. Besides the fractures of the various portions of the pelvis w^hich have been enumerated, there are certain cases of more extensive injury in this region, the whole framework being broken up, as in some mining accidents. I have seen the os innominatum on either side broken through nearly or quite verti- cally, both anteriorly and posteriorly, making four principal fragments. Such injuries are in themselves extremely grave, from the amount of shock which they involve. One of the three cases before referred to as treated in my wards at the Episcopal Hospital, in 1882, was that of a laborer, aged 50, upon whom a bank of earth had caved in. The os innominatum on either side had been broken, as above described, close to the sacro-iliac junction, as well as through the os pubis ; there were profound shock, retention of urine for several days, and subsequent peritonitis. The man complained of severe pain in the right leg from the hip to the toe ; but this gradually subsided along with his other symptoms. As he recovered, the diagnosis above given could not of course be verified beyond question by an autopsy; but the mobility of the fragments, the crepitus, and the long-continued tenderness upon pressure at the points indicated, seemed to warrant my statement of the case. Another was that of a young man, aged 16, who had fallen about sixteen feet. Pressure on his pelvis from side to side, or over the pubis, caused him great pain, as did also a slight blow on the knee if the thigh was flexed. He suffered less from shock than the patient first mentioned, but had retention of urine for four days. He also recovered. The symptoms of fracture of the pelvis need scarcely be dwelt upon at length. There is alw^ays more or less pain, sometimes very severe ; it is apt to be greatly aggravated by any attempt at moving in bed. When the sacrum is fractured, the act of defecation is productive of great pain ; and urination is similarly interfered with when the pubis has given way. In either case the patient's suffering is increased by coughing or sneezing. Crepitus can usually be felt if pressure be so applied as to cause grating of the fragments upon one another, but it is often by no means distinct. Ecchymosis may or may not be present, as sometimes the fracture affects portions of the bone very deeply situated, and the vessels torn may be at the inner surface. Often the fragments are scarcely at all displaced, and hence no deformity is caused. It may readily be perceived, therefore, that the diagnosis of injuries of this kind may present a good deal of obscurity; and even when the fact of fracture is clearly to be made out, it may be a matter of much difficulty to determine the exact line of separation, especially in stout or fat persons. Examination by the rectum, and in females by the vagina, may enable the surgeon to arrive at greater certainty in this respect. But even the most 96 INJURIES OF BONES. careful and thorough exploration nia}^ fail to ascertain the full extent of the injury. Malgaigne quotes from Lyon a case in which " seven or eight frac- tures were discovered by dissection, although no crepitation had been per- ceptible during life, from any movement whatever of the pelvis." I myself know of an instance in which a fracture of the horizontal ramus of the pubis on each side, of the ascending ramus of the ischium on each side, and of the sacrum vertically, with much comminution of its lower extremity and partial separation of the right sacro-iliac symphysis, entirely escaped detection during life. The urethra was ruptured across, and this lesion caused the patient's death a day or two after the accident. The gravity of fractures of the pelvis is due to the complications apt to attend them, rather than to the injury inllicted on the bone. Several cases have been mentioned in which death was the result of rupture of the bladder or urethra. It is not always easy to explain how the bladder is in- volved, as in some instances the fracture of the pubis is so far from the median line that the fragments can scarcely be supposed to have lacerated it, unless greatly distended, and still more difficult is it to understand in what way the urethra is torn across. Yet very possibly the fracturing force may greatly displace the fragments, which subsequently are restored to their natural posi- tion, or nearly so, by the elasticity of the bony structure ; or the urethra may be subjected to violent stress between a foreign body below and the pubic arch above — a supposition rendered more likely by the contused and bruised condition of the tissues of the perineum in some of these cases. Swan^ relates several interesting cases of fracture of the pelvis, in one of wdiich two inches of the urethra were found at the autopsy to have been torn away. The patient had fallen from a horse, breaking the right pubis through its body and ramus, and separating it at the symph^^sis. In another case, the patient having been run over by a loaded wagon, the fracture involved the arch of the pubis, several other portions of the ischium and pubis, the right acetabulum, and the right sacro-iliac symphysis. The bladder had a large rent in its anterior part, and the urethra w^as torn completely through. Earle^ records a very curious case, in which, by a fall from a carriage, " the symphysis pubis was separated to the extent of three inches, and the sacro- iliac symphysis on the left side was nearly separated and gaped to the extent of more than an inch. The prostate gland had been torn away from the bladder, leaving a large aperture communicating directly with the cavity of that viscus. The urethra still retained its connection with the ligament on the right side of the pubis, and the prostate gland hung loose in a cavity filled with coagulum. An extensive laceration communicated with the rectum." Fragments of the fractured pubis have been known to make their way into the bladder. Tillaux^ saw such a case, and quotes one from Lenoir, in which the bit of bone became the nucleus of a stone. He mentions also that ^N'elaton once extracted, through the vagina, a fragment which had wounded the blad- der. By mere pressure, a displaced fragment may obstruct the passage of a catheter. The great vessels are not often wounded in cases of fracture of the pelvis, although it would seem as if they readily might be. Earle* reports a case, , in which, by a fall from a third story window, the left os innominatum was separated at the symphysis pubis and sacro-iliac junction, and " was forced upward to a considerable extent. The common iliac vein on that side had been torn through, and the pelvis was filled with blood." The patient, who ' Mcd.-Cliir. Trans., vol. xii. 8 Op. cit., p. 830. 2 Ibid., vol. xix. p. 257. * Loc. cit., vol. xix. p. 262. FRACTURES OF THE PELVIS. 97 had sustained other injuries also, died an hour after the accident. Lucas* records three cases, in one of which the right internal iliac vein was wounded, while in another the right external iliac artery was divided, and in the third the left external iliac vein was lacerated. Lente^ has reported a case in which the small intestine was wounded b}^ a sharp fragment of the ill um.3 Another danger which occasionally attends these injuries, is that of exten- sive suppuration. Of this an instance has been mentioned in a preceding page, and others are upon record. With regard to the treatment of fractures of the pelvis, there is not very much to be said, "although the subject is one of great practical importan(;e. Abso- lute rest in bed is'generally a necessity clearly perceived by the patient ; and his comfort is often promoted by a broad bandage firndy applied around the pelvis, a thick layer of raw cotton being placed next the skin. AVhen there is a tendency to displacement inward of a fragment, as for instance of the iliac crest, the pressure of the bandage may do harm, and it should either be more loosely fastened, or cut away at this part, or even dispensed with alto- gether. Shock, if it be present, as it is apt to be in the early stage of the case, should be combated by stimulants — alcohol, carbonate of ammonium, hypodermic injections of ether, and external heat. If there be any difficulty in urination, the bladder should be carefully emptied by means of the catheter, and, if the urine thus drawn off be bloody, we may suspect a wound of the bladder or urethra. When the instrument cannot be readily introduced, if the patient have not previously been the sub- ject of stricture,*^ injury to the urethra is probably present, and extravasation of urine must be looked for. Upon the first evidence of this complication, free incisions should be made in the perineum. Wounds of the large vessels are apt to be fatal from internal hemorrhage before there is any clear indication of the nature of the trouble ; but, if this could be made out, the obvious course would be to cut down at the usual point, and apply a ligature. In case of abscess, incisions should be made at such points as to allow of the readiest escape of pus, and the use of drainage-tubes may be of great ad- vantage. The comfort of the patient is often greatly promoted by the use of a frac- ture-bed, as the unavoidable disturban-ce caused by the insertion of a bed-pan is apt to produce pain. Should the treatment be prolonged, the occurrence of bed-sores must be carefully guarded against, although this may be a matter of much difficulty ; a Avater-bed, or air-cushions, may, however, be used with hope of success. In the cases of "double vertical' fracture," before alluded to, it may be necessary to prevent the riding up of the acetabular fragment by applying extension to the foot ; and this is to be done by the weight and pulley, to be hereafter described in connection with the treatment of fractures of the femur. Mention has been made of the influence of muscular action in the ])roduc- tion of fractures of the pelvic bones ; and if this can be ascertained as a cause of displacement of the fragments, the necessity of oln-iating it by position ' Lancet, March 9, 1878. ' New York Journal of Medicine, .January, 1851. 3 The reader will find some interesting and instructive cases recorded by Lidell, in a paper on Ruptures of Pelvic and Abdominal Viscera," in the Am. Journal of the Medical Sciences for April, 1867 ; and may consult with advantage a monograph, published in 1851, by Dr. Stephen Smith, on " Rupture of the Bladder." VOL. IV. — 7 ^8 INJURIES OF BONES. will be evident. Flexion of tlie thighs on the trunk, as well as of the body forward, will be indicated in any such case. A few^ words ma}- finally be said as to the prognosis in fractures of the pelvis. In simple, uncomplicated cases, there may be no grave symptoms from first to last, and entire recovery may take place. When the bladder or urethra has sustained injury, the risk is greatly increased ; and the more so the nearer the lesion is to the cavity of the peritoneum. Complete rupture of the urethra has always, as far as I know, proved fatal. Peritonitis constitutes a very serious complication, but, as in one of my cases above mentioned, may yield to treatment. The other concomitant injuries refen^ed to have always hitherto resulted in death. In non -fatal cases there has sometimes been permanent lameness, but not very great, nor involving serious disability. Occasionally, when recovery takes place from fracture of the pelvis, un- pleasant after-effects manifest themselves. Thus, in the Pennsylvania Hos- pital Museum, there is a specimen,^ taken from a man who had been crushed by a moving car, and who was discharged cured, to be readmitted eighteen months afterward ; he was then " suffering from severe sciatic pain, but was able to w^alk with canes, sitting down, however, only with difficulty. An examination rendered it probable that there was a large amount of callus pressing upon the sciatic nerve, with, perhaps, a fracture of the femur. An operation was performed for removing the head of the femur. Subsequent to the operation, suppurative fever or pyaemia supervened, and death followed on the ninth day." The specimen shows ''that the pelvis had sustained a fracture, separating the pubic portion of the bone from the ilium, passing from about the sciatic notch posteriorly to the acetabulum. This is firmly united, but along the line of the fracture, extending forward into the acetabu- lum, and posteriorly covering more than half the sciatic nerve, are abundant, firm, but porous exostoses. From the spine of the ischium is a hook-like projection, partially surrounding the track of the sciatic nerve. At the junc- tion of the ilium and the ramus of the pubis is a groove measuring nearly an inch in depth, which carried the tendons of the iliacus and psoas muscles. The head of the femur cannot be replaced in its socket, and, at the time of the operation, w^as found resting in the sciatic region." Fractures of the Clavicle. The clavicle, by its articulation with the sternum, affords the upper extrem- ity its only fixed connection with the skeleton of the trunk. Its outer end has a seemingly large, but really quite limited range of motion, and is fast- ened to the scapula, not only by the small acromio-clavicular joint, but hy the wide and strong coraco-clavicular ligament. At its sternal end this bone is thickest ; thence to near the middle it is rounded ; here it is flattened below, and turns upward ; toward the outer end it becomes very broad and flat, curving forward. The degree of curve varies in different bones, as docs also the irregularity of shape just noted, and the size and thickness of the whole bone. Besides the double curve, there is a more or less marked double twist in the clavicle. As to its muscular attachments, this bone is mainly, indeed almost wholly, an intermediate bone ; being placed between the clavicular portion of the sterno-cleido-mastoid and the costo-clavicular ligament, the latter being really 1 No. 1116^*, Catalogue (Suppleiueiit), p. 22. FRACTURES OF THE CLAVICLE. 99 the tendon of origin of the muscle ; while most of the remainder of its length is simply interposed between the trapezius and deltoid. The connection of the pectoralis major with it is only accessory. The only muscle which acts directly upon the clavicle itself is the subclavius, and the function of this is rather to limit the mobility of the clavicle, than to impress motion upon it. Fractures of the clavicle are among those of most frequent occurrence. They are met with at all ages, eveii in intra-uterine life. In children they are very common ; out of 316 cases of fracture treated at the Children's Hospital in Philadelphia, in seven years, the clavicle was affected in 94, or nearly 30 per cent. Between the ages of 15 and 65, according to Malgaigne, the frac- tures of this bone form about one-quarter of the whole number ; and only one-fourth of the patients are females. At a more advanced age, however, he noted that eleven out of eighteen cases were those of women. By most authors, fractures of the clavicle are divided into those of the inner, middle, and outer thirds of the bone. This, although a convenient arrangement, is not strictly accurate, as some oblique fractures, which occupy the outer portion of the inner third, in part, traverse both this and the mid- dle third. I prefer to speak of fractures of the body of the bone, of those near the sternal end, and of those near the acromial extremity. Fractures of the body of the bone, which may concern the middle third _only, or may encroach also upon the inner or more rarely upon the outer third, are by far the most numerous. They are very generally oblique, although occasionally nearly or even quite transverse. Compound fractures of the clavicle are almost never met with, unless they become so secondarily by a sharp fragment penetrating the skin, which hap- pens extremely seldom ; and they are not often comminuted, at least to such a degree as to influence the result. Incomplete fractures of this bone have, however, been repeatedly observed, and not a few instances in which, the periosteum being untorn, the fragments have remained in place. Several such, occurring "in young subjects, have been recorded by Blandin* and Robert,2 and a number are quoted by Malgaigne from different authors. Hamilton mentions several seen by himself in adults; one of his patients, a woman, was eighty years old. A number of such cases are on record, in which the fact of fracture has been unrecognized until after the occurrence of union. Fractures of the clavicle may be caused by direct force, as by a blow, by the recoil of a gun, by the fall of a heavy body upon the shoulder ; by indirect force, as by a fall on the point of the shoulder, or upon the hand ; or by mus- cular action, as by the effort to pull down the brace of a carriage-top ,3 or in striking a blow with a whip."* In inquiring into the mechanism of the production of fracture under either of these conditions, it must not be forgotten that the inner or sternal end of the bone is firmly fixed, and that, as before stated, the range of motion of the acromial end is but limited. There is another anatomical fact, pointed out by me many years since,^ which I believe to be of much importance in con- nection with this subject. It is the close relation which often subsists between the clavicle and the first rib ; by reason of which, when the outer end of the former bone is forced downward, the bone itself becomes a lever of the first order, the rib being the fulcrum. In some persons the upper part of the thorax comes much more nearly to a point than in others, the arch of the • Am. Journ. of the Med. Sciences, April, 1843 ; from Journal de Med. et de Chir. Pratiques, ■ Juillet, 1842. * Ibid., Jan. 1859 ; from L'Union Medicale. 8 Hamilton, op. cit., p. 1-93. "* Parker, New York Journal of Medicine, July, 1852. ' New York Medical Journal, Oct. 1866. 100 INJUKIES OF BONES. first rib being smaller, and the bone itself more delicate. Again, in some persons the clavicle is much straighter, and stands out more directly from the sternum than in others. I think that these two conditions usually correspond. When the first rib forms a wide and strong arch, and the collar-bone runs somewhat backward as well as closer to the rib, the two bones may even be almost in contact as far nearly as to the middle of the clavicle. In such a case, a blow, the recoil of a gun, or any force driving or dragging the outer portion of this bone downward, or downward and backward, would act on the bone as a lever, and tend to break it at any point where it might be weakest. The rib, being a strongly stayed arch, pressed upon at its convexity, would not give way ; while the clavicle would be at a disadvantage, being subjected to a force at its concavity, tending to increase its curvature. I think that this was clearly the mechanism of the following case, mentioned by Malgaigne: "I have seen an incomplete fracture of the clavicle resulting from the pressure of a burden which slipped from the shoulder down on the arm, and thus, pulling downward on the outer end of the bone, bent and broke it at about the middle." Very possibly this leverage over the first rib may have something to do with some fractures by indirect violence, as when a man falls forward on his outstretched hand, and the scapula, forced backward by the head of the humerus, carries the acromial end of the clavicle along with it. There are cases in which it would seem that the clavicle is broken by the forcing upward of its acromial end ; and these can only be explained by the firmness of its ligamentous attachment to the sternum, and the unyielding character of the rhomboid or costo-clavicular ligament. Perhaps, however, more accurate information as to the circumstances would set this theory aside. Often the surgeon has to be content wath very vague statements on the part of the patient or his friends, and caution is needful in drawing con- clusions from premises which may be wholly or in part incorrect. When the clavicle gives way to a force acting at its outer extremity, as in the case of a fall on the point of the shoulder, it may be easily seen that the mechanism is simply the exaggeration of the normal curves, carried so far as to overcome the resistance of the bony structure. And the more suddenly the stress comes, the more likely is the bone to be broken. The point at which the fracture shall occur is determined by the exact direction of the force, and perhaps in some degree by the action of the muscles at the moment. But in the very large majori'ty of cases the line of fracture runs obliquely through the body of the l3one, from within outward and from before back- ward. The relation of the obliquity to the upper and lower surfaces, I do not know ; it is probably not a constant one. Symptom.s of Fractured Clavicle. — Upon the occurrence of fracture of the clavicle, if the periosteum yields, there is generally marked displacement And this may be either a mere prominence of the inner fragment, or a posi- tive projection, the outer fragment being carried behind the inner so as to make the latter start forward. This is the almost universal rule ; but cases have been observed in which the outer fragment has been in front of the inner. The annexed cut (Fig. 821) represents the clavicle of a patient in my wards at the Episcopal Hospital in 1882, in whom the outer fragment was directly below the inner. The man was a German teamster, and said he had fallen down, striking his shoulder ; he could give no details of the accident, and at the time when 1 saw him there was no bruise or other indication of the exact point of impact. The complete reduction of the fracture was im- possible, but a good recovery ensued, with some superabundance of callus. I FRACTURES OF THE CLAVICLE. 101 cannot offer any explanation of these exce[)tions ; but it will be seen that in my case the fracture involved the sternal third of the bone. Sometimes, when the cause of the fracture has been direct violence, it is sufficiently obvious that the outer fragment has been driven back from the inner. But there must be a further reason for the very general existence of this displacement, and I believe it is to be found in the changed position of the scapula. Upon the loss of the stay afforded by the unbroken clavicle, the serratus magnus and peetoralis minor muscles pull the scapula forward and inward, while perhaps the rhomboidei muscles draw up its lower angle. The acromion is thus brought nearer to the median line, and tilted down- ward ; the effect of which is to push the distal fragment of the broken clavicle inward, and to depress^ its outer end. This seems to me to afford an ample explanation of the very constant occurrence of this form of displacement. Very possibly the fibres of the subclavius may also draw upon the outer frag- ment, and aid in the production of the deformity. The forcing of the outer fragment behind the inner will tilt the latter upward and forward ; and my belief is that to this, and not to the action of the clavicular portion of the sterno-cleido-mastoid, is due the projection of the inner fragment so com- monly present. The action of the last-named muscle, indeed, is from below upward (the Germans call it "Kopf-nicker," that is, head-nodder), and through the rhomboid or costo-clavicular ligament it gets an origin from the first rib. This ligament would of itself prevent the drawing up of the inner fragment, unless, as sometimes happens, it should be itself ruptured. By all authors we are told that the shoulder falls forw^ard, inw^ard, and downward, and that this displacement is due to the weight of the shoulder and of the upper extremity. It is true that the shoulder does thus change its position ; yet the muscles which support it are not impaired, and the mei'e lifting of the w^eight does not remedy the deformity. When the scapula itself is drawn back into position, and only then, does the outer fragment of the clavicle resume its normal relation to the inner. The explanation now given of the cause of deformity in fracture of the clavicle finds strong confirmation, I think, in the condition observed when the bone is broken near the acromial extremity. Here the short outer frag- ment is pushed round forward and inward, so as to form almost or quite a right angle with the inner, the broken end of the former even coming in con- tact with the anterior v/all of the latter. Many museum specimens exist in proof of this statement, and two such are in the ^liitter collection in this city. Malgaigne mentions two cases of fracture very near the acromial end, in which union had taken place. In each of them, " the shoulder was de- pressed, and carried forw^ard and inward ; . . . and to this inclination of the shoulder there corresponded posteriorly a notable prominence of the infe- rior angle and posterior edge of the scapula." Both the patients had perfect motion of the arm, except backward. Here it seems to me quite plain that the change of shape is to be accounted for as follows : partly by the action of the clavicular part of the trapezius, drawing up both fragments, and favored in so doing by its attachment to the natural convexity of the bone; partly Fig. 821. Fracture of clavicle with downward displacement of outer fragment. 102 INJURIES OF BONES. by the tilting upward and backward of the lower angle of the scapula by the rhomboideus major muscle, aided by the weight of the arm dragging on the upper and outer angle of the bone, and through the acromion on the outer end of the clavicle ;"but chiefly by the serratus magnus and pectoralis minor carrying the whole scapula forward and inward around the side of the thorax, and thus bringing the outer fragment into exactly the position described with regard to the inner. A case mentioned by Malgaigne so strongly illustrates the theory now stated, that I venture to quote it at length : — The patient had sustained a fracture of both clavicles by a fall from a window fifteen feet high. Non-union had occurred in both bones, and the impairment of function was such that he could not resume his former occupation as a tinsmith, but became a tailor. " Both clavicles had been broken at the middle ; the two inner fragments were nearly horizontal, and very distinct beneath the skin ; the outer fragments had also a nearly horizontal direction, but were buried behind and below the others, to which they seemed to have no adhesions of any kind. The overlapping was considerable. " When he stood up the two shoulders seemed lower, as well as carried further forward and inward, than in a healthy person. The one on the right side was higher, and at the same time closer to the sternum, than the other. Posteriorly the scapulas were sepa- rated from the spinal column by three or four inches, and inclined forward and out- ward ; and, on the whole, the thorax seemed contracted at its upper part. " He could draw the shoulders back a little, but not enough to overcome their appa- rent prominence anteriorly. On the other hand, he could draw them together forward so that they seemed like wings covering the chest, and leaving between them, in front of the sternum, only three inches of space. In this movement the scapulae to the sides of the trunk, and the back seemed rounded from one side to the other, almost like that of a skeleton deprived of its upper extremities. The shoulders could be raised also at will, but not to any extent, from want of muscular power." Professor Gordon, of Belfast, has expressed^ views in regard to the dis- placement in fractures of the clavicle, exactly the same as my own. ^ As he has not referred to my paper, I presume that he is not aware of its existence. Though these views have not as yet received the general assent of surgical writers, my belief is that they are correct, and that they w^ill ultimately obtain acceptance. Prof. Moore, of Rochester, N. Y.,^ regards the relaxation of the clavicular fibres of the pectoralis major muscle, and the consequently unopposed action of the sterno-cleido-mastoid, as the great cause of the displacement; but it does not seem to me that this view is tenable. I say nothing of rotary displacement, because nothing of the kind has ever occurred in the cases under my notice, and I do not think it exists. Pain is an almost constant symptom of fracture of the clavicle. When the line of separation is oblique, as in most cases, this is obviously due partly to the pressure of the ends of the fragments, especially of the inner, against the skin. According to Tillaux, it is the filaments of the supra-clavicular nerve, in the platysma myoides muscle, which are thus irritated ; but the fact that there are often pain and numbness down the arm, and even in the fingers, afibrds proof that the large trunks of the brachial plexus are also interfered with. In order to obtain relief, patients are very apt to assume a position which, by some authors, has been considered almost a diagnostic sign ; they support tlie arm of the injured side by placing the other hand under the forearm, and incline the head toward the aftected shoulder. » Dublin Quarterly Journ. of Med. Science. Nov. 1859. Also in a Treatise on Fractures of the Lower End of the Radius, on Fractures of the Clavicle, and on the Reduction of the Recent Inward Dislocations of the Shoulder-joint. London, 1875. « Trans, of Med. Soc. of State of N. Y., 1870, p. 107. FRACTURES OF THE CLAVICLE. 103 Swelling is very apt to occur, especially in fractures caused by direct vio- lence, and attended with much bruising of the soft parts ; but it is not often so marked as in some other regions, nor does it generally mask the condition of the bone so completely, by reason of the sniall amount of subcutaneous areolar tissue existing here. Ecchymosis may or may not be present, according to the character of the fracture and the amount of injury to the small veins of the skin. It is very rare to have the deep staining of the surface, coming on slowly and very gradually subsiding, which is often met with in the case of the larger bones. Crepitus is very generally to be felt. It suffices to gently i)ress the point of the shoulder forward, the fingers of the surgeon's other hand being lightly laid over the bone, to develop a sufficient sound. Sometimes, indeed, this is the only symptom present. M. Guerin^ has reported the case of a man aged 60, whose clavicle was broken by a fall of earth. During life the only posi- tive symptom of the injury was slight crepitus. After the patient's death (from pneumonia) the fragments could be made to project by means of the linger passed behind the bone. Alono- with the crepitus, and shown by the same manoeuvre, there is often perceptfble an abnormal mobility at the seat of fracture. The degree of this will be dependent upon the completeness, not only of the fracture, but of the tearing of the periosteum, as well as upon the direction of the line of break- age, and often upon the amount of serration of the fragments. But whether slight or otherwise, it is an unmistakable proof of the character of the lesion. Fractures of the sternal j)ortion of the clavicle are much less frequent than those of the acromial extremity, and very rare indeed as compared with those of the body of the bone. They have attracted but little notice, an article by Delens^ being the fullest source of information in regard to them up to the present time. This author states that while they have been observed as the result of both direct and indirect violence, muscular action is by far their most frequent cause. One instance of the latter kind has been reported by Heath :— ^ • A boy of fourteen, " whilst raising his arm violently to bowl at cricket, felt something give way at liis collar-bone. The inner end of the clavicle was found to be unduly prominent, and presented a sharp edge beneath the skin, quite unlike the smooth end of a bone covered with articular cartilage. The supra-sternal notcli was quite distinct, and equally defined on both sides, and a thin lamella could be felt on the right side, intervening between it and the gap caused by the starting forward of the inner end of the clavicle. The treatment consisted in laying tlie patient down, when the bone at once dipped into place, and Avas retained by a plaster-of-Paris bandage." This cannot have been, as was suggested, a separation of the epiphysis, since no such formation takes place, according to anatomists, before the twentieth year ; and perhaps it miglit more correctly be placed under the head of sprain-fracture. Of fractures by indirect violence, the clearest instance is that recorded by Willis:—* A man, aged 54, slipped off a hay-rick, falling on his outstretched right hand, and striking his riglit shoulder. On examination, there was discovered a simple fracture of the right clavicle within a quarter of an inch of the sternal head of the bone. The direction of the fracture was obliquely downward and outward. The outer fragment was tilted up, partly by the direct action of some of the fibres of the sterno-cleido-mas- toid, partly by tlie weight of the arm dragging the acromial end downward ; it wjis very sharp, and threatened to pierce tlie skin. Much difficulty was experienced in coap- tation of the ends, which could only be fully effected by strongly raising the arm — » Gaz. Hebdom., 20 Sept. 1867. 3 Brit. Med. Journal, Nov. 18, 1882. * Arcli. Gen. de Medecine, Mai, 1873. * Lancet, Dec. 2, 1882. 104 INJURIES OF BONES. a position which the patient either could not or would not long tolerate. A sling, and a compress over the clavicle, were employed ; and a year subsequently, the sharp frag- ment had been greatly rounded, and fibrous union had occurred. Willis thinks, and with reason, that in this case the rhomboid or costo-clavicular ligament was ruptured. A case has been published^ (w^ithout the reporter's name) as occurring at the Mount Sinai Hospital, in New York, in which the clavicle was broken about an inch from the sternum. The cause of the injury is not mentioned ; but it is stated that the inner fragment was Vertical, and the other " down upon the chest." The deformity caused no inconvenience, and was not reme- died. The reporter ascribes it to the action of the sterno-cleido-mastoid. I quote this report, notwithstanding its vagueness, because it seems to me to be illustrative of the proper division of these injuries ; the lesion was really, although near the inner end, simply a fracture of the body of the bone, in which the displacement was of the ordinary kind, and due to the same causes as before mentioned ; but was exaggerated by the shortness of the inner frag- ment. Possibly, the rhomboid ligament being torn, the muscle may have contributed to the elevation of the inner fragment, but I do not think it alone could have produced it. The view I wish to maintain is, that the mechanism of fractures of the inner third of the clavicle is the same as that of fractures of the middle third, and that the displacement occurs in the same way; and hence I would simply class them with fractures of the body of the bone. Fractures involving the sternal end of the clavicle are, however, distin- guished by certain features, as may be readily seen in the instances before quoted from Heath and Willis. Lonsdale^ mentions the case of a boy, aged 3, who fell and struck his shoulder against the edge of a step, fracturing the clavicle about half an inch from the sternum ; he says that the crepitus of fracture could be distinctly felt, and the end of the bone moved from its natural position." Fractures of the acromial extremity of the clavicle embrace all those which affect the bone anywhere between the acromio-clavicular joint and the inner edge of the coraco-clavicular ligament. They may be caused by direct or indirect violence ; it is difficult to see how they could result from muscular action, and I know of no record of any such case. Indeed, the clinical his- tory of these lesions is very meagre ; but specimens in which union has taken place are by no means rare. Ossification of the coraco-clavicular ligament, more or less complete, has been noted in some of the cases. It has been already stated, in speaking of the mechanism of fractures of the body of the clavicle, that the condition observed when the outer third of the bone is broken, is dependent upon the dragging forward and inward of the scapula, by the action of the serratus magnus and pectoralis minor muscles. Occasionally the clavicle is broken at more than one point. Malgaigne mentions and figures a remarkable specimen, without history, in which one fracture is near the sternal end and the other near the acromial. He speaks of the case of a little girl who had a double fracture, the middle fragment, less than an inch in length, being tilted up in a vertical position between the others, so that it could not be reduced. Conner^ says that he obtained at an autopsy, Siv the Charity Hospital at 'New Orleans, " a right clavicle which had been broken in two places, the union being ligamentous at both." Simultaneous fracture of both clavicles has sometimes been met with. One case recorded by Malgaigne has already been quoted, in illustration of the « New York Med. Journal, Jan. 1877. 2 Op. cit., p. 206. 3 Holmes's System of Surgery, Am. ed., vol. i. p. 848. FRACTURES OF THE CLAVICLE. 105 /nechanisrn of the displacement. Gurlt gives fifteen, all produced by very great violence. Besides these, Lane,^ Burr ,2 and Wight^ have published cases of the kind. Wight's patient had good union in the bone of the left side, but only ligamentous in the right ; yet he could work as well as ever. These cases have a special interest, to be further referred to, in view of the difficul- ties presented in their treatment. Diagnosis. — The diagnosis of fracture of the clavicle is for the most part easy ; the attitude of the patient, the loss of power in the arm, the seat of pain, the projection of the fragment or fragments which can often be both seen and felt, the crepitus, and the abnormal mobility — all these signs, with the history of a fall on the hand, or on the point of the shoulder, or of vio- lence applied to the part, or of stress put upon the bone by sudden muscular exertion, w^ill generally lead even a non-professional person to a true construc- tion of the case. When, as in transverse fractures, with little or no displacement, deformity is wanting, pain is slight, and crepitus is hardly to be perceived, the existence of tenderness at a special point, developed either by direct pressure oi- by a push or tap on the acromial end of the bone, should suffice to indicate the nature of the injury. The caution given in regard to some other cases, as to undue zeal in the eliciting of symptoms, may be emphasized here ; as there are instances on record in which, in able hands, incomplete fractures have been made com- plete, of course increasing the risk of deformity. Should there be any doubt, it would be right to treat the case as one of fracture ; keeping the arm and shoulder at as perfect rest as possible, and watching for the occurrence of more positive symptoms. Complications. — Examples of complicated fracture of the clavicle, although not by any means of frequent occurrence, have been often enough recorded to make it surprising that Malgaigne should have known of no such cases.'^ These complications may consist in injuries of the artery, veins, or nerves ; of the lungs ; or of other bones. They may ensue immediately, or may be among the later phenomena ; and they differ greatly in the degree of their gravity, of the suffering which they cause, and of their amenability to treat- ment. Evans^ reports a case in which an aneurism of the iyinominate artery was ascribed to a fracture of the right clavicle sustained by the patient, a sailor, many months before he came under surgical observation. Dupuytren is said by Delens^ to have given, in a clinical lecture in 1831, several cases of aneu- rism from a like cause. Injury of the 'veins is somewhat more frequent. Holmes^ says, ''I have once seen death result from this injury in consequence of the fragment hav- ing lacerated the internal jugular vein." Hulke and Flower^ mention a speci- men (perhaps from the same case) of like injury. They also refer to the case of Sir Robert Peel,^ in which there was " a comminuted fracture of the left clavicle, below which a swelling as large as the hand could cover, and which pulsated synchronously with the contractions of the auricles of the heart, 1 Lancet, July, 1876. * 2 Medical Record, May 6, 1882. « Med. Gazette (New York), 1882. ^ Op. cit., p. 471 ; translation, p. 382. ^ Transactions of Pathological Society of London, vol. xvii. 1866. ^ Arch. Gren. de Medecine, Aout, 1881. ' Surgical Treatment of the Diseases of Infancy and Childhood, 1st ed., p. 248. * Holmes's System of Surgery, 2d ed., vol. ii. p. 769 ; Am. ed., vol. i. p. 848. ^ Lancet, July 6, 1850 (editorial article). 106 INJURIES OF BONES. formed." It seemed probable, from the pain, that some cords of the axillary plexus had also been injured. Boone^ reports a case in which a fragment from a comminuted fracture of the clavicle produced somewhat serious symptoms by pressure upon the sub- clavian vein and adjacent nerves. Erichsen^ gives a similar case, in which, however, death ensued from gangrene of the arm. Maunoury^ records an instance of fracture of the clavicle with rupture of the subclavian vein ; great swelling having occurred, an incision was made, and death immediately resulted from hemorrhage and entrance of air into the vein. Of injuries of the nerves a good many instances are recorded, only a few of which need be quoted here. Gibson* saw a young man, who had sustained a comminuted fracture of the clavicle by direct violence ; " the fragments had been driven behind and beneath the level of the first rib, and so compressed the plexus of nerves as to wedge them into each other, and by the subsequent inflam- mation to blend them inseparably together. Complete paralysis and atrophy of the whole arm ensued." The patient desired to obtain relief by operation, but Gibson deemed the chance of success too small, and declined to attempt it. Surgeons of the present day would probably have taken a more hopeful view, and cases will be hereafter mentioned in which operative interference has been attended with good results. Chalot^ reports that " in the case of a man of 35, disturbances of innervation showed themselves in the right arm as a result of fracture of the clavicle. Beginning with a sensation of deadness, formication, and pricking, particularly in the palm of the hand, the affection went on to extreme anaesthesia. Very slight irritation of the finger-tips, or the hollow of the hand, or somewliat greater movements of the flexor surface of the forearm, brought o-n nausea, gagging, and vomiting, with occasional severe diaphrag- matic cramp and thoracic oppression (Beklemmung). The patient became first pale, thfen red ; a cold sweat covered the forehead on the affected side. Irrigation with cold water caused the symptoms to appear to a more marked degree, while warm water made them milder. The extremity became smaller, colder than the healthy side, the skin everywhere dry except in the hollow of the hand, there wet with perspiration. The mus- cles reacted weakly. Pressure upon the branches of the nerves brought on swimming in the head and faintness. Pressure upon the callus at the point of fracture of the clavicle, which had united with considerable deformity, was quite painful, and gave rise to dia- phragmatic cramp. Pressure upon the nerves of the face, throat, and nape of the neck, on the affected side, caused similar symptoms." The further history of the case is not given. Gross^ mentions a case of partial paralysis of the upper extremity, with atrophy and permanent contraction of some of the muscles, in a boy of fif- teen, the clavicle having been broken by the recoil of a shot-gun four months and a half previously. Delens^ records a case in which the superabundant callus of a fractured clavicle (two ribs also having been broken) exerted such pressure on the sub- clavian vessels and nerves as to impair the nutrition and muscular power of the limb. Relief was afibrded by a subperiosteal resection. Two other instances, in which resection of the fragments was practised, one observed b}^ Gosselin and the other by Perier, are referred to in this article. Perhaps it may be remarked here that care is to be taken not to confound » Medical Record, November 15, 1873. 2 British Medical Journal, June 7, 1873. 3 Progres Medical, 1882, tome x. p. 302. Reference is here made also to a monograph by Cham- pomier, " Contribution a I'etude des lesions des troncs veineux de la base du cou dans les fractures de la clavicule." Paris, 1882. * Op. cit., vol. i. p. 254. 6 Philadelphia Medical Times, March 27, 1880, from Centralbl. fiir Chirurgie. 6 Op. cit., vol. i. p. 946. ' Arch. Gen. de Med., Aout, 1881. FRACTURES OF THE CLAVICLE. 107 nerve-lesions due to the original injury with those which may be brought on by the pressure of apparatus, as pointed out especially by Hamilton, and to be further discussed in connection with treatment. Wound of the lung is said to have been several times noticed in connection with fracture of the clavicle, but I am not aware that it has ever been veri- fied by an autopsy except once. Ilammick^ speaks of a man who had had a fracture of the clavicle three days before he came under observation ; he died of pneumonia, and on dissection it was found that tlie fractured portion was so depressed as to have wounded the pleura and torn the lung. Gibier^ reports a case in which the acromial fragment wounded the lung, and produced em- physema; the patient recovered, but with non-union of the fracture. Mer- cier'* gives a similar case, and refers to several others. The uncertainty in all these cases in which recovery takes place, is not with regard to the wound of the lung, which is sufficiently established by the oc- currence of emphysema, and occasionally by haemoptysis, but as to the mode of its production — whether there is not a fracture of a rib as well as of the clavicle. It is not, how^ever, a matter of serious importance ; the relation of the apex of the lung to the clavicle is, in most persons, such that a wound of the former might readily occur by a fragment of the broken bone. The complication of fracture of the clavicle with that of other hones some- times presents itself. It is chiefly of interest in connection with treatment, and will be considered under that head. Prognosis. — As a general rule, the prognosis in fracture of the clavicle is favorable. Union takes place, in children especially, with great rapidity. Berry states that in six cases, the ages ranging between five months and five years, the clavicle was found united firmly in from nine to fourteen days; the longest time being noted in the youngest child. Bouchut^ says that Cloquet saw, at the Hospice de I'Humanite at Rouen, a broken clavicle in a girl aged six, consolidated on the ninth day. In adults, consolidation takes place more slowly, averaging perhaps twenty-five or twenty-eight days. Xon-union is sometimes met with, as has already appeared in the preceding pages ; but it is not by any means as common as in some of the other bones. A "case is mentioned^ of "a girl aged nine, who had broken her clavicle a month before, and had had no treatment ; the sternal fragment projected upward at an angle of 45°, its sharp extremity forming a visible prominence in the side of the neck. The other fragment was fully an inch below this, and connected with it by what appeared to be a band of fibrous tissue, pass- ing nearly vertically between them." Even when the fragments fail to become solidly united, the usefulness of the arm seems to be but little im- paired, according to the testimony of Hamilton and others. As to the avoidance of deformity after fractures of the clavicle, it must be confessed that perfect success is very rarely obtained. In almost every instance there remains a perceptible projection of the inner fragment, even after time enough has elapsed for the disappearance of all swelling due to callus ; and in some cases the deformity thus produced is very marked. But as a general thing the complete restoration of the usefulness of the limb is not interfered with, although HureU assigns the shortening of the bone as the cause of the loss of power sometimes noted. Every experienced surgeon, 1 Op. cit., p. 159. * Bull, de la Soc. Clinique de Paris, 1881. These de Pans, " Des complications des fractures de la clavicule, et en particiilier de la blessure du poumon," 1881. 4 New England Medical Monthly, March 15, 1883. s Op. cit., p. 757. * Holmes's System of Surgery, 2d ed., vol. ii. p. 766 ; Am. ed., vol. i. p. 846. ' Considerations sur les Fractures de la Clavicule. Paris, 1867. 108 INJURIES OF BONES. however, has seen old fractures of this bone united with great overlapping, but with no apparent weakening of the member. The amount of injury done to the soft parts can scarcely be left out of the account in forming a prognosis, since bruising of the large nerve trunks passing beneath the bone may interfere seriously with the nutrition and functions of the arm and hand, perhaps even permanently. Of this there is obviously most risk in fractures due to direct violence. TreMtment — The treatment of fractures of the clavicle is a subject upon which a great deal has been written, and a vast amount of study expended. Hamilton justly says, in regard to the varieties of apparatus : " A catalogue of the names only of the men who have, upon this single point, exercised their ingenuity, would be formidable, nor would it present any mean array of talent and of practical skill." I shall endeavor to set forth the principles involved, and the means devised for carrying them out, as briefly and clearly as possible, referring the reader to other sources for more detailed descriptions of such contrivances as are not now" in general use. Cases occasionally do well even without any treatment at ail. ivTewton^ has recorded one in a soldier, and Porter ^ one in a doctor ; in each the result is said to have been " good." As in the case of other fractures, the treatment of the broken clavicle consists in its reduction, or the correction of the deformity, and in keeping the fragments in proper position until their union is accomplished. The first of these processes varies greatly in the degree of difficulty attending it in different cases ; being sometimes effected with the utmost readiness, while it is occasionally impossible. Oblique fractures, as a general rule, are more easily reduced than transverse ; and those attended with but little irregu- larity of the ends of the fragments, give less trouble than those in which they are deeply serrated. When the displacement is readily overcome, how- ever, it is apt to be as readily reproduced ; or, in other words, the difficulty of reduction and that of retention are inversely proportionate. Some writers, and Malgaigne among them, have described various modes of procedure for the replacement of the fragments ; such, for example, as for the surgeon to apply his knee between the patient's shoulders, while with his hands he pulls the shoulders backward. Unless the views I have pre- sented as to the mechanism of the displacement are at fault, manoeuvres of this kind are needlessly forcible ; and in my own experience I have found that reduction is best effected by grasping the scapula, and bringing it back around the thorax toward the median line. Generally it will be found that as the acromion is thus shifted it carries w^ith it the outer fragment of the clavicle, and that the line of the latter bone is restored. "When the patient is very muscular, or the fragments are strongly inter- locked, it may be well for the surgeon to commit the management of the scapula to an assistant, and to employ his own hands in gently moulding and pressing the fragments, which will often yield to this coaxing process, and the bone will thus resume its normal shape. Such a procedure is especially applicable to fractures seated at or close to the sternal end of the bone. By most authors it has been laid down as the great principle of treatment of fracture of the clavicle that the shoulder must be carried upward, out- ward, and backward. My only objection to this statement is that it is not quite precise enough ; it is the acromion^ upon the position of which the retention of the fragments must depend. That this is quite a different mat- ter may be readily shown. 1 Medical Record, March 4, 1882. 2 Ibid., April 8, 1882. FRACTURES OF THE CLAVICLE. 109 Let a pad be put into the axilla, and pushed up so as to carry the shoulder upward and outward, while the elbow is brought strongly forward so as to bear across the pad, and by leverage to carry the shoulder backward ; all this can be done with a sound clavicle, and the change in the shape and position of the shoulder apparently effected. But, in fact, all that has been done is to put the soft parts on the stretch ; the head of the humerus, and this only, has been forced outward and backward, the capsular ligauient of tlie joint and the muscles yielding before it, while the folds of the axilla are pressed upward by the pad. When, however, the scapula is grasped and drawn around backward, toward the median line, it will be found that the sound clavicle must follow it ; and the motion will be checked as soon as the acromial end of the latter bone has reached the limit of its range. I feel assured that the recognitiou of this principle aud its application to the treatment of these fractures, will lead to the securing of better results than have been hitherto obtained. Indeed, as I shall presently try to show, the ai)paratus employed in these cases is often capable of effecting only the apparent change above referred to ii] the shoulder, and does not act upon the broken bone at all. When a patient with a broken clavicle is laid flat on his back on a firm and even mattress, it will often be found that the deformity disappears simply by reason of the pressure on the posterior border of the scapula ; sometimes, however, this must be aided by the hand of the surgeon bearing backward (downward) against the injured shoulder, or pushing the head of the humerus inward (toward the' median line). Advantage has been taken of this fact, and, in a number of cases, cures without deformity have been obtained by simply keeping the patients on their backs in bed until union has occurred. The irksomeness of this plan of treatment, and the difficulty of carrying it out, are sufficient objections to it in all but exceptional cases. Women will sometimes undergo it for the sake of avoiding an unsightly lump on the neck ; but for the most part patients prefer the application of apparatus with which they can move about, and pursue some at least of the ordinary avocations of life. Much the same principle has been had in view in all the forms of back- splint, from the croix de fer of Heister (or Arnaud) to those of Keckeley^ and Grewcock.2 It appears also, but somewhat modified, in the figure-of-8 bandages and oflier appliances for drawing the shoulders together at the back. In modern times the tendency has been to depend upon bandages and slings of difierent forms, with or without axillary pads. Of these, that of Desault, although cumbersome, difficult of application, and apt to become disarranged, long enjoyed a confidence due rather to the prestige of its author's name than to its own merits; it has now been superseded, and its description, which may be found in many works of easy access, need hardly be repeated here. Mayor^ proposed a very simple dressing, which may answer a good purpose as a temporary resource, but is scarcely to be relied ujion as a permanent mode of treatment. It consists of two triangular pieces of linen ; the elbow being carried inward and forw^ard, one triangle is applied over it, its base upward, and corresponding to the level of the lower third of the arm, its point hanging below and in front of the elbow; the two ends are carried round the chest^and meet to be tied or pinned at the sound side. The point of the triangle is now brought up, passed between the arm and the chest, and drawn strongly up- ward toward the sound shoulder. Xow, the middle of the second triangle ' American Journal of the Medical Sciences, Nov. 1834. 2 British Medical Journal, Nov. 7, 1868. 3 Noaveau Syst^me de Deligation, etc. Zurich^ 1833. 110 INJURIES OF BONES. is sewed to the portion of the first which is behind the back, and its ends are brought up over the shoulders, one to be tied to the point of the first, and the other to come over the broken clavicle and down to the base of the first triangle, to which it is firmly fastened. Fox's apparatus, which has been extensively used in the United States since 1828, and is still employed by many surgeons, consists of a padded ring for the sound shoulder, an axillary pad of wedge shape, and a sling for the elbow of the injured side ; the pad and sling being furnished with tapes in front and behind for attachment to the ring. Levis's apparatus^ (Fig. 822), is constructed on the same principle, but the padded ring for the sound shoul- Fig. 822. der is dispensed with, a band over the back of the neck and front of the sound shoulder being substituted for it. To this the elbow-sling is attached by a band across the patient's back, and two across the chest. Dr. Levis uses straps and buckles instead of tapes, and keeps the elbow by the side — not drawn forward. Professor Moore has proposed' a bandage, which he calls " the figure- of-8 of the elbow." He keeps the arm parallel to the axis of the body, with the elbow close to the trunk, and uses " a shawl or piece of cotton cloth, which Avhen folded like a cravat, eight inches in breadth at the centre, should be about two yards long. Placing this at the centre across the palm of the surgeon, he seizes with this hand the elbow of the patient which corre- sponds with the broken clavicle. The two ends of the bandage hang to the floor. The one falling inward toward the patient is carried upward, in front of the shoulder and over the back, making a spiral movement in front of the shoulder ; this is entrusted to an assistant. The outer end is then carried across the forearm, behind the back, over the opposite shoulder, and around the axilla. This meets the other end, which may be carried under the axilla and over the shoulder of the opposite side, thus making the figure-of-8 turn around the sound shoulder. This twist, it will be seen, makes also the figure-of-8 turn around the elbow of the afi'ected side." The forearm is to be supported, with the elbow acutely flexed, by means of a sling. Hale^ has modified this dressing by the addi- tion of an adjustable back-sling, to be tightened during the day, and loosened at night. What is known as Sayre's apparatus* consists of two broad bands of adhe- sive plaster ; one surrounds the upper part of the arm of the injured side, and thence runs across the back and round the thorax ; the second, beginning in front of the sound shoulder, passes over it, and diagonally across the back to the opposite elbow, thence up again, embracing the whole forearm and hand, to be fastened at or near the point of starting. A longitudinal slit * Am. Journal of the Medical Sciences, Jan. 1856. " Transactions of the Medical Society of the State of New York, 1870. 3 Medical Record, May 27, 1882. * Bellevue and Charity Hospital Reports, 1870. Levis's apparatus for fracture of the clavicle. FRACTURES OF THE CLAVICLE. Ill in this strip receives the elbow, which is to t'ig. 823. be drawn well forward and inward. Satterthwaite^ has proposed the substitu- tion of the rubber bandage for adhesive plaster, and the use of a horseshoe-shaped dilatable bag, to be filled with water, as an axillary pad. The exact advantages to be derived from this change do not clearly appear, and the risk of excoriation would seem to be increased. Hamilton describes his own method as follows : — 2 • "The arm hanging perpendicularly beside the body, a sling is "placed under the elbow and forearm, and tied over the opposite shoulder. An axillary pad, composed of cotton batting inclosed in a cloth cover, is placed well up in the axilla, and the elbow is then secured firmly to the side of the body with several turns of a roller." In addition to the somewhat numerous American devices already spoken of, I may merely mention those of Brown ,3 Chisolm,* Palmer,^ and Bradner f all of these have the advantage of simplicity, and it is claimed by their in- ventors that good results have been obtained by their use. Dr. Sayre's dressing for fractured clavicle ; application of first strip. Fig. 824. Fig. 825. Dr. Sayre's dressing for fractured clavicle completed. Front view. The same. Back view. Professor Gordon, of Belfast, the agreement of whose views with my own has been before mentioned, describes an apparatus of his own devising, consist- ing; of a breast-plate and arm-splint, connected by means of a rod — the idea being to substitute the broken bone by this rod. Without questioning the theoretical value of this contrivance, or the statements of Professor Gordon » Medical Record, September 27, 1879. ' Am. Medical Recorder, Oct. 1821. ^ Am. Journal of the Med. Sciences 6 Medical Record, June 17, 1882. July, 2 Op. cit., 6th ed., p. 218. * Charleston Medical Journal, March, 1858. 1863. 112 INJURIES OF BONES. as to the results obtained with it by him, I think that its complexit}^, and the fact that it can only be made by a skilled mechanic, will preclude its adoption, and, to a very great extent, its trial by other surgeons. Professor Byrd, of Baltimore, has published * an account of an apparatus successfully used by him, consisting of two padded plates which are applied over the scapulae ; these are connected by a flat steel bar, carrying a lever which arches over the shoulder, and which has at its anterior end another padded plate, to press the shoulder backward. The apparatus is adjustable by screws, and kept in place by straps and buckles. O'Connor 2 has recently proposed the use of plaster of Paris, somewhat as in the Bavarian splint (see p. 55), so as to make a sort of mould of the shoul- der, the fracture being first reduced. By some surgeons, compresses are applied to the prominence of the outer end of the sternal fragment, with a view of forcing it back into place. And this may be done with advantage, provided the reduction has first been com- pletely eftected, if the projection still persists. If, however, the cause of the deformity is the pushing in of the inner end of the distal fragment behind the outer end of the sternal — as I believe it to be in the majority of cases — the pressure of a compress can only force back both fragments, and serious harm may result. I have certainly seen it productive of severe pain. With the view of rendering the fragments immovable, it was proposed by Guerin (de Vannes) to fix the sound arm against the side by means of a body- bandage, and to apply a dextrinated bandage to the head and affected shoul- der, the face being averted from the latter. He recommended along with this the use of Desault's apparatus, starched or dextrinated. It is not stated by Malgaigne that this plan w^as ever put into practice ; but probably few patients would be willing to submit to such an encasement, which would in- volve extreme discomfort. Malgaigne suggested " surrounding and confining the two fragments by two steel hooks, like the forceps of Museux; just as in the serrated fracture with an angle upward, I thought," he says, " of passing in at the summit of the angle a double hook, which by. means of a strap and band could be drawn toward the elbow, thus exerting all the necessary pressure." But he very justly remarks that the idea needs maturing ; and I do not know that he ever followed it out any further. Modern surgery has more than equalled the hardihood of Malgaigne. Langenbuch is reported ^ to have treated a fracture of the clavicle by cutting down upon it, and suturing the fragments together with silver wire, the periosteum being also sewed with catgut. A very just criticism of this procedure has been published^ by Dawson, w^ho maintains that the results obtained by ordinary means are sufficiently satisfactory to forbid running the risk involved in making the fracture compound, especially in the neighborhood of such important and vulnerable structures. There are instances, however, in which an operation is entirely proper. Whitson^ reports the case of a boy, aged fifteen, who was knocked down and run over by a reaping-machine, sustaining a compound fracture of the right clavicle, and a compound fracture of the right humerus. On the sixth day, a thick wire suture was passed through the fragments of the former bone, and good union was obtained. When, as in the last mentioned case, fracture of the clavicle is complicated by fractures of the neighboring bones, the treatment may be variously modi- ' Medical News, October 21, 1882. 2 British Med. Journal, March 3, 1883. 8 Medical News, Feb. 25, 1882. ^ Medical Record, May '20, 1882. 6 British Med. Journal, Jan. 6, 1883. FRACTURES OF THE SCAPULA. 113 fied. Thus Schiieck^ reports an instance in which a little girl five years of age sustained, by the kick of a colt, a fracture of the clavicle near its middle, and of the humerus near the shoulder. Fox's ai)paratus was applied, and a hollowed wooden splint along the outer side of the arm, with a girth sur- rounding this and the child's body. The clavicle was united in two weeks, and the humerus in four, w^ithout perceptible shortening or deformity. Having now passed in brief review the principal plans which have been proposed or employed in the treatment of fractures of the clavicle, it remains for me to sum up the subject by a few practical directions. And in the first place I w^ould say that the secret of success lies not so much in the employ- ment of any special method of treatment, as in the recognition of the condi- tions to be met in each case, and in the adoption of means suited to them — in tact, judgment, and, above all, in careful attention. All fractures of the clavicle are not alike, nor can they all be treated in one way. When there is much inflammation about the shoulder, as occasionally hap- pens in fractures due to direct violence, the patient should be laid flat on the back, on a firm mattress, with his head low ; and local applications, such as dilute lead-water and laudanum, evaporating lotions, or simple fomentations of hot water, should be employed for a few days. After the inflammation has subsided, if there remain any malposition of the fragments, it should be carefully rectifled as far as possible ; and to main- tain reduction, I think Say re's plan will be found the most eflicient means; but excellent results may be had with either Fox's or Levis's apparatus. Whichever is used must be carefully adapted to the exact requirements of each case. The forcing the elbow forward, so much insisted on by some authors a few years since, is in my opinion a mistake. Should compresses be required to push back the sternal fragment, I would recommend the use of a well-padded ring, neither too large nor too small, maintained accurately in place by means of the best procurable adhesive plaster. When an axillary pad is used, it should not be too thick, nor too strongly forced up into the armpit, lest undue pressure he made upon the large nerves. Hamilton mentions a number of instances in which harm was thus done. Having had no experience in any of the grave complications of fracture of the clavicle, I shall not discuss their treatment. Non-union "W'ould seem to be productive in most cases of so little inconvenience, that a resort to opera- tive measures need seldom be had ; although the bone is so superficial as to be easily reached, and, if the cervical fascia be not torn, there will be but little risk of deep-seated inflammation. Fracture of both clavicles would seem to me to be best treated by keeping the patient flat on his back, with an arrangement on the principle of a double truss, to keep the shoulders pressed gently backward. Of course the upper extremities should be kept at the most perfect rest. Fractures of the Scapula. The scapula is not often broken, partly by reason of its mobility, and partly because of the degree of protection aftbrded to its flat portions by the layers of muscle in which it is imbedded, while its spine, its neck, and the coracoid process, are but little exposed to violence. Of the recorded instances, the great majority w^ere in male adults ; about one in five were in women. Among the 816 cases of fracture before mentioned as treated at the Chil- > Am. Journal of the Med. Sciences, April, 1858. VOL. IV. — b 114 INJURIES OF BONES. Fig. 826. dren's Hospital in Philadelphia in seven years, the scapula was afiected in only three. In by far the greater number of cases, fractures of the scapula are due to direct violence. There was a man in my wards at the Episcopal Hospital in 1882, who, while working in a dye-house, had been jammed in a narrow space under a roller weighing 500 pounds, by Avhich the body of the right shoulder blade was broken across. Many years ago I saw a railroad laborer who had had the bone comminuted by a blow from the rapidly revolving crank of a hand-car. A not unfrequent cause is a fall from a height, the patient striking on the back and shoulders. Muscular action has been assigned as the cause of fracture of the scapula in two cases. One of these, quoted by Callaw^ay,^ as observed b}^ Dr. Heylen, is given in detail, and admits of no doubt ; the patient, a man of 49, hung by one hand to a cart while the horse ran a distance of about one hundred yards ; the diagnosis of fracture w^as clear, and there was no bruise or other indication of a blow on the part. The other case is very briefly reported by Mr. M. Morris f it was that of a locomotive engineer, Vv^ho was making some exertion, and fell forward, striking his chest against the lever ; he felt at the same time a crack in his shoulder, and the scapula Avas found to have been broken. The fracture is said to have been through the spine, about an inch from the triangular surface over w^hich the trapezius plays. Union took place, but a ridge was left at the seat of injury. Fracture may occur at different portions of this bone. Fig. 826 shows a not unfrequent form, the spine and the body of the bone being affected. As in the case of other flat bones, fissures are often seen in connection with complete fractures. iN'o instance is on record of a fracture involv- ing the spine alone, although the acromion pro- cess has occasionally been broken off, either by a blow from above, or by the humerus being forcibly driven upward. The loicer angle of the bone is sometimes separated. When the Jine of breakage is higher up, it is apt to be more irregular, and the bone may be comminuted. Callaway gives a representation of a fracture produced by the fall of a mass of slate on the patient ; one line runs across the bone just below the base of the spine, terminating at the root of the coracoid process, w^hich is broken ofl"; another runs oft* from near the mid-point of this line, downward and outward to a point perhaps an inch from the lower margin of the glenoid cavity. The bone is thus broken into four pieces : one comprising the upper angle, the spine, and a strip of the body ; a second, the lower angle with part of the body ; a third, the glenoid cavity, neck, and part of the body ; and, lastly, the coracoid process. A fw instances are upon record in which the coracoid process has itself been broken off. One such occurred under my own observation many years since, in the person of an elderly woman, who fell backward in a narrow ])assage, striking on her elbow, and thus forcing the head of the humerus upward and forward. Fracture of the scapula. • A Dissertation npon Dislocations and Fractures of the Clavicle and Shoulder Joint. London, 1849. « British Med. Journal, Sept. 16, 1876. FRACTURES OF THE SCAPULA. 115 Fractures of the neck of the scapula have been by some authors regarded as of more common occurrence than they really are. In fact, the neck of the scapula as described by anatomists — the constricted part of the bone close to the glenoid cavity — has never been found fractured upon dissection. A few cases, however, have been studied, and among them one reported, and the specimen figured, by Callaway,^ in which the line of breakage has run from some point in the upper margin of the bone, so as to include the supra- scapular notch and coracoid process, downward and outward to some point in the outer margin, more or less close to the glenoid cavity. Upon an examination of a normal scapula, it will be found that such a line of separation, running as in Callaway's case for example, first downward and then outward, would surround a portion of the bone which constitutes really its thickest part. A portion of the root of the spine is included in it. By Gnrlt and others it is proposed to call this the "surgical neck'' of the scapula, while to the narrowed portion just around the glenoid cavity is given the name "anatoiiiical neck." The extreme improbability of a fracture through this last-named part will be obvious at once to any one wiio looks at a vertical section displaying the arrangement of the bony texture, and who considers the relations it bears to surrounding parts ; the former being such as to diffuse as much as possible any stress brought to bear upon the bone, in any way whatever, and the latter being such as to render its fixation, so that a cross-breaking strain" could be exe'rted upon it, impossible. I think, therefore, that it may be asserted that the neck of the scapula, surgically speaking, corresponds to the line above mentioned ; and that when fracture occurs in this part of the bone, it follow^s very nearly the direction thus marked out. With this view clinical facts are entirely in accord. In order to arrive at a clear understanding of the mechanism of the dis- placement in fractures of the scapula, the attachment of the muscles to it must be carefully studied. Let it be remembered that this bone finds its sole direct connection with the thorax through its articulation with the clavicle. Apart from this, it is merely supported by muscles. When fracture takes place across the flat part below the spine, the low^er fragment tends to ride up, either in front of the upper or behind it, according to the action of the fracturing force ; and this tendency is favored by the con- traction of the rhomboidei and teres major; the latter aided by some-, at least, of the fibres of the serratus magnus. A number of museum specimens which I have examined, as well as several figured by Gurlt, and two by Malgaigne, illustrate this. In one case, recorded by Easley,^ wdiere a longitudinal frac- ture of the body was caused by great violence, the patient having been run over by a wagon the wheel of which passed lengthwise over the scapula, the displacement from muscular action was very marked. When the upper angle is broken off', the tilting action of the levator anguli scapulae is quite distinct, as in a bone represented by Gurlt ;^ a gap is even left at the posterior edge between the fragments. When the fracture affects the body and spine, as in the case seen by me, from which Fig. 826 w^as taken, the fragments may be so nearly balanced by the contraction of opposing muscles, as to be in reality very slightly disturbed in their relations to one another. In the cases of fracture of the neck of the bone, it appears that there is sometimes very little displacement. Thus, in an instance reported by Ash- Imrst,* in a boy five years old, the diagnosis could only be made by exclusion. 1 Op. cit., p. 93. Plate I. fig. 1. 2 Am. Journal of the Med. Sciences, Jan. 1878. 3 Op. cit., Bd. ii. S. 528, Fig. 45. » Trans, of Coll. of Phys. of Philadelphia, 3d s. vol. i. 1875. 116 INJURIES OF BONES. This may be explained in great measure by tbe fact that the fragment is supported by the coraco-clavicular and coraco-acromial ligaments, as well as to some extent by the long head of the biceps. But the tenden<^y is for the fragment to be merely tilted downward by the action of the coraco-brachialis, the short head of the biceps, and the middle head of the triceps ; with the result of somewhat flattening the shoulder, and thus producing an appearance at first sight simulating downward luxation of the head of the humerus. This fracture may be, as in the case quoted by Gurlt from Duverney, com- plicated by fractures of the ribs ; and from the violence requisite to cause it, other bones also in the neighborhood are apt to sufler. Fracture of the glenoid cavity has been, in most of the recorded cases, observed in connection with luxation of the shoulder, the latter being the lesion seemingly of most importance. But in one instance, re^^orted by Assakyi to the Societe Anatomique, the history is given as follows : " A man, aged 65, got a fall, striking his shoulder against a beam lying on the ground ; he was taken to the Hopital de la Charite, where the interne thought he detected and reduced a subcoracoid luxation. About a month afterward the man died of pleuro-pneumonia ; and at the autopsy there was found a stellated fracture of the glenoid cavity, the fissures, three in number, extend- ing back into the substance of the neck of the bone, w^here union had occurred with superabundant callus, composed of fibrous tissue with osseous deposits. A fracture of the acromion also existed, at which suppuration had taken place ; there were some irregular bony deposits in the neighborhood." The diagnosis of these fractures has been incidentally referred to in con- nection with their symptoms. It is generally not difiicult to determine the fact of the bone being broken, by the tenderness on pressure, the loss of cer- tain motions of the upper arm — especially those upward and backward, the abnormal mobility of the bone when grasped above and below, the detection of distinct irregularities of outline, and the crepitus elicited, especially by rotating the arm. But to make out the precise line or lines of separation is a matter of far more difiiculty. I had in my ward at the Episcopal Hospital, in 1882, a man who had had a heavy beam fall on his shoulder, in whom a fracture could be plainly felt at the posterior edge of the scapula, but it could not be traced any further forw^ard. Fracture of the neck of the bone is distinguished from luxation by the facts that the humerus is freely movable in every direction ; that the hand can be placed on the opposite shoulder, the elbow being kept at the side ; that the displacement is readily corrected, but as readily reproduced ; and that crepitus is present. The analogy between these cases and those of double vertical fracture of the pelvis is very marked. When the coracoid jjrocess alone is broken, the fragment can be grasped and felt to be movable upon the rest of the bone ; the crepitus, if perceived, gives the sensation of smallness of the surfaces in contact ; and the action of the biceps and coraco-brachialis muscles is lost. Hamilton cites a number of instances in which the diagnosis was clearly established, both by himself and by others ; and dissections have been made, which set beyond a doubt the fact that this fracture may occur. Yet very careful examination is requisite before it can be asserted to exist in any case. Fracture of the acromion^ w^hen it takes place, is not diflacult of detection, by means simply of the pain, tenderness on handling, loss of power (from pain), mobility, awd crepitus. Many of the museum specimens, which are > Le Progres Medical, 11 F^v. 1882. FRACTURES OF THE HUMERUS. 117 supposed to exhibit non-union after fracture of this process, are in fact merely examples of want of consolidation of the epiphysis. In regard to prognosis^ it may be said that fractures of the scapula in general unite readily, and often without perceptible displacement ; and that the functions of the arm are seldom permanently impaired. Very little can be done in the way of treatment of these injuries. The arm should be supported with a sling, in such a position as in each case may be found best adapted to obviate whatever displacement exists ; and the shoulder should be confined by adhesive plaster applied so as to steady and control the fragments. In fractures of the neck of the bone, an axillar}^ pad may be of service; but it should not be too large, lest it should aggravate, by pressure on the muscles, the very condition it is intended to relieve. Fractures of the Humerus. These injuries are by no means infrequent, but the testimony of those authors who have offered statistics on the subject is not uniform ; and it is probable that the experience of different surgeons, or the records of different hospitals, would be found, as in other matters, to vary somewhat. Thus Gurlt, quoting those of the London hospitals, says that out of 22,616 frac- tures treated during twenty years, there were 1651, or 7.3 per cent, affecting the humerus. But Malgaigne, among 2358 fractures observed at the Hotel Dieu, found 317 of the humerus — over 13 per cent.; and of the 316 cases derived by me from reports of the Children's Hospital in Philadelphia for seven years, there were 72, or about 22.6 per cent. I do not, however, pro- pose to dwell upon these statistical points, and mention them merely in illus- tration of the difficulty of arriving at conclusions in regard to questions of this kind. Very marked differences exist between different portions of the humerus in their liability to fracture ; but before discussing these, the anatomy of the bone must be briefly sketched. The head of the humerus, nearly hemispherical, looks upward, inward, and slightly backward ; a very shallow constriction at its circumference, made apparently deeper by the prominence of the greater and lesser tuberosities, is called the anatomical neck. Just below this, beginning at the upper margin of the tuberosities^ and extending to the insertion of the teres major muscle, is the surgical neck ; the tapering of this portion of the bone from above downward should be speciall}^ noted. Below this is the shaft ; cylindrical above, and flattening out at its low^er part, it widens .greatly towards the elbows The lower end of the bone is turned somewhat forward, and presents the pulley-like surface on which the ulna plays, with a rounded eminence at the outer side of this for the head of the radius. Above the trochlea., at the inner margin of the bone, projects the process called the internal condyle or epitrochlea, and corresponding to it on the outer margin is a smaller promi- nence, the outer condyle, sometimes called the epicondyle. The upper epiphysis of the humerus, which unites wdth the shaft at about the twentieth year of life, is somewhat dome or cap-shaped, and comprises the head and tuberosities, developing from tw^o centres. The lower epiphysis, having four centres, comprises the portion below the sigmoid cavity, and corresponds quite closely in extent with the articulating portion of the bone, although the epicondyles, internal and external, are on a slightly higher level on either side. 118 INJURIES OF BONES. A thorough familiarity with the muscular attachments afforded by the humerus, will enable the student of the fractures of this bone to comprehend much more readily the mechanism of their production, as well as of the resulting displacement. This matter will be further referred to in connection with the fractures of different portions of the bone. Fractures of the humerus may be divided roughly, and for general pur- poses, into those of the upper end, those of the shaft, and those of the low^er end. Under each of these heads are comprised several varieties, distinct in their anatomical and clinical features. But before entering upon the dis- cussion of these, I would call attention to the curious statistics presented by Gurlt^ as to the influence of age and sex upon their relative frequency. Of 194 cases of fracture of the humerus, there were — Between 1 and 10 years of age, 62 cases, or over 31 per cent. 11 ' ' 20 42 " 21 " 21 ' ' 30 22 " 11 31 ' ' 40 16 " nearly 9 " " 41 ' ' 50 9 " " 51 ' ' 60 22 " over 11 " 61 ' ' 70 16 " nearly 9 ** 3 71 ' ' 80 5 " Malgaigne's statistics present a different view. He says that of 310 cases of simple fracture of the humerus, there were — From 2 to 20 years of age, 45 cases, or over 14 per cent. " 20 " 40 " 80 " " 25 40 " 60 " 105 " " 33 " " 60 " 80 and over 80 " " 25 The remarkable discrepancy between these two sets of figures must be at once apparent, but I confess that no explanation of it Occurs to me. 'Now as to the relative frequency of fractures of the various portions of the bone at different ages, Gurlt gives the following : — Age. Upper end. Shaft. Lower end. Between 1 and 10 " 11 " 20 " 21 " 30 " 31 " 40 41 " 50 51 " 60 " 61 " 70 71 " 80 4 = over 6 per cent.^ 11 = " 26 3= " 13 3 = " 18 " 6= " 66 11= " 50 8= " 50 2 = " 40 48 14 = over 22 per cent. 10 = 25 13= 59 5 = over 31 " 2= " 22 9= " 40 7 = nearly 44 ' ' 2 = 40 " 62 44 = 70 per cent. 21 = 50 6 = over 27 " 8 = 50 1= 11 " 2= 9 1 = over 6 " 1 = 20 84 194 The reader will scarcely fail to observe the great preponderance of frac- tures at the lower end of the humerus in the first two decades of life, and the increase of those of the upper end of the bone between the ages of 51 and 60 — the time when, although active pursuits are not yet abandoned, the ability to avoid falls is diminished. As to the influence of sex, I will merely say that the males are very largely in excess of the females hi every portion of Gurlt 's table except four ; in the first decade of life the fractures of the shaft, and between 71 and 80 years those of the upper end as well as of the shaft, show equal numbers for the two » Op. cit., Bd. ii. S. 653. 2 It should be noted that the percentages in the above table refer to the totals for the different ages, given in the first table quoted from Gurlt. FRACTURES OF THE HUMERUS. 119 sexes, while in the latter period the only fracture of the lower end of the bone was in a female. Fractures of the Upper End of the Humerus. — Fractures of the upper portion of the humerus include those of the liead, of the anatomical neck, of the tuberosities (the greater being the only one clearly made out to have been broken off), ancl of "the surgical neck. Under the last head are embraced separations of the upper e[)iphysis. Fracture of the head of the huifierus by itself is certainly very rare. Dorsey^ speaks of one case seen 'by him in which the lesion was "within the capsular lio-ament, the fracture extending through the head of the bone." Gross^ says that he has seen "an instance of the kind, wdiicli had been mistaken by the attendants for a fracture of the acromion process, and tlie true nature of wdiich was not detected until several years after the occurrence of the accident, \vhen the man, who w^as upwards of forty years of age, died of disease of the liver. The fracture, as was shown on dissection, had extended obliquely from above downward throuo;h the head of the bone ; and although it had become per- fectly consolidated, there were several rough prominences which, while they unmistakably indicated the seat of the injury, had greatly impeded the movements of the shoulder-joint. The accident had been caused by a fall from a carriage." Mal2:aio:ne records and figures several cases in which the head of^ tlie bone was more'^or less distinctly broken, but in connection with other injuries. Our sources of information in regard to these lesions (and in fact in regard to very many injuries in the neighborhood of joints) are narrowed by the difficulty of accurate diagnosis. When the patients recover, the real char- acter of the damage done must, of course, always remain open to some doubt. And even dissection, except in cases in which the fatal result has occurred soon after the hurt, may fiiil to clear the matter up, the condition of the parts being often such as might have resulted from disease, inflammatory or other- wise, altogether independent of fracture. These fractures would seem to be always due to direct, crushing violence, the head of the bone being, perhaps, most frequently driven against the glenoid cavity, by a force acting in such a direction as to take it at a dis- advantage. A greater or less degree of arthritis of the shoulder must almost certainly ensue'^with pain and "swelling in the part, and loss of power in the limb. Displacement is not noted in any of the recorded cases, and, if it did occur, would be attributable to the fracturing force, since there is no muscular action which could cause it. Fraser^ reports a case which he regarded as fracture of the head of the humerus, complicated with a laceration of the axillary vein. The vessel was tied above and below the opening in it, and a portion of bone— exactly what part of the humerus is not clearly stated — was sawed off. A tedious convalescence ensued, but the ultimate result seems to have been excellent. Holmes^ mentions a case of fracture of the anatomical neck of the humerus, in whi(;h a subordinate line of fracture ran upward into the joint. There was partial rupture and obstruction of the axillary artery, leading to gangrene of the arm, and necessitating amputation at the shoulder-joint. Fractures of the anatomical neck of the humerus are by no means uncommon. They are often spoken of as intracapsular, although it is likely that the line of > Elements of Surgery, vol. i. p. 141. 2 System of Surgery,* 6th edition, vol. i. p. 980. 3 Lancet, July 8, 1848. * Principles and Practice of Surgery, Am. ed. p. 260. 120 INJURIES OF BONES. separation seldom lies Avholly within the joint. Elderly persons are the most frequent subjects of these injuries, the mechanism of which it is not easy to determine with certainty. My own belief is that a blow either on the front or back of the shoulder, or perhaps the forcing of the humerus upward against the acromion, may in many cases be assigned as the cause. Very curious displacements of the fragment have been noted. Gross^ records two: one in which the head of the bone was "turned upside down, the centi-e of the articulating surface corresponding with the outer border of the shaft," and the other in which the fragment was " tilted over the greater tuberosity against the posterior surface of the bone." Firm union had taken place in i3oth. E. W. Smith^ gives some very singular instances : one in which the head of the bone w^as simply sunk deep into the cancellous structure of the other fragment, and two in which it had been so completely rotated as to have its rounded articular surface applied to the same part; he quotes a third case of the same kind as having been observed by iSTelaton, and a fourth as recorded by Malgaigne. Occasionally these fractures of the neck of the humerus are complicated by actual luxation of the head of the bone downward, or downward and forward. At least two of Smith's cases were of this character. Cock^ men- tions a case treated by Poland, which was thought to be a dislocation into the axilla ; but under chloroform a fracture was detected ; the head of the bone could not be replaced ; and the patient finally left the hospital with the arm shortened about two inches. He is said to have " regained considerable use of the limb." Dr. Fraser, of Michigan,"* reports a case in which a boy aged 15, being caught in some machinery, sustained, among other severe injuries, a fracture of the anatomical neck of the left humerus^with disi3lace- ment downward of the head. It is simply stated that the luxation was reduced under chloroform, and that " perfect recovery" took place in forty- five days. ^ Bennett^ reports five cases of dislocation of the humerus, com- plicated with fracture, beginning at the anatomical neck and passing obliquely into the shaft, detaching the les^ser tuberosity along with the head. He sug- gests that the luxation occurs first, and that the fracture is produced by pressure against the edge of the glenoid cavity. This explauation is much more probable than that oftered by Hutchinson,^ who thinks that the sup- posed cases of fracture with dislocation are really instances of fracture very high up, in which the head of the bone has gradually travelled downward to a new articular facet, by what mechanism does not appear. A case recently occurred at the Pennsylvania Hospital, in a man of about seventy-six, who fell down stairs and sustained a fracture of the neck of the humerus, with displacement of the head of the bone into the axilla, where it gave so much trouble that Dr. Morton excised it ; the result was satisfactory. Fractures of the greater tuberosity of the hmnerus have been observed mainly in connection with other injuries, either fractures of the anatomical neck of the bone, the upper fragment having been forced down into the lower so as to split it, or luxations, in which stress must have been put upon the muscles attached to the process in question. In a few instances, however, the tube- rosity has been separated by itself; and in three, according to Gurlt, the lesser tuberosity has been in like manner detached. It seems to me that these lesions may be appropriately classed with sprain-fractures ;" and I venture to refer 1 Op. cit., vol. i. p. 981. 2 Op. cit., pp, 187 et seq. 8 (xuy's Hospital Reports, 3d s., vol. i. 4 Am. Journal of the Med Sciences, April, 1869. 5 British Med. Journal, Aug. 28, 1880. 6 Med. Times and (razette, March 10, 1866. FRACTURES OF THE HUMERUS. 121 the reader to the very full discussion of them by Gurlt, merely remarking that the influence of muscular action is distinctly traceable in the displace- ment of the fragments in these cases. 11. W. Smith^ has recorded a case examined by him after death, in which the greater tuberosity, together with a very small portion of the outer part of the head of the bone, had been completely separated from the shaft of the humerus. This })ortion of the bone occupied the glenoid cavity, the head of the humerus having been drawn inward so as to project upon the inner side of the coracoid process ; it was still, however, contained within the capsular ligament. Nothing was known of the history of the injury, which was of ancient date. In all these cases of fracture occurring in the immediate neighborhood of the shoulder-joint, there is apt to be a very abundant deposit of new bone in irregular, stalactiform shapes, and this is one chief cause of the impaired free- dom of motion which generally ensues upon such injuries. In this, as in many other respects, there is a very marked analogy between fractures in this region and those which affect the corresponding portion of the femur. Along with the separation of the greater tuberosity, and in consequence of it, there is apt to be a displacement of the tendon constituting the long head of the biceps muscle. If the lesser tuberosity is also broken off, the tendon may slip forward and allow the head of the bone to be pushed outward ; otherwise the subscapularis will tend to rotate the whole humerus inward, and thus add to the appearance of depression below the acromion, as well as to the increase in breadth of the shoulder. Epiphyseal disjunctions are sometimes met w^ith at the upper part of the humerus. About the fifth year of life, the head and tubercles become con- solidated, and the mass thus formed unites with the shaft at or near the twentieth year. Examination of a vertical section of a young l)one shows that the line marking the epiphysis begins at the axillary margin of the head, and runs across, rising slightly toward the centre, in a direction nearly hori- zontal, to terminate at the" outer side just below the tuberosity. Hence it is evident that the epiphysis, like a cap, rests with its concavity upon the con- vex end of the shaft. Below this the bone tapers somewhat decidedly ; and, as before said, the surgical neck of the humerus., in the adult bone, comprises all between the upper part of the tuberosities and the insertion of the teres major, the lower boundary being but ill-defined. Fractures of this part have so much in common with epiphyseal separa- tions, that I have thought it best to discuss them together, merely pointing out the clinical difi:erei'ices existing between the two. Bouchut mentions that Foucher saw, in a girl aged 13, the upper epiphysis of the humerus separated by muscular action, in taking a frame down from a wall above her head. An abscess formed, and death ensued in about seven weeks, when the diagnosis was verified by an autopsy. Hutchinson^ mentions a case in which, by a fall from a mast, both the upper and lower epiphyses of the humerus were detached. A somewhat similar case is reported by Macnaughton Jones f a double fracture of the humerus, near the neck and near the elbow, with separation of a longitudinal fragment from either ex- tremity of the shaft. All fractures of the humerus between the tuberosities and the shaft proper of the bone, present the peculiarity, that there is a short upper fragment, acted upon by strong muscles, the supra-spinatus, infra-spinatus, subscapularis, and teres minor, the eflect of which is to roll the head of the humerus over 1 Op. cit., p. 178. 2 Med. Times and Gazette, March 10, 1866. 3 Britisli Med. Journal, Dec. 24, 1881. 122 INJURIES OF BONES. inward, and thus to tilt up the lower end of the upper fragment, so that its fractured surface tends to look outward. The lower fragment is at the same time drawn inward by the muscles attached to its upper end, while it is pulled upward by the deltoid, biceps (short head), coraco-brachialis, and sca- pular head of the triceps. Hence, the moment that there is any engagement of the two fragments in their changed relation, the tendency of the muscles is to keep up, and even to increase, the disturbance of the upper fragment. The line of separation in epiphyseal disjunctions has already been spoken of ; in fractures through the surgical neck, I think it is, as a general rule, from without inward and downward, or nearly parallel with the plane of the anatomical neck — a circumstance which tends to lessen the degree of the deformity, since the long point of the upper fragment within, and that of the lower fragment without, are in the way each of the other's displacement. When, however, there is an obliquity also from before backward, or from • behind forward, the upper fragment may be so tilted as to point outward. Of this form of displacement one notable example exists in the Miitter Museum, in a specimen of epiphyseal disjunction, the lower fragment over- lapping the other inwardly, and in close contact with it, while the latter is so tilted by the action of the scapular muscles, that a space, filled up, however, by callus, is left between the two fragments at the outer part of the fracture. This is by no means an isolated instance. In the majority of the speci- mens figured by Sir A. Cooper, Malgaigne, Gurlt, and other authors, and notably in one illustration first given by Moore, and borrowed by Hamilton and others, the same mechanism is clearly traceable ; and this evidence is the stronger, in that it is altogether unintentional on the part of those pre- senting it. Malgaigne, indeed, says : " The upper fragment is in a position answering to the greatest elevation of the arm in its normal state." A striking illustration of this tilting action once came under my notice in a case of railroad injury, the humerus being crushed to within a few inches of the shoulder. While the patient was being etherized preparatory to the removal of the limb, the point of the upper fragment was repeatedly thrust strongly against the inner surface of the deltoid by the muscles mentioned. Further confirmation of this view is aftbrded by the fact that in most cases of fracture in this region there is, after recovery, a limitation of the move- ment of the arm directly upward, by reason of the approximation of the points of insertion of the scapular muscles to their origins. Sometimes, along with fractures in this region, the head of the bone becomes dislodged from the axilla. Hingeston's case,* in which the neck of the hone was broken into six pieces, which became united again, is a very remarkable one. Dr. J. Watson^ reports two cases, in both of which the cause of injury was direct violence ; in one the fracture was through the surgical neck(?) "midway between the upper end of the bone and the insertion of the deltoid," and in the other "near the tubercles." Reduction was efiected immediately in both, without splinting the limb ; in the latter case the arm was drawn out at right angles with the body, and the head of the bone coaxed into the glenoid cavity by manipulation with the fingers. Eichet^ has placed on record a case of fracture of the surgical neck of tSie left humerus, with luxation of the head of the bone into the axilla. Eeduction was effected by manipu- lation with the fingers, a few days after the accident, and ultimately the shape and usefulness of the limb were entirely regained. I^orris* reports a case 1 Guy's Hospital Reports, 1st S., vol. v., 1840. 2 New York Mediqal Times, July, 1854. * Quoted in Am. Journal of the Med. Sciences, April, 1854. * Am. Journal of the Med. Sciences, Jan., 1855, and Summary of Transactions of College of Physicians of Philadelphia, N. S., vol. ii. No. 6. FRACTURES OF THE HUMERUS. 123 under his care, which had been treated for fracture for twenty-six days, when jt was discovered that the head of the humerus was in the axilhi. S'o effort vras made at reduction. One other case, which had occurred in the Pennsyl- vania Hospital, rei3orted by Ihirtshorne, is referred to, as well as others recorded by Ilouzelot, Dupuytren, Earle, Peyrani, and A. Cooper. Walton* has reported the case of a man, aged 48, in whom a fracture of the neck of the humerus was treated, but a distocation downward was not recognized for ten weeks. Union of the fracture had then occurred, but the displaced head of the bone gave great pain. The reduction was effected by extension con- tinued for three-quartei^ of an hour, the whole arm- being very carefully and firmly put up in splints beforehand. " A good deal of local and general disturbance followed, but at the end of three weeks passive motion was com- menced, and at the end of six weeks the arm could be used nearly as well as the other." The s]/mptoms of separation of the upper epiphysis of the humerus are often somewhat obscure. There is pain and loss of power, with some swell- ing ; and a rather rough ridge is apt to be felt across the front of the joint, atVhich crepitus is more or less distinctly felt on rotating the arm. In the few cases which I have seen the ridge has been less prominent than it is repre- sented by R. W. Smith in his work ; it is due to the projection forward of the edge of the lower fragment. The degree of mobility is not great, and the crepitus conveys an idea of smoothness of the surfaces in contact as compared with those of an ordinary fracture. In making the diagnosis, the age of the patient is an important point to be considered. Fractures of the surgical neck of the bone are, as a general rule, easily recoi>:nized ; besides total loss of power in the limb, free preternatural mobility, and distinct crepitus, the exact line of the fracture can often be made out by feeling. Sir A. Cooper has represented^ a double fracture in this region, but gives no history of the case. Such an injury, probably due to great direct violence, would not be likely to offer any special difficulty in diagnosis, unless the swelling of the soft parts were excessive. Fractures of the upper portion of the humerus for the most part unite readily, with the exception of those in which there is displacement of the head of the bone from the glenoid cavity. Even when the change of rela- tion between the fragments is most marked, as in the instances before quoted from Gross and R. W. Smith, consolidation seems to have occurred in every instance. And, as a rule, the usefulness of the limb is in great measure regained, although the mobility of the shoulder-joint is of necessity impaired, either as a result of inflammationc, or by the change of the points of attach- ment of the muscles, or by the substitution of some portion of one or other fragment for the head of the bone, in contact with the glenoid cavity. Xon-union is, however, occasionally met w^ith, as in a case recently reported:^ A girl, aged twenty, had the surgical neck of the right humerus fractured three times, twice by direct violence, and the third time by the stress put upon it in drawing on a tight boot ; the fragments remainiiig ununited, Mr. Croly cut down on the fracture under the spray, drilled the ends of the bones, and wired them. The case was not a favorable one for the operation, inasmuch as the periosteum Avas separated to a considei*able extent, and the ends of the bones were widely apart. Xecrosis setthig in, and extensive suppuration and hectic threatening the patient's life, amputation was de- cided on." The patient was doing well at the time of the report. ' Lancet, Oct. 30, 1868. ' Treatise on Dislocations and Fractures of the Joints, p. 433. London, 1842. 8 British Med. Journal, March 17, 1883. 124 INJURIES OF BONES. Compound fractures of the upper third of the humerus are extremely rare, except as the effect of gunshot injury. They are always of grave import- ance, and may demand excision, or even amputation. Skey^ met with a case in which a dislocation of the humerus was reduced; eight or ten days afterwards, a large traumatic aneurism was developed in the axilla, and the artery was tied above and below. After the patient's death, it was found that he had had " a fracture of the neck of the humerus," and that the artery had been " torn across" by the pointed end of the shaft. In the Museum of St. Bartholomew's Hospital ^ there is a specimen of un- united fracture of the neck of the humerus, with obliteration of the axillary artery by pressure of the lower fragment of the bone against it. The subject, a man aged 75, had received the injury ten years previous to his death. " The fracture extends transversely through the humerus, immediately below its head and below the tuberosities ; and it communicates with the cavity of the shoulder- joint. A small detached piece of" the bone is connected with the synovial membrane. The synovial membrane is thickened, and its internal surface is rough. The axillary artery is obliterated to the extent of half an inch, in the situation in which the end of the lower portion of the bone pressed against it. Immediately above the obliterated part, the infra-scapular artery arises, of its usual size, and pervious. Close to the infra-scapular is the posterior circumflex artery, obliterated in the first half inch from its origin, and then pervious by means of the collateral circulation. About two inches above the origin of the infra-scapular, a large branch arises from the axillary artery ; this branch, extending down inside of the arm, was continued into one of the arteries of the forearm, and formed a principal channel for transmitting blood to the lower part of the limb." The nerves are very rarely injured. One such case is recorded by Berger,^ in which the musculo-spiral nerve was pressed upoh, and paralysis of the parts supplied by it resulted, with some superficial sloughs. The patient, a man, died of malignant scarlet fever. Treatment of Fractures of the Upper Part of the Humerus, — In fractures near the upper end of the humerus, the proximity of the shoulder-joint, and the danger of its stiffening, should always be borne in mind. When there is much swelling and inflammation, the most prompt and efficient means should be employed to allay it ; the patient should be kept at rest in bed, with the arm and hand on a pillow, and hot fomentations should be con- stantly used. Where the injury has been caused by great direct violence, it may be well even to apply leeches to the part. On the subsidence of the inflammation, the condition of the fragments should be very carefully ascer- tained, and measures adopted for correcting any displacement that may exist. If this be very slight, as may happen- in feeble persons, or when the perios- teum is not wholly torn through, the suspension of the arm in a sling, with a small and soft axillary pad, may suffice ; or the arm may be confined to the side by a bandage applied around it and the body, the hand merely being placed in a sling. Some surgeons employ a splint along the inner side of the arm, with a leather or pasteboard cap fitted on the shoulder, the whole being kept in jjlace by a bandage, a few turns of which are carried around the chest. But in very many instances, in which the upper fragment is tilted imvard by the scapular muscles, as before explained, it affords so little purchase that the only efficient method of correcting the displacem.ent is to carry the lower fragment upward, which is best done by putting an angular splint in the 1 Lancet, May 5, 1860. 2 Catalogue, vol i. p. 32. * Bulletin de la Soc. Anatomique, Juillet, 1871. FRACTURES OF THE HUMERUS. 125 axilla, so that one branch of it fehall be applied to the side of the chest, and the other along the inner side of the arm. This splint, well padded, may be secured by a bandage, which in the case of very restless patients may be im- bued with plaster of Paris or some other solidifying material. Such a splint was long ago recommended by Tyrrell, and has been more recently employed by Middeldorpf, Gely, and others. It is not needful to retain the arm in this position during the whole period of repair, but only for the first two or three weeks, after which a gradual lowering of the elbow may be effected without putting too much stress upon the newly-formed uniting material. When this splint is used, the binder's board shoulder-cap may be dispensed with. In any case, the cap need extend no further over the shoulder than just to cover in the acromio-clavicular junction. I recently had a woman, aged 57, in my ward at the Episcopal Hospital, w^ho had sustained a fracture of the surgical neck of the left humerus, and in whom the upper fragment projected into the axilla, while the lovver was drawn up so as to overlap it at its outer side. I succeeded in overcoming this deformity by means of gentle pressure with a small, firm compress, held in place by a wide strip of adhesive l)laster carried around the arm and up upon the shoulder (Fig. 827), the hand being, of course, supported in a sling. F^s- ^27. The ultimate result of the case I do not know. Fractures of the tuberosities admit of very little in the way of treatment, as the purchase afforded by the sepa- rated portions is so slight. The elbow, however, should be supported, and the arm placed and kept in such a position as may be found to correct the deformity most completely. When, along with fracture, there is dislocation of the head of the bone from the glenoid cavity, it becomes a question whether the dislocation or the fracture should be first treated. Cases might be cited in favor of either course ; but it seems to me that, as a general rule, an efibrt at immediate reduction of the head of the bone ought to be made. Such a procedure is certainly difficult ; but, on the other hand, the fragments can scarcely be brought into p^t^Ind Idheswe pLt proper relation as long as the head of the bone remains ter to overcome defor- out of the glenoid cavity, and the reduction cannot be easy mity in fracture of the if put off until after the occurrence of union. Indeed, from ^^^^ ■L . humerus. the cases quoted on a previous page, it must be evident that a change in the position of the head of the bone is very apt to occur even when there is no luxation. Should the reduction be found impos- sible, the shaft should be placed in the best attainable position for union between it and the head, in hope that after four or five weeks the attempt may be renewed, with the advantage of the leverage afforded by the length of the bone ; although there may be adhesions, changes in the capsule, etc., as in other cases of old luxation, which may foil the best directed efforts. Hence, it must be evident that the prospect in cases of this kind is anything but encouraging. When, reduction being impracticable, the displaced head gives rise to serious trouble, the proper course is to excise it. Fracture of the shaft of the humerus is of very frequent occurrence, and is met with at all ages and in both sexes. An instance is reported by Lowen- hardt^ in which a fracture of the upper third of the left humerus took place ' Am. Journal of the Med. Sciences, Jan. 1841 ; originally in Medizinische Zeitung, 6 Mai, 1840. 126 INJURIES OF BONES. dnriog the expulsion of a child from the mother's pelvis, the arm lying across the chest ; and Hamilton mentions a similar case as having been seen by him, which had occurred in the practice of a Dr. Lockwood, as well as another related to him by Dr. Fanning, of Catskill, [N". Y. The latter case was one of head-presentation, and, as the right shoulder passed under the arch of the pubis, a snap was heard, the humerus giving way in its upper third. From Gurlt's table, before quoted, it would seem that females are very much more liable to this injury duriiig the tirst decade of life than in any subsequent one, whiie it is most common in males between the twentieth and thirtieth years. Under ten years, the cases in males and females are equally numerous, as they are also after the seventieth year ; but in the intermediate period the cases in males are largely in excess. These statements, it must be remembered, are based upon a comparatively small number of cases; but they are sufficiently in accord with ordinary experience to be accepted, although further observa- tion may modify them to some extent. Under the term " shaft of the humerus," is comprised all of the bone between the lower limit of the surgical neck and the abrupt widening just above the condyles. Every variety of fracture may occur in the region thus included, and from every variety of cause — direct or indirect violence, or muscular action. Fractures from the last-named cause are, indeed, more frequently met with in the humerus than in any other bone in the body. A thorough knowledge of the muscular connections of the humerus is essential to a proper understanding of the mechanism of the production of these lesions, afe well as of the displacements w^hich ensue upon fractures from whatever cause. The upper extremity constitutes a mechanical system, of which the clavicle and scapula form a part, and in which the humerus is an intermediate lever; the ultimate object of the whole being the discharge of the functions of the hand. The muscles operating this system begin at the spinal column, taking their origin from its whole length, and from this point to the fingers each successive member of the system is in a rapidly increasing ratio of complexity of structure as well as of function, and in a diminishing ratio of mere strength. Perhaps it scarcely needs demonstration that on the humerus, as the only single lever of this system, and the member upon which are exerted the fix- ing muscles from the trunk, while from it arise the greater part of the moving muscles of the hand, the actions are all concentrated. The exact conditions of the leverage must vary indefinitely with the motions executed by the limb, as well as with the postures it assumes ; and in very many of them the muscles passing downward from the humerus combine the arm, forearm, and hand into one continuous lever, in which case the stress upon the humerus must be proportionately increased. Accordingly, the humerus is by far the strongest of the bones entering into the system. Fractures of the humerus by direct violence need hardly be discussed, as regards the conditions of their production, since these are simple enough. Those produced by indirect violence, as b}^ falls on the hand or on the elbow, or by striking a blow w^ith the fist,^ are not difficult of comprehension. And the cases of fracture by muscular action, which is generally the efl:brt of throw- ing, take place in obvious accordance with the law^s of mechanics. So many instances of this kind are on record, that it is scarcely necessary to refer to them. I may, however, mention one reported by Lyon,^ in which a man, aged 30, had "a comminuted fracture of the right humerus, caused by violent muscular contraction in throwing a base-ball by the ' underhand' method. The bone was broken into several parts, extending from the lower to the ' Lonsdale, op. cit., p. 166. 2 Trans, of Med. Society of Pennsylvania, 1878. FRACTURES OF THE HUMERUS. 127 upper third ; besides this, several of tlie minor bloodvessels were lacerated to such an extent as to threaten gangrene." I know of no other case in which an injury of this kind resulted from such a cause. Bellamy/ recording the case of a boy of 14, whose humerus gave way just below the insertion of the deltoid, as he was making a great exertion in throwing a cricket-ball, speaks of the twisting motion which is apt to be the finale of this act, as probably the real cause of the breakage ; and this view certainly seems to be correct. The suddenness of the stress upon the bone is also to be taken into account. As to the point at which the bone yields, whether above or below the insertion of the deltoid, this would appear to be determined by slight varia- tions in the character of the movement executed. It must be borne in mind that, in the act of throwing, the humerus is steadied by its upper end against the scapula, its head rolling in the glenoid cavity, while its lower end describes a somewhat large arc, and carries the weight of the forearm and hand, the latter describing the largest arc possible to it. Under these cir- cumstances the bone is act^d upon by the deltoid, pectoralis major, and latis- simus dorsi, much as the mast of a vessel is by its stays ; and it yields just as the latter sometimes does when overloaded above. By Malgaigne, Lonsdale, and others, cases are recorded in which the humerus has been broken in trials of strength ; the opponents " facing one another, their elbows resting on a solid plane, their forearms touching by their ulnar margins, their fingers interlocked, and in this position each tries to turn outward the wrist and forearm of the other." Here the twisting mechanism is so evident that it need hardly be demonstrated. In one case reported by Mr. Henry Smith ,2 a fracture of the humerus was caused by the attempt of the patient to lift himself by grasping the top of a wall. Dr. W. B. Hopkins, in a recent article,^ has reported three instances of fracture of the humerus by muscular action. In one, the patient was throw- ing a base-ball " over-hand ;" in a second, the man made a miss in striking a hard blow at another with whom he \vas fighting ; and in the third, a woman was carrying a heavy tub of clothes.'* 1 Lancet, May 11, 1878. 2 Med. Times and Gazette, July 25, 1857. 8 Philadelphia Medical Times, March 24, 1883. * In connection with these cases Dr. Hopkins says : — "When the forearm is flexed at the elbow-joint by the contraction of the muscles of the arm, the lower end of the humerus acts as tlie fulcrum, the biceps and brachial muscles as the power, and the hand, with whatever it may grasp, as the weight. The forearm is, in other words, a lever of the third kind. In such the power must always be greater than the weight, technically expressed by the phrase 'mechanical disadvantage.' The amount of mechanical disadvantage to which the muscles of the arm are put to raise a known weight placed in the hand, is com- puted by multiplying the weight to be raised by its distance from the fulcrum, and dividing the product by the distance of the power from the fulcrum. " The following measurements were taken from the bones of a well-developed male skeleton : From the bottom of the sigmoid cavity of the ulna to the metacarpo-phalangeal articulation of the middle finger, fourteen inches, and from the same point to the tuberosity of the radius, two inches. (For convenience in computation, the attachment of the biceps alone will be used, as it is the more important flexor muscle, and as it presents less mechanical disadvantage tlian the brachial.) The power, then, in this lever, is to the weight as seven to one. If, therefore, a weight of one hundred and fifty pounds is raised in the hand by flexing the forearm, the power exerted by the muscles in executing this movement is represented thus : ^ ^''^ = 1050 2 pounds — a force well calculated to part a tendon or break a bone. "The fact that the forearm cannot be extended with as much force as it can be flexed, though with greater velocity, of course depends upon the difference in distance between the power and the fulcrum in the two cases. For, in the same specimen, the distance from the point of insertion of the tendon of the triceps in the olecranon to a point opposite the bottom of the sigmoid cavity of the ulna, was found to be only half an inch. The power, then, in this lever, is to the weight 128 INJURIES OF BONES. One point of importance in the mechanics of the upper arm is the attach- nient of the forearm muscles, especially the extensors and supinator longus, the action of which, when the elbow is flexed, is to draw forward the lower part of the humerus, and thus to increase the forward angular deformity when this bone is broken anywhere below its middle. The effect of the con- traction of these muscles is even more marked, as might be supposed, in frac- tures near the lower end of the bone, in connection with which it will be again mentioned. In fractures of the humerus in children, the periosteum, by reason of its comparatively great thickness, may escape complete rupture, and there may be but little displacement. The same is generally the case in adults when the bone is broken by muscular action, or by slight violence. Sometimes, however, the fragments may be very widely separated, and occasionally the overlapping is so marked as to materially shorten the arm. In fractures by great violence, especially if compound, this condition^ of things may give much trouble. Pierson^ gives a striking instance of this kind : — A seaman was brought under my care, who, forty-five days before, while at sea, had fallen from the maintopsail-yard upon the deck of the vessel, fracturing the hume- rus obhquely. The superior fragment penetrated the skin, and, after ploughing a furrow in the plank half an inch deep and two inches long, was finally broken off in it. Gn my first visit this fragment, which was about three inches long, was presented to me, which the captain assured me he had had much difficulty in extracting, two days after the accident, from the plank in which it had embedded itself." This man recovered with anchylosis, partial in the shoulder and complete in the elbow ; the arm was, of course, shortened. Syme^ has reported a case of fracture at or about the middle of the hume- rus, the head of the bone being at the same time luxated; into the axilla. The patient had fallen through a trap-door into a cellar, entangling the arm in a ladder as he fell. Reduction was effected by firmly splinting the bone, and then attaching an extending band above the seat of fracture. The subse- quent progress of the case was satisfactory. The symptoms of fracture of the shaft of the humerus are the same as those of the long bones generally : pain, loss of power, preternatural mobility, often deformity, and generally crepitus. Scarcely any fracture is less likely to pre- sent difficulties in dias^nosis. As to the course of these cases, in most of them union takes place favorably in from four to six weeks ; but it must not be forgotten that the humerus has afibrded more instances of pseudarthrosis than any other bone in the skeleton. In Agnew's tables, containing 685 cases of non-union, there were 219, or a little less than 32 per cent., in which the humerus was the bone involved. Out of the 219, the exact seat of the lesion is not stated in 52, leaving 167 ; and of these, 17 are said to have been of " the upper third" or " the surgical neck," and 1 of the external condyle. Hence the shaft of this bone would seem to have been the seat of non-union in 149, or nearly 22 per cent, of the whole number. Fractures of the humerus in children sometimes unite with great readiness. Thus, among the cases reported by Berry ,3 there were three in which this bone was aftected ; in one consolidation had occurred on the 11th day, and in the other two on the 13th. as twenty-eight to one. Therefore, when a sixty pound dumb-bell is put up from the shoulder, the force exerted by the triceps muscle is shown thus : ]iA_^= 1680 pounds, or 630 pounds 2 more force than is required to raise 150 pounds by flexion." • Remarks on Fractures, Boston, 1840. ^ Edinburgh Medical Journal, July, 1849. 3 New England Med. Monthly, March 15, 1883. FRACTURES OF THE HUMERUS. 129 It very often happens that fractures of the shaft of tlie hunieriis aiv united with scarcely any perceptihle deformity; and in the Museum of St. liar- tholomew's Hospital^ there is a "section of a humerus, in which a fracture of the shaft at the attachment of the deltoid muscle has heen exactly united, so that hoth the walls and the cancellous tissue are uninterruptedly contiiui- ous ; and except by a slight deviation of its axis, and a small external deposit of new bone, the situation of the fracture could hardly be discerned." Some- times, however, the deformity is very great, when the fragments are allowed to overlap one another; yet even in these cases the usefuhiess of the limb is not necessarily impaired. The vessels and nerves, as a general rule, escape injury, except in cases of compound fracture. Laurent^ relates one case, connnunicated to him by Ri- chet, in which a boy ten years old had a fracture of the right humerus, one fragment of which woimded the brachial artery and gave rise to an aneurism, whtcb was cured by ligation of the vessel above and below. Malgaigne quotes two cases in which suppuration ensued ; but this is vory rare. In- stances of the almost complete absorption of this bone after fracture have been referred to in the general part of this article.^ Occasionally cases are'met with in which, in the course of union of fractures of the humerus, nerves are entangled in the callus or pressed upon by it, with the result of causing pain or paralysis, or both, of the limb. Generally it is the musculo-spiral nerve which is thus interfered with. Trelat^ reports, that a young man, in consequence of a fracture of the left arm, had an exuberant callus which, by inclusion, caused paralysis of the parts supplied by the above- mentioned nerve. An operation was performed, the nerve being disengaged, and the projecting part of the callus being resected. Two months afterward movements began to be possible, and the functions of the limb were gradually restored. Tillaux is said to have referred to a similar case seen by him. G-ross^ speaks of having seen two cases of wrist-drop from pressure of callus upon the musculo-spiral nerve, in cases of fracture of the humerus ; he says that the only remedy is the removal of the callus, but does not state whether by operation or by local medication ; nor does he give the results in the two cases whicli he cites. Agnew^ mentions such a condition, in a boy aged ten years, and says : "As the absorption of the redundant callus took place, and under the stimulus of an electro-galvanic current, his improvement was quite noticeable." The treatment of fractures of the shaft of the humerus is simple enough in principle, but much difference of opinion has existed as to its details. Re- duction can generally be effected without great difficulty, and the line of breakage is not often so oblique as to prevent the fragments from being kept in good position. Yet, as has been already stated, no other bone has offered so many examples of non-union. My own belief is that the true explanation of this fact is to be found in the leverage upon the lower fragment, exerted by the forearm and hand, which can only be counteracted by care in securing the whole arm — the upper fragment as well as the lower, ^^o matter how exactly an apparatus is applied, if it does not extend upward sufficiently to get a purchase upon the portion of bone above the seat of fracture, there is danger of deformity, if not of failure of union. But if the fragments are controlled, the forearm may be simply supported in a sling across the front of the chest. I am inclined to urge this, from having more than once or twice • Catalogue, vol. i. p. 139. 2 Des Anevrysmes corapliquant les Fractures, p. 42. Paris, 1875. a See page 45. * Gazette Medicale de Paris, 23 T>6c. 1882. » Op. cit., vol. i. p. 976. ^ Op. cit., vol. i. p, 887. VOL. IV. — 9 130 INJURIES OF BONES. seen cases in which angular splints had been carefully bandaged on, but not far enough up the arm ; the effect being simply to convert the whole limb below the fracture into a powerful bent lever, by which the lower fragment was moved upon the upper, and the amount of callus augmented, with the chance of deformity, more or less permanent, as well as of entanglement of nerve- fibres, or of interference with the bloodvessels. By the older surgeons, the use of an immediate bandage — a roller applied next to the skin — was considered indispensable for the prevention of muscu- lar spasm. Such a bandage, although less objectionable here than in the case of the forearm or leg, can do no good, and may do harm by hindering the surgeon from accurately judging of the position of the fragments. It is, however, sometimes well to apply a roller to the hand snd forearm, and per- haps to include the lower part of the arm itself, in order in some deo-ree to prevent swelling of the distal part of the limb. But the bandage Should never be carried up as far as the fracture, and the condition of the fino;ers should be watched, lest trouble arise from the pressure. There are no landmarks by which, in the living subject, the proper line of the humerus can be clearly determined. Perhaps as good a test as any is, that the posterior surface of the upper arm being even and vertical, and the thumb held upward, the whole anterior surface of the forearm is in apposi- tion with the side of the chest. Rotary as well as angular displacement is guarded against by observing this position in cases of fracture. At the back of the arm, the firm and even mass of the triceps muscle, and in front that of the biceps and brachialis anticus, afibrd an opportunity for making very accurate and eftective pressure on these surfaces of the bone. On the inner side, except in very muscular subjects, the projection of the epicondyle is such as to leave quite a marked hollow above it, but on the outer side the hollow, which is much less, is filled up by the deltoid above and by the outer borders of the triceps and brachialis below\ Stromeyer's cushion,* a sort of double wedge-shaped pad, upon which, in- terposed between the body and the limb, the latter i^ests, is sometimes of great use as a temporary arrangement, but can hardly be relied upon as a permanent dressing. By some surgeons, it has been thought sufficient to confine the arm to the side by means of bandages, with an axillary pad in the form of a long, fiat wedge. In very quiet and submissive patients this may answer ; but it is safer to apply also four strips of wood, lightly padded, one on each aspect of the arm, confined either by adhesive strips or by a roller, and then to fasten the whole limb to the chest. My own preference is for a right-angled splint of wood, extending from the axilla to the ends of the fingers, along the inner side of the limb ; the angle corresponding to the elbow, and the arm-part, well padded, so as to allow for the projection of the inner condyle. In the case of a very lean adult, it is better to cut a hole with bevelled edges, large enough to permit the condyle to sink into it and thus escape pressure. Short slips of wood, binder's board or sole-leather, properly padded, are fitted to the anterior, posterior, and outer faces of the arm ; the edges and corners of these small splints should be care- fully bevelled. Adhesive strips an inch or more in width may be first put on near the ends of the splints, and then an ordinary roller ; by this means the occasional removal of the latter for the purpose of examining the limb may be rendered safer. The limb, thus bound up, should be suspended in a sling passing under the wrist ; and in children or restless adults, a few turns of a wide roller may be applied to confine the elbow to the side. When the frac- 1 See Fig. 275, Vol. II. p. 160. ' FRACTURES OF THE HUMERUS. 131 ture is above the middle of the shaft, the outer short splint may be extended upward into a shoulder-cap such as has already been described, and the roller continued upward, and made to form what is known as the "spica" of the shoulder, a few turns being carried around the upper part of the chest. Bandages imbued with plaster of Paris, or other solidifying material, have been used by some surgeons in fractures of the shaft of the humerus, but they aftbrd no special advantage, unless, perhaps, in the rare instances where a patient must undergo transportation, or, in the later stages of the treatment, if the dressings cannot be often examined. If applied during the earlier period they need to be carefully watched, lest the swelling of the soft parts should subside, and the requisite control of the limb be thus lost. Let me again repeat, that the importance of so arranging the dressings as to secure the upper fragment can scarcely be overrated. The inside splint should extend well up into the axilla, onl}^ guarding against pressure upon vessels and nerves ; and the outer one should bear upon the bone in its whole length. Sometimes additional security may be given by placing on the exposed surface of each of the splints a strip of adhesive plaster, doubled, so as to present its sticky side outward to the roller, as well as inward to the splint. Sometimes it happens that extension is desirable to prevent overlapping of the fragments of the humerus. According to Swinburne,^ this is the only thing needful in the treatment of these injuries; and he recommends the em- ployment of an apparatus which certainly has the merit of simplicity. This consists in a board-splint, applied either on the outer, inner, or posterior surface of the arm, and attached to it below by loops of adhesive plaster for extension. Counter-extension is made from the axilla. Ingenious splints on the same principle, but provided with ratchets for lengthening them, have been devised and used by Lonsdale,^ Vedder,^ and others. The objection to all of these lies in the fact that the axilla is made the resisting point for the counter-extension, and that it is wholly unreliable for this purpose. Harlan* obtained great advantage by applying the counter-extending ad- hesive strips obliquely over the chest and back. He used in one case a wooden splint for the outer side of the arm, with a bracket screwed into its upper end for the attachment of the counter-extending band ; and in the other, an iron bar of suitable length, bent ati>oth ends. Dr. H. A. Martin^ has employed an apparatus in wdiich, while the counter- extension is obtained by strips applied to the front and back of t]ie thorax, the splint itself consists essentially of a double iron bar, the two portions of which are movable upon one another by means of a ratcliet aAd pinion, worked by a key. 1 have myself attained the same object by employing a wooden splint applied to the outer side of the arm, but extending several inches beyond it upward and downward, the counter-extending adhesive strips being simply wound around the arm above the seat of fracture, while the extension was made in like manner from below. * Treatment of Fractures of the Long Bones by Simple Extension. Albany, 1861. 2 Op. cit., p. 174. ' Vedder's splint may be found described and figvired in the Medical and Surgical History of the War of the Rebellion, Part II., Surgical Vol., pp. 812 and 822. There is also here mentioned an ingenious expedient, suggested by Dr. Foster Swift, which consists in fastening together two forked branches so as to get a fork above and another below, to which the extending and counter -extending bands may be attached. Under some circumstances this idea might be car- ried out with very great advantage. * Med. and Surg. History of the War of the Rebellion, Part II., Surg. Vol., pp. 509, 562. 6 Ibid., p. 822. 132 INJURIES OF BONES. Hamilton mentions that a plan, first suggested and tried by Clark of St. Louis, has been found satisfactory, viz., the attachment of a weight to the lower part of the arm by means of adhesive strips. Without questioning the statements in favor of this method, I must say that ic seems to me to present certain practical difiaculties in its carrying out, which are not easily met. The humerus must, of course, either be kept vertical, or the weight must pull it out of shape, and when the patient lies down the weight must be sus- pended over a pulley ; but a slight change of posture would interfere with its action, or cause it to make traction out of the proper line. A very complicated contrivance has recently been described^ by Dr. Hubbell, of Colorado, having a crutch-head for the axilla, a screw for extension, a splint for the forearm, and a hand-rest ; short splints are added if the fracture is not compound. It serves as an instance of the revival of old ideas in a slightly modified shape. Dr. Hamilton has suggested a method of dressing these fractures, with a view of preventing or curing non-union, which is certainly original, and which can hardly be passed over, although I cannot say that it commends itself to my judgment. After referring to the peculiar tilting motion apt to be impressed upon the lower fragment, he proposes straightening the elbow, and applying a firm, straight splint from the top of the shoulder to the hand, making it fast with rollers. 'Not only would such a posture be aw^kward and inconve- nient, but the tendency would, I think, be to tilt the i.pper end of the lower fragment forward, and thus to give rise to deformity. In fractures near the lower part of the shaft of the humerus, the portion where the bone begins to widen out, there is apt to be a displacement of very marked character from muscular action. The flexors, 2Dronators, and exten- sors all tend to pull the lower fragment forw^ard, and, as it yields, its upper end must, of course, tilt in this direction ; the triceps draws the olecranon upward, and anteriorly the biceps and brachialis anticus do the same. Hence the combined effect of all these forces is to tilt the lower fragment at an angle with the upper, as in Fig. 828. If union takes place under such circum- stances, it must be clear that when flexion of the forearm upon the arm is Fig. 828. Fig. 829. Diagram illustrating tilting of lower fragment in Splint of binder's board for fracture of lower part fracture of humerus near elbow. of humerus. attempted, it will be checked as soon as the coronoid process of the ulna comes in contact with the lesser sigmoid cavity of the humerus, and that in the changed position of the lower fragment the power of full flexion of the elbow must be lost. In order to obviate the tendency to this condition of » Therapeutic Gazette (Detroit), May, 1883. FRACTURES OF THE HUMERUS. 133 things, I long ago devised the splint shown in Fig. 829, which is intended to be cut out of the exact size required (ascertained by taking an outline of the sound linih). The material I generally use is binder's board, but sole-leather or patent felt w^ould answer the same purpose, except in the (,'ase of unusuall}'' large limbs. The part marked a is bent so as to come in front of the arm; b is bent up behind the elbow, while c, c, are bent so as to give the forearm support and steadiness on the ulnar side. Properly proportioned and care- fully applied, I think that this splint gives me more perfect control of a broken humerus, especially at the lower part of the bone, than I have succeeded in getting by any other. As consolidation progresses, it is my practice to cut awav more and more of the splint at each dressing, so that the patient gains the use of the hand before the arm can be left to itself. Another plan which w^ould seem to promise well, in fractures of the lower part of the humerus, is to place the elbow at an acute angle, and keep it so for perhaps two weeks, when union may be supposed to have begun, and when the forearm may at each dressing be very slightly brought down, until at last the bones are found firm enough for complete passive motion to be attempted. By this method, entire relaxation of the flexors and pronators v^ould be attained, and forward angular displacement could scarcely occur. Should it be found that the lower fragment projected backward, the angle of the elbow^ might readily be made more obtuse, and a short splint be applied along the posterior surface of the arm. The subject of pseudarthrosis has already been discussed at such length in the general part of this article, that the treatment of such cases in this region need not be again spoken of here. Fractures of the lower end of the humerus, as has been already stated, and as may be seen from Gurlt's table quoted' on page 118, are much more frequently met with than those of either the shaft or the upper end. In children this predominance is especially marked, since up to the tenth year the lower portion of the bone is broken considerably more than twice as often as both the other divisions put together. Between the tenth and the t\ventieth year the numbers become, in the set of cases upon which this table is based, exactly equal. Later in life there is a very great diminution in the liability of the lower part of the bone to fracture ; but the fact must not be lost sight of that the shaft also shares in this decrease, so that the difierence of propor- tion is not as great in reality as it would at first sight appear to be. The boundary between the shaft of the humerus and what we call the lower end is not exactly defined ; even less so, perhaps, than that between the neck and the shaft. It is a surgical and not an anatomical division ; and a doubt may sometimes arise in regard to certain fractures, as to whether they should more properly be classed among those of the shaft, or with those of the lower end. But in general the cases which belong to the latter category present features which render them plainly distinguishable. One of these is the eftect of muscular action, and another is due to the neighborhood of the elbow-joint ; they will be further referred to directly. Under the present head are included a variety of fractures, the j^rincipal lines of which are shown in the annexed diagrams (Figs. 830 and 831). Thus, there are cases in which the bone is separated more or less transversely, just above the condyles, the line of division sometimes running up along the outer or inner side of the bone so as to involve in the lower fragment nearly or quite a third of its length. Often, along wath this, one or more lines of breakage pass downward into the joint. Occasionally the outer portion of the lower end only is involved, the condyle only, or with it the epicondyle, being broken ofi'. Or the inner part of the lower end may be separated — the 134 INJURIES OF BONES. trochlea, with or without the epitrochlea, or the latter process by itself. Finally, there are disjunctions of the lower epiphysis, or of its articular portion only. It may, perhaps, be as well to say here that although these various forms of fracture can be thus enumerated theoretically, they are not in practice by Fig. 830. Fig. 831. Diagram showing transverse fracture of lower Diagram of T-fracture of lower end of humerus, end of humerus. The curved line shows com- with lines of fracture of internal condyle or trochlea, plete epiphyseal disjunction. of epitrochlea, and of external condyle. any means so easily distinguished. The lines of separation may run very irregularly ; occasionally the combination of two or more fractures, or the existence of luxation along with fracture, may present a condition of things in the highest degree perplexing. But this matter will be more appropriately discussed in connection with the diagnosis of these injuries. Fractures of the eirtcondyle may, I think, be dismissed without further mention, since there is no case on record in which such a lesion has been verified beyond a doubt. It is true that ZuckerkandP claims to have seen one, and that Gurlt figures a specimen. Sir Astley Cooper^ also represents one, in which, however, the bone was " somewhat thickened," and the original lesion may have been more extensive. Fresh doubt is thrown upon these specimens by the statement of McBurney3 that " he had found in the dissecting-room similar isolated pieces of bone resembling detached epicondyles, and existing symmetrically at both elbows." Fractures detaching the epicondyle along with the condyle are, however, known to have occurred in numerous instances. A careful study of the anatomy of the lower end of the humerus, and of the muscles attached to it as well as to the adjoining bones, is essential to the understanding of fractures in this region. Especial attention should be paid to the shape and extent of the epiphysis, in view of the fact that so many of the subjects of these injuries are at an age when it has not yet become con- solidated with the shaft, and therefore when the question of its disjunction is apt to arise. The fiattening of the bone antero-posteriorly as it widens out toward the condyles, and its consequent thinning, have already been mentioned, as well as the muscles by which the position, bent or extended, of the elbow- joint is controlled. The epiphysis consists of four parts, developed, according to Gray, in the following nianner: "At the end of the second year, ossification commences in the radial portion of the articular surface, and from this point extends inwards, so as to form the chief part of the articular end of the bone, the gentre for the inner part of the articular surface not appearing until about the age of twelve. Ossification commences in the internal condyle about the ' London Med. Record, May 15, 1878, from Allg. Wie^ier med. Zeitung, Feb ]878. 2 Dislocations and Fractures of Joints, p. 467. ' Stimson, Practical Treatise on Fractures, p. 395. FRACTURES OF THE HUMERUS. 135 fifth year, and in the external one not until between the tliirteenth and four- teenth year^?. About the sixteenth or seventeenth year, the outer condyle and both portions of the articulating surface, having ah-eady joined, unite with the shaft; at eighteen years, the inner condyle becomes joined." (The reader will note that ni this description the term internal condyle" is equivalent to "epitrochlea," and the term "external condyle" to "epicondyle.") The im- portance of these facts consists in their bearing, not as much upon the separa- tion of the epiphysis as a whole, as upon disjunctions of portions of it, which I have no doubt are more frequent than they are generally sup[)ose(l to be. Another matter of great moment in this connection is the anatomy of the elbow-joint. The trochlea, upon which the ulna moves as upon a hinge, drops at its inner margin considerably below the level of any other })art of the joint, and thus locks in the articulating extremity of the latter bone. Hence, lever- age through the ulna is often brought to bear most pov»'erfully upon the lower endof the humerus, tending to twist it off; and if the ei)iphysis is yet ununited to the shaft b}' bone, its disjunction may ensue, while if it has already become consolidated, a fracture may be produced above. The radius, although it shares in the flexion and extension of the forearm, rotates freely upon an axis passing through the centre of its head, and hence is far less likely either to be itself broken, or to be the means of breaking the corresponding portion of the humerus. As has been already stated, fractures occurring near the lower end of the humerus very often run into the joint ; but even when this is not the case, the near neighborhood of the joint constitutes a complication of all these injuries, as ifs extensive synovial membrane inflames with extreme readiness, and the swelling from eflusion into its cavity not only greatly increases the difliculty of recognizing the exact nature of the lesion, but also embarrasses its treatment. In front of the joint, the median and the musculo-spiral or radial nerve, and behind it the ulnar, are in very close relation with the bone ; so that either by actual pressure upon these nerves by the fragments, or by their injury or displacement, special symptoms, of no small importance, are not utifrequently induced. The causes of fracture of the lower part of the humerus are very generally falls on the hand or on the elbow ; they are in the former case due to indirect violence, m the latter to direct. Often, however, it is impossible, to arrive at any certainty as to the way in which the hurt has been received, from the youth of the subject, or from the confusion and terror induced by the accident. It is highly probable that the tension of the muscles, in the eftbrt to avoid fall- ing, may have something to do with the production of the fracture, or at least with determining its seat and direction. As a general rule, even if in the act of falling the forearm is fully extended upon the arm, it becomes flexed to some degree when the hand strikes the ground ; the ulna is forced against the humerus, and held there by the muscles before mentioned, so that there is a combination of leverage and muscular action, to which it is not surprising that the bone should yield. Still another condition favoring fracture is the irregular way in which the force is suddenly brought to bear, so that the stress comes, not in the axis of the humerus, but at an angle to it, as a " cross- breaking strain." The symptoms in these cases, to be appreciated, must be observed at a very early stage, as otherwise the swelling which rapidly comes on, especially if the elbow-joint be directl}^ involved, makes everything obscure, except the fact of fracture. By the direction of the fracturing force, as well as by the muscular action already repeatedly mentioned, the upper fragment generally presents itself, in fractures just above the condyles (to use Malgaigne's term) 136 INJURIES OF BONES. in front of the lower. Occasionally, but very rarely, the lower fragment is found in front of the upper ; this is probably due to the direction of the frac- turing force, driving the wluole elbow forward. Malgaigne has figured a case of this kind. And in any case, unless the injury has been the result of great direct violence, there is a tendency to the tilting forward of the lower fragment, and thus to the formation of an angle, salient forward. Thus the antero-posterior diameter of the arm just above the elbow^ is increased in a marked degree. Along with this change in the bone there must be more or less shortening of the arm, although this is seldom sufficient to attract notice. I think, however, that I have observed one sign of this, in the wrinkling of the skin at the back of the arm, just above the olecranon ; but this disappears, or at least becomes less distinct, as swelling takes place. Pain is nearly always present, and may be very severe ; it is aggravated by the least motion of the elbow, so that the patient generally supports the arm and hand very carefully with the sound hand. There is, of course, total loss of power, involving the whole limb. In many of these cases the abnormal mobility is clearh' perceptible, and it can almost always be detected upon careful examination. Sometimes, indeed, it is so free ^is to be in itself puzzling, as in cases where from a transverse fracture there are two or more subordinate lines of breakage running down- ward into the elbow-joint. Here the sensation imparted to the touch, when the forearm is rotated on the arm, is that of a loose rattling ; and, especially if swelling has already begun, it is difficult to get a starting point from which to measure the relations of the fragments. When, however, there is any lateral mobility of the elbow, the fact of frac- ture may be regarded as established. In the complexity of the movements performed by the hand, we are apt to lose sight of the simplicity of the parts of the system upon which they depend. At the elbow, in the normal state, there is absolutely no motion except the hinge-like Hexion and "extension of the ulna upon the humerus, and the rotation of the radius upon an axis pass- ing through the centre of its head, and thence downward through the ulnar border of its carpal articulating surface. When the forearm is semi-fiexed on the arm, and the hand moved outward and inward, it seems as if there must be a lateral movement at the elbow, but this appearance will be found to be wholly due to rotation of the humerus around its long axis ; the real motion is altogether confined to the shoulder. If the hand can be thus moved when the arm is grasped and held still, it is proof positive of the existence of frac- ture. Luxation does not free the elbow in any way. When the upper extremity hangs by the side, with the elbow extended and the hand in supination, it will be seen at once that the eJbow forms a very obtuse angle, salient inward, and that the hand hangs out from the side. Now, if without any rotation of the humerus at all, the forearm be fully flexed, it will be found that the hand comes up at the outer side of the shoulder, and that not even by the utmost pronation, with flexion of the wrist, can the end of the middle finger be brought opposite to the mouth. These facts are all accounted for by the outward slant of the trochlear por- tion of the lower articular end of the humerus, and are of great importance in the recognition, and especially in the treatment, of fractures in this region. I have already referred to the muscles by which deformity is produced or kept up in fractures of the lower half of the humerus, and need hardly urge that the shorter the lever upon which they act, or, in other words, the lower the seat of fracture, the more direct and decided will be their influence. But it must be remembered that the line of separation of the bone is very seldom directly transverse ; even wdien it runs almost directly across in front, as I have seen in a few specimens, there is apt to be irregularity somewhere in FRACTURES OF THE HUMERUS. 137 the thickness of the bone, and this gives rise to a lateral tilting, by a me- chanism too obvious to need more than mention. Hamilton^ has detailed a ninnl)er of instances in which the ultimate effect of this displacement was clearly shown ; and it has occurred to me to see it repeatedly. When union takes place without the correction of this angle forward, the articulating surface of the humerus is directed downward and backward, and the result is that flexion of the forearm is limited, while its extension may be abnormally increased. The reason why extension is not always thus increased, is sometimes the tension of the anterior muscles, the biceps and brachialis anticus, and sometimes the irregularity of the fracture at the posterior part of the bone, just above the joint. Another efl:ect of the abnormal mobility in question, which has been already hinted at, is the bringing up of the transverse line of the elbows-joint to a horizontal direction instead of the obliquity natural to it. This change is often favored by the treatment resorted to — as w^as long ago pointed out by Dorsey,^ and more recently by Allis^ — the result being to do away with the obtuse angle, salient inward, wdiich the limb should present at the elbow, and to substitute for it a bending in the opposite direction. Such a condition, when existing in a marked degree, produces a very noticeable awkwardness at all times, and interferes with the strength and usefulness of the member in lifting and carrying, as well as in some other of its functions. Solar, I have been speaking only of fractures traversing the humerus just above its lower articulating extremity, whether accompanied or not by fis- sures running downi into the joint. With regard to separations of the outer or inner angles of this extremity, of the epicondyle or epitrochlea, or of the epiphysis, it is impossible to lay down any distinct and definite statements, partly because of the small number of recorded cases, and partly because of the obscurity of the conditions attending these lesions. As regards the epitrochlea^ there can be no doubt of its occasional separa- tion from the rest of the bone, the elbow-joint remaining intact. First described by Granger,^ this lesion has been recognized by Sir A. Cooper, Malgaigne, Grurlt, and others. But, as Gurlt remarks, the line cannot be sharply drawn between cases of this kind and those in which the fracture involves also the trochlea, wholly or in part. Cooper^ represents a specimen of the latter form of injury ; he does not refer to any other, and the only case he records is that of a girl " who, by a fall upon her elbow, had fractured the olecranon, and also broken the internal condyle of the os humeri, the point of the broken bone having almost penetrated the skin." Hamilton® gives an account of eleven cases, examined by him at various periods after the occurrence of the injuries. In one only does he state positively that the fracture did not pass into the joint. Six of these cases of Hamilton's have a special interest in reference to the permanent displacement of the fragment. 1. Case 45. Examined seven years after the accident. " The apopliysis is carried backward about two lines, and upward toward the shoulder about three lines." 2. Case 49. Examined after sixteen years. " The internal condyle was displaced forward. " 3. Case 51. Examined after three months. "I find a fragment — the apophysis of the internal condyle — broken off, and removed downward toward the wrist one inch and a quarter, where it is immovably fixed." 1 Report on Deformities after Fractures. Trans, of Amer. Med. Association, vol. ix. 1856, p. 106. 2 Elements of Surgery, vol. i. p. 145 ; also Plate V. * Annals of the Brooklyn Anatomical and Surgical Society, August, 1880. * Edinburgh Med. and Surg. Journal, April, 1818. ^ Op. cit., p. 466. ^ Report, etc., before quoted, pp. 110 et seq. 138 INJURIES OF BONES. 4. Case 52. Examined after five weeks. " The inner condyle is displaced upward three-quarters of an inch. The olecranon process has followed this fragment. Large amount of callus in front at seat of fracture. The elbow is nearly anchylosed at an obtuse angle." 5. Case 53. Examined after six years. " The internal condyle is displaced down- ward toward the wrist half an inch." Extension, flexion, pronation, and supination are stated to have been all impaired in this case. 6. Case 55. Examined after five years. " The inner condyle displaced downward and forward half an inch." The reader will perceive from the above quotations, I think, more distinctly than from a mere general statement, the influence of the muscles in produc- ing and keeping up displacement of the fragment, when the epitrochlea, with or without part of the joint surface, is broken off. It will be noted that the separated portion had been moved in various directions — backward and upward, forward, downward (in two instances), upward, and downward and forward. When the fragment is drawn upward along the arm, it seems to me that it must be by portions of the triceps and brachialis anticus, the fibres below the fragment being probably torn across. Other displacements may be due to traction by the-^ pronator radii teres, or by the superficial flexors. Very possibly the action is a gradual one, the separated portion of bone being drawn into its new position during the period preceding the organization of the callus. Certainly, in some cases there is at first distinct crepitus, showing that no such gap exists between the fractured surfaces as is brought about afterwards. When a fracture runs obliquely into the elbow-joint, separating the outer or inner portion of the articulating surface of the humerus, it is not diflScult to see how in the former case the radius, and in the latter the ulna, loses its support, and, under the influence merely of the muscles, pushes the fragment before it. Sometimes the fracturing force itself may cause the displacement, and in that case the muscular action would surely tend to keep up the de- rangement of the parts. An obvious result of either disturbance of relation must be to twist the forearm into an abnormal direction, and, by changing the position of the points of origin of muscles, to interfere with some actions, while others are made more free, although less powerful. Pick^ has recorded a curious case of fracture of the external condyle^ the fragment having been carried up and attached to the outer side of the bone. Hunter ^ met with a case in which the external condyle was broken oft', the radius and ulna being at the same time luxated outward. The fragment " had apparently becoixie wedged in between the bones forming the elbow-joint," and reduction was impossible. Strength was regained in the joint, but not much motion. In 1856, I saw a washerwoman in whom a fracture of the inner condyle had resulted from muscular eftbrt in lifting a heavy tub. The accident had occurred some two months previously ; there was much eftusion into the cavity of the joint, and the head of the radius was widely separated from the ulna, but some use of the arm remained. The nature of the lesion was quite clear, and the patient's account of the matter plain and straightforward. I do not know any further history of the case. Disjunction of the lower epiphysis of the humerus is an accident which can of course happen only in childhood or youth. It is probable that here, as else- where, the line of separation may not always be exactly confined to the carti- lage, but that a portion of the bone may be torn oft". On the other hand, I think the fracture may concern a portion only of the epiphysis, and thus be entirely within the joint. The cases of this kind which have come under 1 Trans, of London Pathological Society, 1870. 2 Philadelphia Med. Times, April 1, 1871. FRACTURES OF THE HUMERUS. 139 my notice have been in children, and the mechanism of their production was not known. On passive motion of the elbow, distinct crepitus was elicited, and no other sign of fracture existed except loss of power in the limb, and pain, aggravated by handling; there was no i)erceptible deformity. The limb was in each case kept at perfect rest by means of an angular splint, and in the two cases of which I have kept notes, complete recovery ensued in about six weeks. When the epiphysis is separated as a whole, the epitrochlea and epicondyle are of course included in the lower fragment, and the line of division curves downward above each of them, to run almost transversely above the edge of the articular surface. In the cases of this kind which I have seen, the lower fragment has always been carried backward, the radius and ulna following it, and the lower end of the up})er fragment projecting somewhat strongly in front of the elbow. I think that the anterior edge of this fragment corre- sponds pretty nearly with the fold of skin at this point. All motion of the part is painful, and there is especial difficulty in flexion ; crepitus is easily detected. Tlie antero-posterior diameter of the joint is increased, and swell- ing comes on with great rapidity, augmenting the deformity and in great measure obscuring the condition of the parts. ' The course and ultimate result of fractures of the lower part of the humerus is apt to be very unsatisfactory. Inf.amrnation of the elboiv-Joint is commonly set up, and although it may be actively combated, and may not run high, a certain amount of stiffening is almost always induced ; this, as a general rule, is in time overcome, but there is often left a tendency to occasional attacks of pain and tenderness. A curious point may here be noted, namely, that in some cases the stiffen- ing of the elbow may be limited to the uhiar portion of the joint. Thus Lallemand ^ had a patient aged thirty-two years, who, in consequence of a crush of the elbow, opening the joint extensively, had the humero-cubital articulation anchylosed, but the radius was still capable of motion on the ulna, and with some supplemental aid from the shoulder-joint all the motions of pronation and supination were accomplished. In one of Hamilton's cases,^ a fracture of the inner condyle, he found that " the arm was nearly anchy- losed in a rectangular position ; pronation and supi- nation were perfect." The inflammation of the elbow occasionally leads to more serious results. In one case recorded by Wright,^ a strumous boy, aged twelve, had a frac- ture detaching the capitellum of the humerus, which gave rise to pulpy degeneration, for which excision of the elbow was performed. Perhaps it may be regarded as strange that the vessels so seldom suffer in these fractures, but in fact they are not only separated from the bone by a thick layer of soft parts, but are by their flexure in a position to yield readily, and thus to escape tearing. When the fracture is a compound one, however, the course of things may be different. Fig. 832 represents a fracture of the humerus in a boy, aged about twelve, who fell from a low fence; the upper fragment was forced out through a 1 Am. Journal of the Med. Sciences, Jan. 1841 ; from Lancette Fran9aise, Mai, 1840. 2 Report, etc., p. Ill ; Case 48. ' Guy's Hospital Reports, 3d ser., vol. xxiv., 1879. Fracture of lower end of humerus. 140 INJURIES OF BONES. wound in front of the arm, and the artery was torn completely across, render- ing amputation necessary. Sometimes, but more rarely than might perhaps be supposed, the circulation is interfered with by ill-applied apparatus, as in a case recorded by Wright,^ m which by the pressure of an anterior angular splint, in a case of separation of the lower epiphysis of the humerus, the artery was occluded for twenty- two days ; no permanent harm, however, resulted. Occasionally, serious damage is done to nerves in connection with the fractures in question. The close relation of the ulnar nerve to the bone would seem to involve it in constant danger ; yet the usual character of the displacement, the lower end of the upper fragment going forward, is ob- viously such as to diminish the risk. Callender^ gives a number of cases in which this or the median nerve suffered, and suggests that they may l)ecome adherent, and be stretched by sudden movements. Lange^ has re- corded the case of a girl, aged eight, who, after a supra-condyloid frac- ture of the humerus, had pain at the seat of injury, the wrist and fingers being flexed, with a very limited degree of motion. A sharp edge of bone could be felt. Electricity, massage, and systematic movements were tried for six weeks, at first with some apparent success. An operation was per- formed, and the median nerve found flattened against the edge of bone ; above this point it was thickened and swollen. The nerve was loosened, and the edge of bone excised, with decided relief to the symptoms. " There was one interesting point, namely, that since the operation an entirely diflerent and more normal form of nail was growing, and there were ridges on all of the nails alike, marking the parts before the operation from those afterward. The color and temperature of the skin had also markedly improved." Another danger in these cases is from the abnormal or excessive development of callus^ which however happens more rarely here than in some other regions. In the Museum of the [N'ew York Hospital^ is a specimen of T -fracture at' the lower end of the humerus, in which the ulna and radius are anchylosed to each other and to the external condyle by bone effused between their con- tiguous surfaces. A case is recorded^ in which Mr. Croly excised the elbow- joint of a man about thirty years of age, who had about fifteen months pre- viously sustained a fracture of the joint. A large amount of callus prevented flexion of the joint or use of the fingers. The olecranon, the head of the radius, and the end of the humerus were removed ; the coronoid process was left in order to keep the brachialis anticus muscle intact. The ultimate result is not stated. Malgaigne refers to a case, seen by Monteggia, in which tetanus ensued upon a simple fracture near the lower end of the humerus, and proved fatal, although amputation was performed. As to the diagnosis of these fractures, it presents in some cases little or no difiaculty, while in others it is more or less obscure, and occasionally ex- tremely so. Much depends upon the time which has elapsed between the receipt of the injury and the examination, since often a very few hours suffice for the occurrence of such swelling as to completely mask the parts. Under such circumstances the patient should be placed under the influence of an anaesthetic, and the utmost care used in determining whether or not there is luxation of the bones of the forearm — a point which can generally be de- cided, if in no other way, by the degree to which passive motion can be made. This is a matter of the utmost importance, as the reduction can be ' Ibid. 2 St. Bartholomew's Hospital Reports, 1870. » New York Medical Journal, April 28, 1883. 4 Catalogue, p. 68. 5 Lancet, Feb. 17, 1883. FRACTURES OF THE HUMERUS. 141 tar more easily effected at once than at any later period ; but its discussion belongs more appropriately elsewhere. As a general rule, fractures in this region resemble luxations in the abnor- mal projection backward of the olecranon ; in fact, the two lesions are often undistinguishable from one another by the mere api)earance of the parts. (In both, the elbow is sligbtly Hexed; although some authors have represented it as iixed, or nearly so, at a right angle, when luxated. The former has been the position in the eight cases of children and boys which have come under my own observation, and this experience is confirmed by that of Mal- gaigne* and Hamilton. In adults I have seen the elbow quite rigid, and semi-Hexed ; but the other condition obtains sometimes in them also.) But in case of fracture, if the surgeon places his thumbs in front of the projection of the humerus, he can with his hngers press the olecranon forward into its normal place, and keep it so until he relaxes its hold. Dislocations, I need hardly say, are often very difficult to reduce, and are very unapt to recur. Dislocation having been set aside, the surgeon's attention should be directed to the allaying of the inflammation by the usual means, the limb being kept in the most comfortable posture ; and as soon as possible the attempt to esta- blish an accurate diagnosis should be renewed. Either before the occurrence of inflammatory swelling, or after it has sub- sided, the eye may detect certain abnormities in the shape of the limb. One of the most important of these is the increase of its antero-posterior diameter either at or just above the elbow. Another is the change in the relative directions of the axes of the arm and forearm. Still another is a widening of the arm transversely at the elbow. But when either or all of these signs are present, they need to be interpreted by means of further investigation. If, upon applying the fingers to the bend of the elbow, or perhaps a little above it, the more or less sharp and ragged edge of the upper fragment is felt, the fact of fracture is established ; in case of luxation, the rovmded articular surface of the lower end of the bone w^ould pi'esent itself. The processes commonly known as the condyles, but more correctly as the epi- condyle and epitrochlea, should now be found — as they often can be even where the parts are swollen — and pressure made through them across the bone. If pain be thus caused, a fracture running into the joint may be sus- pected ; if crepitus, it may be regarded as certain. Unless sw^elling have occurred, it may be possible to grasp the epicondyle or the epitrochlea be- tween the thumb and finger, and determine its mobility or fixedness upon the rest of the bone. The attempt may be made also to sway the forearm from side to side, which ought not to be possible. In so doing, crepitus may be elicited. Upon making passive motion, flexing and extending the elbow, and pro- nating and supinating the hand, it will be found, if there be fracture, that in one or -more of these movements there is crepitation. If this occur in flexion only, or in flexion and extension, it may be that the humerus is simply broken across; but if every- motion develop it, the probability is that the joint itself is involved. Measurement may now be made of the breadth of the joint, from the epi- condyle to the epitrochlea, and it may be compared with that of the sound limb. The best means of doing this is of course a pair of callipers ; but as these are not likely to be at hand, resort may be had to other methods, the simplest being to apply the back of the elbow to a plane surface, on which a sheet of paper has been placed, and then to put a book on either side of it, standing edgewise on the paper. The distance betw^een the lower edges of 1 Op. cit., tome ii. p. 576. 142 INJURIES OF BONES. the books being marked on the paper, the same may be done for the sound elbow, and the two measurements compared. An increase in the width may be regarded as probably due to fracture involving the joint. Wright^ gives two test-lines which may be useful in the diagnosis of inju- ries about the elbow. He says that it will be found " that a line can be drawn in- all positions of the joint, from the most prominent point of the internal condyle, through the upper border of the olecranon, obliquely down- ward and outward to the head of the radius, and that such line is bisected at a point corresponding to the superior and external angle of the olecranon." The relation of these points to the line would obviously be altererl in case of fracture of the olecranon or of the inner CQudyle. Wright says further : If also a line be drawn across the back of the joint in full extension, from the external to the internal condyle, or vice versa, that line will lie above the upper border of the olecranon, or, in other words, the angle it forms with the first test-line will be on the distal side of the inter-condyloid line. This line is most conveniently taken by extending the arm horizontally, with the humerus rotated so that the bicipital or anterior aspect looks toward the middle line of the body, and dropping a j)erpendicular through the condyles." There is one condition in wdiich the test afi:brded by these lines wx)uld fail, that, namely, of a separation of the articulating portion only of the humerus. Here the relation of the condyles (epicondyle and epitrochlea) to the olecra- non would be changed, perhaps indeed in a very slight degree, but still per- ceptibly ; yet the inference that the case was one of luxation and not of frac- ture w^ould be incorrect. Here, however, the application of the other means of diagnosis, the development of crepitus, and the fact of the ready correc- tion of the slight displacement, together wdth that of its equally ready recur- rence, should sufiice to prevent any mistake. The significance of a change in the relative direction of the axes of the arm and forearm must depend upon the other features of the deformity. H, for instance, the obtuse angle before noted as existing at the normal elbow is done away with, it may be either by a fracture across the humerus just above the joint, or by the separation of the trochlea, or b}^ luxation backward of the ulna and forward of the radius. If it is rendered more acute, there may be fracture of the outer angle of the lower end of the humerus, allowing the head of the radius to slip somewhat backward ; or, the humerus being broken very low down, there may be a slight twist of the short lower fragment upon the upper. The foregoing statement embraces the leading facts in regard to the diag^ nosis of these injuries ; but in practice there are shades of difierence in the phenomena presented, which it would be in vain to attempt to set forth. 1 do not hesitate to say that no class of cases demand more care, tact, and judgment for their detection and discrimination, than those involving the elbow. As to prognosis, the surgeon should always bear in mind the fact that the elbow-joint is apt to be at least temporarily stiftened after injuries in its neighborhood ; and that a slight displacement of the fragments, when the lower part of the humerus has been broken, may give rise to a permanent limitation of mobility. Hence he should be very guarded in his promises of complete restoration of the functions of the limb ; and it is much better to warn the patient, or the friends in the case of a child, that stiftening of greater or less duration is likely to occur. If the fracture can be clearly made out to be entirely above the joint and above the line of the epiphysis, the prospect for complete recovery is more promising than if the joint be involved ; yet ' Log. cit., 3d ser., vol. xxiv. 1879, p. 54. FRACTURES OF THE HUMERUS. 143 (iven here, unless the tilting of the lower fragment, hefore spoken of, can he ])revented, there will be some limitation of movement. Moreover, this limi- tation is permanent, and not to be diminished by any treatment ; which is not usually the case with mere stiffening of the joint. I have occasionally seen in adults, after injuries of this kind, the stiffening recur from time to time, unless guarded against by continual exercise ; and it is, of course, well to mention the possibility of such a result beforehand. The treatment of fractui-es of the lower portion of the humerus presents difficulties of a very serious nature. Su imposing the diagnosis to have been clearly made out, the object of the surgeon must of course be, in accordance with general principles, to correct any existing deformity, and to maintain the fragments in their normal relation until union shall have occurred. But plain as the indications are, the fultilling of them is by no means easy, nor, as before stated, are the results apt to satisfy either the surgeon or the patient. The difficulties referred to are four : to keep the fragments in contact and at rest ; to prevent the formation of an angle, salient anteriorly ; to maintain the oblique line of the articulation by avoiding upward pressure on the inner portion of the joint-surface of the low^ei- fragment ; and to obviate stiffening of the elbow. As to the first of these difficulties, it is due to the extreme shortness of the lower fragment, which gives very little purchase to any confining apparatus ; in the case of T-fractures, or separations of the trochlea, the tendency is to a forcing apart of the articulating surfaces, or, what is equally bad, a gaping of the fractured portions above, and, perhaps, the insertion between them of part of the upper fragment. In epiphyseal disjunctions, the correct posi- tion of the detached portion is almost wholly a matter of conjecture, and must of necessity be so, until a favorable result affords proof of it. I^'ow, if an anterior angular splint, or two lateral ones, be carefully applied to a sound arm, it will be found that a certain amount of rocking motion can be given, with the effect of loosening somewhat the upper portion of the bandage ; should the same thing be done in a case of fracture, it may readily be seen that the part of the limb below the breakage is converted into a bent lever, the short arm of which is the lower fragment ; and upon this a very slight amount of force applied to the hand will act most powerfully. Hence, scarcely any good can be expected from means of fixation of this kind, un- less bound on so tightly as to endanger interference with the vascular supply, or with the innerv^ation of the limb. ^ The force of this statement is still greater, if the fact is considered that the parts about the elbow are apt to be largely swollen at the time of the first dressing, and that a daily subsidence of the swelling must be looked for, so that the controlling power of any apparatus is continually becoming less and less, until the inflammation has gone down and its products have been absorbed. Of the second difficulty I have already spoken at some length, so that it need not be further discussed at present until the details of "treatment are tak-en up. The third difficulty is one which has been more fully appreciated of late years than formerly. Dorsey, as already said, pointed out the frequent occui^ rence of deformity from the substitution of an angle, salient outward, for the normal one, salient inward; and Allis has recently, wath much force, called attention to the same point. Yet it seems to me that the real source of the trouble is the want of recognition of the obliquity of the line of the articu- lation, and the application of dressings, no matter in what position — flexed or extended — which press straight across the front of the joint, and tlius by their posterior bearings push the trochlea upward, and force the upper INJURIES OF BONES. and inner angle of the lower fragment past the corresponding portion of the npper fragment, whether behind it or in front of it. Allis's method, putting the forearm in extension, with the normal angle maintained, and keeping the limb in this posture by means of the plaster-of-Paris or starched bandage, or other form of immovable apparatus, is a very sound one in theory, and no doubt has given good results. But I believe that the same advantage may be gained by other means, and perhaps with more comfort to the patient, if only the normal shape of the joint be borne in mind. Any one may readily satisfy himself, by inspection of a sound arm, of the obliquity of the anterior fold of the elbow ; and a glance at the skeleton of the limb will show that the line between the bones corresponds with the furrow in the skin. The means of preventing stiffening of the elbow will be spoken of here- after. Now, as to the special plans of treatment of these fractures, they may be classed as those without apparatus, those with apparatus for maintaining flexion, and those with apparatus for keeping the limb extended. The principle of treatment without apparatus is merely to suspend the limb in a sling, the elbow being flexed, and to favor a certain amount of change of angle of the joint, in order to obviate stiflening. I have heard the opinion expressed by a surgeon of large experience and high reputation, that the formation of a false-joint near the elbow was by no means a misfortune ; he had seen a number of cases of permanent disability from anchylosis of the joint, the fractures having united. But I do not believe that it is necessary to run the risk of deformity by leaving the joint uncontrolled, lest it should stiften ; nor does it seem to me that the favoring of a pseudarthrosis to take the place of such a joint as the elbow, is a good surgical procedure. The only proper aim, in dealing with the cases in question, must be to obtain union of the fracture, and to preserve the mobility of the elbow; and my conviction is, not only that these ends can in the majority of instances, by due care and attention, be accomplished, but that any other course would justly fail to receive the approval of the profession. Various plans have been proposed and adopted for treating these fractures in the flexed position. By some surgeons, a rectangular splint has been employed, extending along the whole posterior surface of the limb ; and to this Sir Astley Cooper added an anterior arm-splint to correct the angle forward. Physick's splints, also rectangular, and applied along the lateral surfaces of . the arm and forearm, had for many years a popularity in this country, due more to the name of their advocate than to the excellence of the results obtained with them. To these succeeded the anterior angular splint, somewhat hollowed to fit along the front of the arm and upper surface of the supinated forearm. Physick's splints, as used by him, and I believe by all of his followers, were made of wood: for the others, wood, tin, binders' board, gutta-percha, and felt, have been employed. My own practice has been to use binders' board, shaped as shown in Fig. 829, giving the lower edge of the part applied to the front of the arm an obliquity corresponding to that of the crease at the bend of the elbow, and bevelling it oft' so as to avoid painful pressure on th*e skin. The advantage obtained in the pressure of the upper part of the lower fragment backward, while the olecranon is pushed forward by the projection at the angle of the splint, bent around against it, has seemed to me to be very great. Another plan, which I think would answer well, although it has never to my knowledge been employed, would be to place the forearm in a state of flexion at a somewhat acute angle, keeping the hand semiprone, and directed a little outward, so as to maintain the normal angle before referred to. In this way FRACTURES OF THE HUMERUS. 145 the projection forward of the upper end of the lower fragment would be in great measure, if not altogether, obviated, since the nniscles which cause it w^ould thus be relaxed. The posture, although not as comfortable for a length of time as the rectangular, would still not be unendurable, and w^ould not need to be maintained after the process of union had begun. The method by extension, advocated by A 11 is, has already been described. It is recommended also by Ingalk.' A most important matter, in the treatment of all these cases, is the making of passive motion. This ought, in my opinion, always to be begun as early as possible; but the proper time varies with circumstances. When the line of fracture is wholly outside of the joint, and the latter does not become swollen by effusion within its cavity, I think it well at the very first dressing to grasp the lower part of the arm firmly, but gently, and to slowly and (j^uietly make flexion, extension, pronation and supination, not to extreme degrees, but freely enough to exercise the wdiole joint. Properly done, this process involves no risk of disturbing the fragments, nor is it followed by any pain, tenderness, swelling, or other evidence of inflammation. Even if the joint is involved in the breakage, I think that as soon as the inevitable inflammation has subsided, passive motion may be very gently made, and with advantage; perhaps, at first, the movements may be limited to pronation and supination, and flexion may be added subsequently, extension being postponed on account of the risk of tilting the lower fragment forw^ard. Should marked irritation ensue, it may be allayed by hot fomentations, by poulticing, or by the local use of lead-w^ater and laudanum, and no further attempt should be made for a few^ days, perhaps for a week. When stiffening of the elbow has already occurred, whether early or late in the progress of the case, it is very desirable to overcome it ; and the means to be adopted with this view must vary according to circumstances. If it is early, an attempt should be made to change the angle from day to day, or oftener. This may be done either by employing difterent splints, with slightly varying angles, sub- stituting at each dressing a fresh one, or by the use of a single splint with a hinge corresponding to the elbow, and with the two portions movable by means of Stromeyer's screw (Fig. 833). A modi- fication of this appliance has lately been proposed by Keen, consisting simply in attaching the screw by curved arms, so as to place it well over at one side, and avoid interference with the bandaging of ^'"^strom'"* ^'"^ the arm to the splint. I think advantage is some- romeyer s screw, times gained by poulticing the joint for a day or two previous to attempting to change the angle. Violence should never be used in these cases. An important point to be noted is the degree to which flexion can be made, and the character of its limitation. If the forearm is checked at an angle of say 30°, there is reason to believe that the lower fragment is tilted forward ; and this is the more likely if extension can be carried beyond its natural limit. In such a case, it becomes a question whether an attempt should be made, under anaesthesia, to correct the abnormal position of the lower fragment, or to do the same thing by gradual means — changing the posture of the limb by dressing it in a state of flexion; or it may be, especiallj^ if the previous history of the case shows the joint to be readily inflamed, that the more prudent course will be to let things remain as they are, notifying the patient or his friends that there will, probably, be a permanent limitation of movement. 1 Medical News, Jan. 7, 1882. VOL. IV. — 10 146 INJURIES OF BONES. As extension is made, the degree to which the normal angle between the axes of the arm and forearm has been preserved, should be noticed, and if it has been lost, the propriety of an effort to restore it must be obvious. Compound fracture of the lower extremity of the humerus^ not involving the joint, is of rare occurrence. It differs from simple fracture of the same part mainly in the difficulty of treatment, and in the risk of inflammation of the joint, w^ith consequent stiffening. Almost always due to great direct violence, it may present any of the forms before spoken of, wdth like displacements. When the elbo^v-joint is involved, the lesion is a very serious one, and is extremely apt to be followed by anchylosis, in spite of all the eftbrts of the surgeon. The fact that the joint is opened is generally revealed by the escape of svnovia ; but the absence of this symptom does not prove that the joint is intact. When the external wound is large enough, an exploration may be properly made with the finger ; but if otherwise, the ordinary rule should be followed, to close the orifice at once as completely as possible, in the hope that it may heal, and thus render the fracture a simple one. Occasionally, if the bone seem to be extensively smashed, with only a small skin-wound, the latter may be enlarged by incision. The injury to the soft parts is very generally on the posterior face of the limb, unless it be due to the projection forward of the upper fragment, in w^hich case, as in one instance before mentioned, the vessels or nerves, or both, may have sustained damage. Amputation is some- times unavoidable. The advocates of Listerism advise that, if the joint has been entered, it should be washed out with carbolized water, with the view of destroying germs, and thus preventing suppuration. I believe that the practice is followed by good results, but not on the theory just mentioned. It is a matter of obser- vation that, when any serous membrane is laid open, pure water applied to it acts as an irritant ; and the anaesthetic property of carbolic acid is also a known fact. By virtue of this, a weak solution of the acid may, it seems to me, prevent the inflammatory action which would naturally follow the admission of air to the joint-surface. Dirt or other foreign matter forced in at the time of the receipt of the injury must be carefully washed out, and for this pur- pose the carbolized water answers as well, if not better, than anything else.^ When the fracture, besides being exposed to the air, is comminuted, it is important for the surgeon to see that any loose fragments are removed, and that those that remain are in proper place. Otherwise, even if the joint con- tinue free from adhesions, its motions may be interfered with, and the usefulness of the member be proportionally lessened. A small wound may be closed with lint and collodion, or with any good, non-irritant adhesive plaster. Another excellent plan is to apply lint satu- rated with Peruvian balsam. Good results have also been attained by the old plan of saturating lint with the blood, and allowing it to dry over the wound. For the first few days, until the subsidence of the acute inflammatory con- dition which must attend an injury of this kind, the application of a splint is needless, unless it be merely a wide rectangular one, well padded, upon w^hich the limb can be laid for the purpose of keeping it steady. Irrigation may, in these cases, be sometimes employed with advantage. When the wound has healed or has begun to suppurate, and the swelling has gone down, atten- tion must be paid to" the position of the fragments, as w^ell as of the forearm and hand. Anchylosis is so likely to occur, that it is important to arrange the limb in such a way as to make it most useful even with a stiftened elbow; the proper plan is therefore to flex the forearm at an angle of about 90°, and to keep the hand semi-prone. FRACTURES OF THE BONES OF THE FOREARM. 147 When the services of a skilled mechanic can he liad, some form of hracketed splint, one portion to fit the front of the arm, and the other that of the fore- arm, may be employed. Or, by a little ingenuity, the surgeon may adapt a strip of tin, of sheet-zinc, or of hoop-iron, so as by means of a plaster-of- Paris bandage to control the limb properly. In either case, a sufficient space should be left opposite the wound for the application of suitable dressings. When there is much discharge, cleanliness requires that the renewal of the dressings should be frequent; and it is well to protect the adjacent edges of a plaster-of-Paris bandage, either by a strip of oiled silk folded over them, or by a coating of varnish. As to the character of the dressings to be employed, nothing need be said here, the subject having been fully d'lscussed in previous portions of the En- cyclopaedia. Before dismissing the subject of fractures of the humerus, I wish to add a case which came under my notice too late to be mentioned in its proper place. It is recorded by Mr. R. Jones,* and was that of a man, age not given, who fell from a height, and in falling grasped at a door. He thus sustained a subclavicular dislocation of the right humerus, which bone was broken at the middle, and a dislocation backward of the elbow. The fracture was secured in splints, and the dislocation reduced. Some eftusion occurred in the elbow- joint on the third day, but was rapidly absorbed ; and the movements of both elbow and shoulder were free and painless in six weeks. He had previously dislocated both hips, and on three occasions the left shoulder. Fractures of the elhow^ properly so called, in which not only the low^er por- tion of the humerus, but the upper portions of the bones of the forearm, are involved, present certain special features which entitle them to separate con- sideration. They can, however, be more suitably spoken of after the discussion of fractures of the last-mentioned parts. Fractures of the Bones of the Forearm. Taken collectively, the fractures of this part of the skeleton constitute a very large proportion of the whole number of these inj nicies. Wide difi:er- ences exist, however, between the two bones of the forearm, as well as between the difi:erent portions of each, in regard to their liability to fracture. Thus, the ulna by itself is rarely broken, especially at its lower part; the radius by itself is almost exempt above, but fractures near its lower extremity are among the most common of accidents. Both bones may give way at once, to a crush- ing force, in any part of their length ; but more frequently they are broken by indirect violence, somewhere near the middle, or below it. The order of frequency of these accidents .may therefore be stated as follows: The radius alone near its lower end ; both bones about their middle third, or in the upper part of the lower third ; the olecranon ; the coronoid process ; the radius alone near its upper end ; the ulna alone in its lower part. ]^ow these ditterences, far from being unaccountable and as it were capri- cious, find a clear explanation in the anatomy and mechanical conditions of the forearm and of the bones themselves ; as does also the fact, at first sight strange, that the thickest and seemingly the strongest portion of each bone is the one which most frequently gives way. 1 Lancet, April 28, 1883. 148 INJURIES OF BONES. Fracture of the olecranon is very rare in children, although it is men* tioned three times among the 316 cases in the records of the Children's Hos- pital, before quoted, while Malgaigne quotes three cases recorded at the Hotel Dieu between the ages of eleven and fifteen. Holmes^ figures a speci- men of "fracture of the cartilaginous epiphysis of the olecranon," but does not mention the age of the patient ; the head of the radius was dislocated for- ward. By far the most common cause of this injury would seem to be falling upon the elbow, the joint being strongly flexed at the moment. A blow, or any other direct violence, may cause it in like manner. An old woman once came under my care, who had fallen down in ascending a staircase, striking her elbow on a pebble which lay on one of the steps, and breaking the ole- cranon. Muscular action has been thought to produce this fracture in a number of cases, although Malgaigne, while admitting four, says that " in- stances of this kind call for careful scrutiny." Dupuytren^ says: "A sud- den and very violent extension of the forearm, by the action of the triceps, may also produce fracture of the olecranon, which happened whilst I was a student, to a person who, whilst playing at tennis, gave the ball a violent back-stroke with the racket, and immediatel}^ felt a sharp pain at the elbow, I examined the arm, and found that the olecranon was fractured." It must be remembered that the triceps is not inserted into the tip of the olecranon, but " into the back part of its upper surface, a small bursa, occa- sionally multilocular, being interposed between the tendon and the front of this surface."^ Moreover, the tendon of the triceps, expanding over the upper and back part of the ulna, gets a much larger attachment than merely to the upper surface of the olecranon, and the " tearing off" of this process, described by some surgical writers, is actually impossible. In one case, quoted Dy Malgaigne from Yeyne and Robert, it is said that these surgeons " made out a detachment of the apex of the olecranon ;" and this is the only one of the instances mentioned by Malgaigne in which the exact seat of the fracture is stated. Lonsdale^ suggests that fracture of the olecranon may sometimes be ex- plained " by the ulna being thrown back against the humerus with great violence, which motion produces extreme extension, and throws the olecranon process forcibly against the humerus, which may be sufiicient to break it off from the rest of the bone ;" I may say that this idea had crossed my own mind, but that it had seemed to me that the anterior attachments of the fore- arm, both muscular and ligamentous, would prevent such extreme extension. The olecranon may give way at either of several points. Sometimes the line of fracture runs through the slightly constricted part which corresponds to the middle of the sigmoid cavity, as looked at from the side. Sometimes it passes across the middle of the process, and occasionally it is much closer to the apex. In one specimen in the Warren Museum,^ in Boston, there is a double fracture, with close fibrous union. " The lines of fracture are, respec- tively, J inch and 1^ inches from the extremity of the bone ; and at this last the union was so close that it only appeared when the pieces were separated by maceration." Very probably there is often a certain amount of crushing of the edges of a fracture produced by direct violence, but the above is the only instance known to me of double fracture. The direction of the line of fracture varies, although it would seem to be mainly transverse. ' Surgical Treatment of Children's Diseases, p. 265, Fig. 45. 2 Diseases and Injuries of the Bones, Syd. Soc. Transl., p. 37. ' Gray's Anatomy, Descriptive and Surgical, p. 305. 4 Op. cit., p. 154. 6 Catalogue, p. 171. FRACTURES OF THE BONES OF THE FOREARM. 149 Both olecranon processes are reported to have heen hroken in one case observed by Mr. Fletcher the patient was a youth of sixteen, and it seems likely that the lesions might have been more correctly called epiphyseal sepa- rations. They were due to direct violence. Hamilton mentions liaving had occasion to reduce a backward dislocation (of nine weeks' standing) of the radius and ulna in a boy aged seven, in whom the olecranon, still, of course, an epiphysis, was separated by forcible Hexion during the operation. He says further: "I have twice since broken the olecranon in attempts to reduce old dislocations of the radius and ulna backward, and I have not regretted the occurrence, since it enabled me to reduce the dislocations without cutting the triceps." In most cases there is a perceptible gap between the detached portion and the rest of the bone, due in some measure at least to traction on the fragment by the triceps muscle ; but there may be so much of the periosteum left intact as to prevent any separation. Cases do occur in which the fragment is drawn up along the back of the arm, but they are more rare than might be supposed. Flexion of the elbow increases the gap when one exivsts. Tillaux^ expresses the opinion that when there is separation of the frag- ments, it is due not to the drawing up of the upper one, but to the flexion of the elbow, removing the lower one ; and cites in proof of this view^ the fact that the gap disappears when the elbow is again extended. As soon as there is any separation at the point of juncture, the elbow-joint is of course opened, and, although the injury is subcutaneous, effusion takes place from the torn and irritated synovial membrane ; a circumstance which, although it would not in itself suffice to push the fragments apart, certainly does not tend to diminish the gap.^ The symptoms of this injury are: immediate loss of the power of extend- ing the forearm, and pain in the elbow on attempting to do so ; some pain and soreness in the part, although this has not been marked in the cases I have seen ; a cleft or gap between the fragments, filled up when wide by a soft, almost or quite painless, fluctuating swelling ; generally there is also some bulging of the triceps muscle at its lower part, just above the seat of injury. Lonsdale'^ quotes from Earle the case " of a gentleman who fractured the olecranon, and where the separation did not take place till the sixth day after the injury, at which period it was caused by the patient attempting to tie his neck-cloth." The detached portion can be grasped between the surgeon's thumb and finger, and moved by itself with more or less freedom. Crepitus is, of course, wanting unless the fragments are in contact ; and the smaller the portion broken off, or, in other words, the nearer the fracture is to the sum- mit of the process, the less likely is it that the surfaces can be rubbed upon one another. Ecchymosis is very commonly present, and may gradually extend along the ulnar margin of the forearm for several days. These symptoms may vary considerably in distinctness, but they are, as a general rule, well enough marked to make the diagnosis clear. Bransby Coopei-^saw a case in which the power of extension of the forearm was so far retained as to give rise to much doubt. ' Med. Times and Gazette, Aug. 16, 1851. 2 Anatomie Topographiqne, p. 578. In this respect the olecranon differs from the patella, which is of less size as compared with the knee-joint. In fractures of the latter bone, it is held by some high authorities, that the sepa- ration of the fragments depends largely upon the free effusion of liquid into the articular cavity. But the patella clearly belongs among the " sesamoid" bones, while, according to Owen (Gray's Anatomy, p. 135, note), the olecranon is homologous with an extension of the upper end of tho fibula above the knee-joint, which is met with in the Oruithorhynchus, Echidna, and some other animals. * Op. cit., p. 156. A Treatise on Dislocations and Fractures of the Joiuta, by Sir Astlev Cooper. Edition of 1842, p. 471. ) .7 . r 150 INJURIES OF BONES. Fractures of the olecranon are, for the most part, united by fibrous tissue only, the length of the band, as well as its thickness, varying in different cases. Yet there are many instances on record of true bony union ; and this might be much oftener obtained, but for the difficulty of keeping the frag- ments in complete apposition. In Fletcher's case of fracture of both olecra- nons, before quoted, this result took place on each side, as proved by dissec- tion after the patient's death nearly a year subsequently. When osseous union occurs, there is on the outer aspect of the bone a deposit of callus, which gradually becomes absorbed ; on the articular surface there is, as in other cases of fracture running into joints, a depression or groove marking the line of the fracture. In the case of ligamentous union, there are sometimes numerous bands passing from one fragment to the other, sometimes two or more at either side, and occasionally a thin membrane-like sheet, apparently derived from the periosteum. A curious specimen exists in the Warren Museum,^ of " a piece of bone broken from the olecranon, and fifteen years afterwards removed from the elbow-joint." It seems probable that this was a fragment from a comminuted fracture, torn away entirely from its fibrous connections, the remainder of the bone having become solidly united ; but the account is not as full as it might be. The difiiculty often met with in maintaining the contact of the fragments, is due to several circumstances. One of these is the contraction of the tri- ceps muscle, which, when the fibrous tissues surrounding the bone are torn through, must tend to draw the fragment up along the back of the arm, tilt- ing itiat the same time so as to widen the gap posteriorly. Another is the efiusion which takes place in the joint, and which may be very copious. Still another is the upward traction not only of the triceps, but of the biceps and brachialis anticus (the latter especially), tending to crowd the end of the humerus between the fragments. All these belong especially to the early period, and vary in their degree in difterent cases. Sometimes the smaller fragment, drawn upwards, contracts adhesions in its new position, and thus, when swelling has subsided and muscular contraction has been quieted, may resist all efforts at bringing it down. The result of experience is that the usefulness of the limb after a fracture of the olecranon is not dependent altogether upon the shortness of the band uniting the fragments. Even if union is effected by bone, there may be adhe- sions within the joint, about it, limiting the movements of the forearm upon the arm. And, on the other hand, it sometimes happens that, although the separation of the fragments is considerable, the freedom and strength of the limb are but little impaired. In most of the ordinary functions of the hand, act we extension of the elbow is less indispensable than flexion. The analogy between fractures of the olecranon and those of the patella, in reo-ard to the recovery of function even with a fibrous connection of some length, will be pointed out in connection with the account which will be given of the fractal res of the latter bone. Absorption of ligamentous union is recorded in one case by Mr. E. Cooper.^ He says : — "The patient should be cautioned against using his arm too freely, till the uniting Jigament has acquired strength and firmness. A patient of Mr. Mayo's, whose olecra- non had been fractured, and liad united in six weeks by a ligament of the ordinary firm- ness, suffered severely from neglecting this precaution ; for after using the arm as much as possible for some time, he found that it became weaker and weaker ; the uniting liga- 1 Catalogue, p. 171. * Op. cit., p. 475, note. FRACTURES OF THE BONES OF THE FOREARM. 151 ment was entirely absorbed, so that the fractured olecranon was drawn up by the tri- ceps, the power of extending the elbow was almost lost, and the limb became wasted and useless." The time required for the union, whether fibrous or bony, of a fractured olecranon, must vary somewhat, especially in the former case. About six weeks may be stated as the average period. AVlien the fragments are united by bone, the strength of the limb is soon regained, and less caution is needed than if they are joined by fibrous tissue only. Such cases as that of Mr. Ma^^o, just quoted, are extremely rare ; yet the stretching of newly-formed li2:ament may impair greatly a result which, if the tissue had time to gain strength, would be satisfactory. Anchylosis of the elbow-joint sometimes follows fracture of the olecranon, and the chance of its occurrence, although remote, is one which ought always to be borne in mind. Some degree of stittening is very common, but usually disappears without special treatment ; it depends upon the thickening and contraction of the fibrous tissues about the joint, as well as upon loss of tone in the muscles from want of exercise. When adhesions occur within the joint, they may be the result of inflammation due to the severity of the original injury ; but there can be no doubt that they may be also occasioned by injudicious treatment, and that they are very apt to end in fixation of the parts. The means of avoiding this very unpleasant issue will be presently discussed. The treatraeMt of fracture of the olecranon consists in placing the arm in such a position as to facilitate bringing the fractured surfaces in contact, and contining it so until union shall have taken place. When there is veiy little separation the surgeon's task is simplified, as it is also by the absence of high infiammatory action in the jcint. Yet it must be remembered that without the further advantage of proper care, stretching of the fibrous tissues connect- ing the fragments may take place, and the ultimate result be unsatisfactory. For the first few days the arm should be laid in an easy position, with the elbow well extended, and means taken to allay any inflammation that may arise. I do not think that anything is gained by bringing the upper fragment down until all effusion into the joint has subsided ; but, after this, the earlier and the more completely it is done the better. Of course, if no inflammation is set up, and the joint does not swell, there is no reason for w^aiting. Modern surgeons are agreed that the best results are obtained by placing the foreai-m at a very obtuse angle with the arm, and keeping it so by means of an anterior splint. The splint should extend well up towards the shoulder, »,nd far enough down to thoroughly control the forearm ; I think it should go down into the palm of the hand, so as just to allow of flexion of the fingers. An ordinary roller, snugly applied, suffices to keep it in place. As to the material for the splint, it may be of wood, binders' board, or felt ; tin, which answers very well when properly shaped and fitted, has the great advantage of not adding miich to the bulk of the limb, and thus of allowing a loose sleeve to be slipped over it. Some surgeons employ the plaster-of-Paris or starched bandage, but I can- not see that it is of any especial use in these cases. A skilfully applied roller will remain in perfect efficiency for three or four days, and the whole appar- atus should be removed at least as often as this, for the purpose of ascertaining the condition of the parts. Various devices have been employed or recommended for the purpose of preventing the retraction upward of the upper fragment in these cases. Figure-of-8 turns of a bandage, with or without the previous application of a compress, have often been used. Hervez de Chegoin^ employed with success 1 Am. Journal of the Med. Sciences, July, 1848 ; originally in the Gaz. des Hopitaux. 152 INJURIES OF BONES an elastic compress, drawn downward bv tapes attached to tlie lower end of a hollow, jointed splint. Sir A. Cooper,^ who advocated the straight position, advised that after bringing the fragment into apposition with the ulna, a piece of linen should be laid longitudinally on each side of the joint, and wetted rollers applied above and below the elbow ; the extremities of the linen were then to be doubled down over the rollers, and tightly tied, so as to cause approxima- tion. It is not distinctly said that he ever used this plan, which would seem to involve great discomfort at least to the patient, as well as risk of interference with the nutrition and innervation of the distal portion of the limb. This objection, indeed, holds good with regard to all the ligure-of-8 and other bandages which encircle the limb ; if tightly enough applied to be efficient, they may do harm. AYith the excellent adhesive plaster now procurable, it is easy to keep the fragment in place without any such binding ; a strip of suitable length and width being put on so that its middle shall press just above the fragment, while its ends are carried down along the ulnar side of the forearm, one in front and the other at the back, far enough to take a firm hold. The splint and bandage are then applied as before directed. A compress is needless, and might indeed do harm by tilting the fragment, so as to produce a con- dition such as Malgaigne quotes as seen byPasquier: "the fragments, far- ther separated posteriorly than anteriorly, were only in contact by their ante- rior edge.'' It has been suggested b}^ my self ,2 as well as b}' others, that in cases of much difliculty an instrument analogous to Malgaigne's patella-hooks might be used — ^a small metallic plate or wire frame, with either one or two short recurved hooks, to be inserted into the posterior and upj^ei' part of the olecranon, drawn down, and fastened in place by means of a strip of adhesive plaster carried along the forearm, as before described. Such a contrivance could be readily made, and probably could be used without danger ; 3'et I think that the ma- jority of surgeons would be content with the results procurable by less for- midable appliances. Dieftenbach,^ many years ago, proposed and practised the division of the tendon of the triceps, bringing the upper fragment down into place, and occasionally rubbing the two fragments forcibly together ; he claimed to have obtained firm union in this way. Suturing the fragments has been proposed, and the operation has been per- formed in a number of instances. Mac Cormac^and others have thus obtained bony union in cases attended with marked separation. Sheldon had already, in 1789, proposed the laying bare of the bone and rasping of the fractured surfaces, but says, in his work,^ that he never had attempted the operation. The introduction of the wire suture made the procedure far more eflective, and the advocates of the so-called antiseptic sj^stem claim that their precau- tions make it safe. I must confess that no case has ever come under my own observation, in which it has seemed to me that the amount of advantage likely to be derived from such severe measures w^ould warrant their substitu- tion for the less brilliant methods above described. By care and accuracy in the adaptation and use of simple apparatus, satisfactory results can, as a general rule, be obtained. > Op. cit., p. 474. 2 New York Medical Journal, Dec. 1866. 8 Casper's Wochenschrift, 2 Oct., 1841. Trans, of Clinical Society of London, vol. xiv., 1881. * An Essay on the Fracture of the Patella, or Knee-pan ; containing anew and efficacious method of treating that accident: With Observations on the Fracture of the Olecranon. By John Shel- don. London, 1789. FRACTURES OF THE BONES OF THE FOREARM. 153 Compound fracture of the olecranon is occasionally met with. Its gravity must depend, in a measure, upon the possible admission of air into the joint, (.r the effusion of blood into that cavity, either of which occurrences would be of serious import as to the prognosis and treatment of the case, by reason of the inflammation likely to ensue. W^hen the synovial membrane remains intact, the wound must be closed, and the fracture dealt with as in ordinary cases ; wdien the joint is laid op'en, it ought to be carefully cleansed with carbolized water, and all inflammation allayed by appropriate means before splints are applied. Anchylosis is very apt to ensue under such circumstances. Fracture of the coronoid process ot the ulna is a lesion usually described as very rare, and it has certainly been very seldom recognized as occurring by itself. It may, however, be questioned wliether it does not sometimes attend backward luxations of the forearm, as in a case reported by Say re. ^ The flrst published observation of this lesion, according to Malgaigne, was that of Brassard, in 1811. The patient had fallen, three months pre- viously, on his outstretched hand ; the motions of the forearm were all free and painless, except flexion, which was limited. "In front of the uhia, between it and the end of the humerus, was found a hard body, somewhat movable, against which the ulna was arrested when the attempt to flex the forearm was made." Dorsey,^ in 1813, says : — " The coronoid process of the uhia, Dr. Physick has once seen broken. The symp- toms resembled a dislocation of tlie humerus forward, or rather of the forearm back- ward, except that when the reduction was effected the dislocation was repeated, and by careful examination the crepitation was discovered." Hulke^ mentions the case " of a man killed by a fall from the roof of St. George's Hospital, in whom the coronoid processes were found to be frac- tured, and the two bones of the forearm dislocated backward, on both sides." Bradford^ has reported the case of a man, aged twenty-four, who fell a dis- tance of forty feet, and died of his injuries, among which was a fracture of the coronoid process of the ulna, part of the trochlea of the humerus being also chipped oft'. The main symptom is stated to have been constantly recur- rino; dislocation backward. Sir Astley Cooper's two cases,^ one of which was verified by dissection, are well known. In the account of the latter, it is stated that the coronoid process had been broken oft" within the joint," which is obviously an anatomical impossibility, although the fracture must of course have entered the joint. Another very often quoted case is that of Liston, in which a boy aged eight sustained the injury by hanging by his hand from the top of a high wall, afraid to drop down. Fahnestock® reported the case of a boy who " fell from the haymow, and received the whole w^eight of his body on the back part of the palm of the left hand, whilst the arm was extended forward, by which impulse the coro- noid process of the ulna was displaced ;" the limb presented the appearance of one in which the forearm was dislocated backward, but on being reduced the deformity recurred, and the recurrence was attended by an evident crepi- tation. It is stated that the boy " recovered very speedily," but the degree to which the power of flexion was restored is not noted. Duer^ saw a boy, aged six, who, seven weeks before, had fallen from a haymow and dislocated the forearm iDackw^ard. The displacement still existed, " and the arm being some- what flexed, the detached portion of the coronoid process lying in front of the > Transactions of Med. Soc. of State of New York, 1871. 2 Op. cit., vol. i. p. 152. 3 Holmes's System of Surgery, 3d edit. vol. i. p. 162. * Boston Med. and Surg. Journal, July 17, 1883. ^ Op. cit., p. 469. « Am.. Journal of the Med. Sciences, May, 1830. ' Ibid., Oct. 1863. 154 INJURIES OF BONES. joint could be distinctly felt, and freely moved in any direction over a small space." Every effort at reduction failed, and the case was dismissed, prona- tion, supination, and extension being unimpaired. Gross^ mentions a case reported to him by Dr. Scott, of Missouri, in which "the coronoid process formed a distinct prominence upon the anterior and inferior surface of the humerus, a short distance above the joint, movable from side to side, the ole- cranon being at the same time displaced slightly backward, and the forearm somewhat flexed. The accident was caused by a fall upon the hand while the forearm was forci])ly extended." In Sayre's^ case the fragment was adherent to the anterior surface of the (inner ?) condyle of the humerus. He refers to a specimen of Dr. Darling's, shoAving this condition of things, and to another in which ligamentous union had occurred. The latter was ob- tained in the dissecting room, and was without history. Bryant mentions and figures a specimen in which the coronoid process and the anterior margin of the head of the radius were detached in an old woman by a fall ; the frac- tures were compound, and amputation was performed. From the foregoing quotations it sxill be at once perceived that the frac- ture in question may occur at almost any age, and has been ascribed to veiy various causes. I do not think it needful to discuss the correctness of the diagnosis in each case, as Hamilton has done, because the fact that the lesion occurs has been placed beyond doubt ; and for practical purposes this is sufi- cient. Equally useless is the enumeration by Lotzbeck^ of twenty-four varie- ties of the injury. There can be no difficulty in understanding how, if the ulna is forcibly driven upward against the humerus, in any position, but especially in extension of the forearm, the coronoid process as a whole, or its tip only, may be split ofi". In the case of muscular action, as in the boy seen by Liston, the muscles arising from the inner side of the lower part of the humerus would pull the coronoid process backward against that bone, while the brachialis anticus would tend to drag it away from the body of the ulna. And a glance at a longitudinal section of the upper part of the nhia will show at what a disadvantage the cancellous structure of the base of the coronoid process would thus be placed, and how readily its separation might be brought about. The cases of this fracture may be practically divided into two classes, according to the extent of the portion detached. If the tip only of the pro^ cess is broken off, the fragment will be very small, and there will be no marked separation, except by the slipping backward of the ulna, and the consequent relative forward displacement of the humerus, limited by conta^-t with the head of the radius. But when the whole of the coronoid process is split off from the ulna, the action of the brachialis anticus will serve to draw it upward, and the gap between the fractured surfaces will of necessity be more considerable. Perhaps yet another division might be made, of those cases which aie complicated*^ by fractures of other bones in the neighborhood, as when the olecranon also is broken, or when, as in one of Sir A. Cooper's cases, the external condyle has been likewise separated. But here the fracture of the coronoid would as a general rule be the less important injury, and hence it would be more properly assigned the secondary place, as being itself a mere complication of the graver lesion. The symptoms of fracture of the coronoid process have already been given incidentally. The power of flexing the elbow must be more or less seriously impaired ; pain in attempting this motion, and tenderness in front of the 1 Op. cit., p. 697. * Noticed in Schmidt's Jahrbiicher, 1866. 2 Loc. cit., p. 108. FRACTURES OF THE BONES OF THE FOREARM. 155 joint, with occasionally the perceptible presence of the fragment, are to be looked for. Crepitus, if it exist at all, can be but slight. A tendency to luxation backward of the ulna may exist, but can hardly be marked unless some loosening of the attachments of the head of the radius has also occurred. The diagnosis may sometimes be very obscure, and only to be arrived at by exclusion. Separation of the articulating portion of the lower epiphysis of the humerus might induce symptoms almost identical with those of this lesion, although inlhe former case it is probable that the interference with flexion alone would be less distinct. The treatment of fracture of the coronoid process consists simply in flexing the forearm upon the arm, at an angle of about 90° or less, and securing it in this position by means of an anterior angular splint. Pressure should also be made upon the'^olecranon by applying the middle of a strip of adhesive plaster around it, and carrying the ends forward to be secured to the splint over the forearm ; in this way the tendency to displacement of the forearm backward may be overcome with more certainty than by the turns of the bandage, which may slip and become loosened. Especial care is to be taken in the treatment of cases in which the whole process is separated, as the action of the brachialis anticus will tend to draw the frao;ment up along the front of the arm, and permanent impairment of flexion'must be expected. If the tip only is broken ofl:*, it will be subject to no such traction, and the fragment can only give trouble either by being entan- gled in the joint, or by adhering to the anterior face of the humerus just at fts lower end. When the process is drawn up, it may be carefully coaxed down by the surgeon's fingers, and perhaps the pressure of the splint may keep it in place : ""or the forearm may be flexed at an acute angle so as to let the lower fragment follow the upper. Doubt must always exist, however, as to the eflficiency of any treatment adopted, until the patient attempts to resume the use of the limb ; and the prudent surgeon will be chary of giving assurances which the l-esult may not justify. Fractures of the head of the radius are very rare, unless along with other severe inj uries of neighboring bones. Bryant's case has already been mentioned, in which the coronoid process of the ulna was also broken ofl'. Malgaigne could only cite two cases, in both .of which there was also fracture of the coronoid, and backward luxation of the elbow. The head of each radius was split lon- gitudinally in Hulke's case of fracture of both coronoid processes, referred to on a previous page. In the Warren Museum^ there is a specimen (No. 1026) of " one-third of the head of the radius broken oft', with a comminuted fracture of the upper extremity of the ulna," taken from a man who had fallen from the roof of a house. Another (No. 1031) is described as " longitudinal fracture of the head of the radius, with fracture of the ulna from the coronoid process downward ;" and further as " a clear and regular split, involving very nearly one-half of the head of the radius, and cleaving outward so as to extend no further than the neck of the bone." Stimson^" saw a fracture of the outer half of the head of the radius, produced by direct violence and followed by suppurative arthritis, in a boy aged thirteen ; the excision of the joint enabled him to establish the diagnosis. Adams exhibited to the Pathological Society of London^ a specimen in which several fissures radiated from a point just below the head of the radius upward to the articulating surface ; the injury was the result of a fall from a height. 1 Catalogue, p. 172. 8 Op. cit., p. 433. ' Transactions, vol. xxii. 1871. 156 INJURIES OF BONES. Other cases, followed by recovery, and hence open to some doubt, have been reported. The causes of fracture of the head of the radius are those of similar injuries in the other bones of the same region ; cases resulting from blows, falls, in which there is sometimes a doubt whether the violence has been direct or indirect, and railroad crushes, have thus been observed. In Hulke's case, affecting both arms, it can scarcely be doubted that there was indirect vio- lence ; in Bryant's, it is distinctly stated that the woman had a fall, striking on the elbow. But in either class of cases, the mechanism is readily enough explained. As to the symptoms^ they are by no means as clear as might be supposed, in view^ of the ease with which the head of the radius may be felt in the normal state. Pain, loss of power of rotating the hand, as well as of flexing the elbow, crepitus on passive motion, very rapid swelling, and synovitis of the elbow, are quite sure to occur ; but the determination of the exact nature of the injury is not so simple a matter, especially in view of the fact that in so many of the recorded instances other lesions have also been present. The prognosis of these cases must, of course, depend, in some measure, upon the amount of damage done to the joint, and to neighboring parts, as well as upon the success of efforts directed tow^ard allaying inflammation. A con- siderable degree of stiffening may always be looked for, and this, in some cases, will be permanent. As to the treatment, the first object must be to keep down inflammation in the joint, by the usual means, the forearm being semi-flexed. Nothing can be done in the way of correcting displacement, should such exist, which does not seem to have been the case in any of the recorded instances. The limb should be placed in the posture which affords the greatest ease, and lightly bound to a well-padded, angular splint. Passive motion should be attempted at. about the tenth day, and repeated every twenty-four or forty-eight hours ; the movements should be made with the utmost gentleness, but very thor- oughly, and any irritation caused by them must be allowed to subside com- pletely before the joint is again disturbed. If the irritation run very high, and last long, and if, on each successive occasion, it become more decided, the forearm must be bent at a right angle with the arm, in semipronation, in order to give the greatest use of the hand in >case the stiffening becomes permanent. Fractures of the Elbow. — A few words may be said here in regard to these injuries, which comprise all those in which not only the lower end of the hume]»us, but one or both of the other bones entering into the joint are involved. They may be either simple or compound, and the extent of the lesion, whether of the bones or of the soft parts, may vary greatly. Some- times the fragments are very much displaced, while, in other cases, they may remain almost undisturbed. Generally the cause is great direct violence, such as the passage of a wheel over the arm, or other crushing force. When these fractures are compound, the position and extent of the wound of the skin will be influenced in some degree by the character of the cause. If the latter be direct violence, the wound may be at the back of the elbow ; but if indirect, the skin being, as it were, burst open by the projection of the bone, the anterior surface of the arm just above the flexure is most frequently involved. In the former case, also, the wound is apt to be smaller than in the latter ; although this, of course, is by no means a constant rule. Some- times, although the fracture is compound, the joint is not laid open to the air, and this fact lessens the gravity of the injury. Fractures of the elbow may occur to either sex, at any time of life ; but. FRACTURES OF THE BONES OF THE FOREARM. 157 for obvious reasons, adult males are most exposed to the causes of such injury. The diagnosis is sometimes quite clear as to the nature of the hurt, but it may not be easy to determine exactly which bones are involved, and to what extent. Malgaigne mentions a case, as follows : " In the only example of comminuted fracture of the elbow which I have seen, the humerus was intact, except that its articular cartilage was stripped otf ; the patient had fallen from a second story upon the elbow, and the wound answered merely to a transverse fracture of the olecranon, leading me to think that this process alone was involved. The patient dying on the fifty-eighth day, the autopsy revealed a comminuted fracture of the coronoid process of the ulna, as well as of the head and neck of the radius." When the external wound is large, exploration with the finger may aftbrd much more exact information as to the precise nature of the damage to the bones. There are very few injuries in which the prognosis is more doubtful than in those now under consideration. Every pathological cabinet contains speci- mens illustrating most extensive fractures involving the elbow, from which recovery has taken place, with deformity indeed, yet apparently with a fair degree of usefulness of the limb. In Malgaigne's case, just mentioned, there was an incessant oozing of blood from the fractured surfaces, which filled the joint, and doubtless had to do with the unfavorable result ; such a complica- tion might occur in any case, and disappoint hopes otherwise well founded. On the other hand. Sir A. Cooper^ relates the case of a brewer's servant, in wdiom the elbow w^as crushed by the wheel of a dray, so that the finger ccmld be passed through the joint, and the artery thus felt. He refused to subnjit to amputation, and recovered, with suflB.cient motion in the elbow to allow him to resume his former occupation. Another case is given by the same author, in which a man, aged seventy-four years, with very extensive frac- ture, made a complete recovery ; " although the form of the joint was irregu- lar, yet a considerable degree of motion was preserved." I think it may be assumed that, in the latter case, the joint was not laid open — a circumstance which, as a general rule, renders the chance of a good result much greater. When this can be ascertained, the surgeon may, there- fore, venture to give the patient much more encouragement than if the latter is likely to undergo the risk of a suppurative arthritis. When the joint does not show any sign of stifliening, and especially if passive motion neither gives pain nor excites inflammation, the prospect is favorable, even if the outward shape of the part is disfigured — the result of several displacements being to give something like the natural mechanism. Much, however, depends upon the judgment with which passive motion is employed. For the treatment of cases varying so widely in the degree and character of the lesions presented, it can scarcely be expected that definite rules should be laid down. When the fracture is a simple one, the course to be pursued is identical with that recommended when only one of the bones entering into the joint is concerned. In compound fractures, if the joint be not laid open, the fragments must be adjusted, and any that are entirely loose removed ; the wound is next to be closed as securely as possible, and the limb placed upon a rectangular splint ; inflammation is to be expected, and must be met by fomentations, evaporating and anodyne lotions, or irrigation. Upon its subsidence, the same treatment should be instituted as for simple fractures, provision being made for the dressing of the wound until it has completely healed. 1 Op. cit., p. 477. 158 INJURIES OF BONES. When the joint is extensively laid open, or if the bones are very badly crushed, it may be good practice to excise the whole joint ; a procedure which, although not mentioned by Malgaigne, has been resorted to with suc- cess in many instances, and is at- present of recognized value. Sir A. Cooper cites two cases in which it was employed with excellent results by Mclntyre, in one as early as 1829. I myself had at the Episcopal Hospital, a few years ago, a young man, who, by a fall from a roof, had sustained a very extensive compound fracture of the elbow ; I freely excised the joint, and he recovered with so good an arm that he was able to resume his business as a tin-roofer. When excision is decided upon, it is important to remember that much depends upon the removal of a sufficient amount of bone to leave the forearm freely movable ; upon sparing muscular attachments as much as possible ; and upon avoiding interference with vessels and nerve-trunks. Partial ex- cisions have, in some instances, been done with success; but I think that the general result of expei'ience is, that it is better to remove all the articulating surfaces, that healing thus takes place more quickly, and that to leave any portion of the joint adds nothing either to the safety of the procedure or to the subsequent usefulness of the limb. Occasionally, besides the damage to the bones, the vessels are torn across, or such extreme injury has been inflicted on the soft parts as to be irrepara- ble, and amputation must then be performed. The question may be raised with regard to either amputation or excision, whether the better plan is to operate at once, or to wait until suppuration has been established ; in other words, whether a primary or a secondary ope- ration affords the best chance of a good result. I think it should be decided, not abstractly, but according to the circumstances of each case. If it is clear that operative interference must be resorted to, and the patient's condition does not forbid, there would seem to be no valid reason for postponing it. But if there is a doubt in the surgeon's mind, either as to the necessity of any operation, or as to which he should adopt, or if grave constitutional symp- toms are present, a few days' delay may be of momentous advantage. Such questions, however, belong rather to general surgery than to the special branch now under consideration. Fractures of the shaft of the ulna are rare as the result of indirect vio- lence, although Bellamy! has reported one in the upper third of the bone from a fall on the hand, in a child six years of age. Yoisin is quoted by Malgaigne as having seen " a detachment of a longitudinal splinter from the articular facet" at the lower end, produced in the'same way. Macleod has reported* a case seen by him in which the patient, in striking a blow, sustained a frac- ture of the styloid process of the ulna, with separation of the triangular car- tilage. A more frequent cause is direct violence, as when a pugilist wards off a blow^, and receives it on the edge of the forearm ; or from a fall, striking the same part against a step or other resisting body. The ulna is subcuta- neous in its whole length, and hence is specially exposed to injuries of the kind just referred to. Labatt^ saw a healthy girl w^ho had sustained a fracture of the lower third of the ulna by muscular action, as she was engaged in wringing clothes. A previous injury had impaired the power of supination. In the statistics from the Children's Hospital, already quoted, in tlie 316 cases, the ulna by itself is said to have been fractured 11 times, or in very nearly ^ per cent. Yet the causes are much more prevalent among grown 1 British Medical Journal, Sept. 16, 1876. « Edinburgh Medical Journal, Nov. 1874. 3 Dublin Med. Press, April 8, 1840. rKACTUKES OF THE BONES OF THE FOREARM. 159 persons, and particularly in men, who, according to MaJgaignc, contribute )bur-tifths of the subjects of this injury. Of the different portions of the bone, it would seem from the statistics given by Hamilton, as well as from those of Agnew, that the middle third is somewhat more frequently affected than either the upper or the lower ; and the reason of this may be readily perceived. In the Museum of the Pennsylvania Hospital there is a specimen^ of double fracture of the ulna, the forearm having been bent around a revolving shaft. " The upper fracture is near the junction of the upper and middle thirds, and is somewhat oblique. The lower fracture is in the lower third, and is trans- verse. At the time of removal the fractures were not complete, the fibres of the bone which remained unbroken being much bent." The patient was a boy aged fifteen. Wlien the ulna is broken by direct violence, the fracturing force M^ill obviously tend almost invariably to drive one or both of the fragments toward the radius, and thus to diminish the interosseous space. The upper fragment, from the nature of its connection with the humerus, is not as movable, laterally, as the lower, which is moreover acted upon, in some degree at least, by the pronator quadratus muscle. But the upper fragment may be tilted either forward or backward, as indeed the lower may be also; and thus will result a deformity and change of relation between the bones, by w^hich, if uncorrected, the pronation and supination of the hand would be almost altogether prevented. For the production of this unfortunate effect, it is not necessary that either fragment should be very markedly displaced ; a very slight change of angle is sufficient to destroy the parallelism of the two bones, and thus to impair the efficiency of their mechanism. Hamilton says that there is no other long bone the fractures of which are so often complicated as are those of the ulna; and Agnew makes nearly the same statement. The former author saw, in 12 cases out of 36, the radius dislocated forward, or forward and outward, and in one a backward luxation of both radius and ulna, while in four cases the fracture was compound. The rationale of the displacement of the head of the radius, after the support of the sound ulna is lost, is not difficult to comprehend. A curious specimen exists in the Warren Museum,^ which has been already noticed on account of the lesion of the radius ; that of the ulna is thus described : " The fracture of the shaft of the ulna is very oblique, commenc- ing at the depression of the articular surface, marking the separation of the coronoid proces,s and the olecranon, extending almo&t longitudinally 3 J inches downward, and detaching from the shaft that portion of the bone to w^hich the olecranon was attached." A somewhat similar case, but extending down- ward only two inches, and followed by non-union, was reported by Brainard.^ Very generally the fractures of the ulna present but a slight degree of obliquity. The symptoms are pain and loss of power in the forearm and hand, swelling, ecchymosis, and tenderness at the seat of fracture. Sometimes the fingers of the surgeon, passed along the edge of the forearm, perceive a depression or angle, and crepitus is elicited on pressure. Occasionally, in order to develop this latter sign, it is necessary to grasp the upper and lower portions, of the forearm, and make a slight effort as if to rotate the low^er upon the upper. Care must be taken, however, to avoid any manipulation which might cause displacement, or increase it if it already exists. ^ The diagnosis is not often difficult, the subcutaneous position of the bone giving a fair opportunity for its thorough examination. The possibility of » Catalogue, p. 23, No. 1095. 2 Catalogue, p. 173, No. 1031. • Transactions of the Am. Med. Association, vol. vii. 1854. 160 INJURIES OF BONES. complications should not be lost sight of ; the slirgeon should see, for example, that the head of the radius is in its proper place. Union generally takes place readily, but a number of cases of false joint have been observed in this bone, perhaps on account of rotary motion com- municated to the lower fragment through too great liberty allowed to the hand, or it may be by the entanglement of a torn edge of the interosseous membrane between the fragments. Callenderi has recorded a case in which the styloid process of tlie uhia, carrying with it the triangular ligament (?), was torn off, and in which, when the parts were examined, '"the ulnar nerve was found wedged between the two portions ot bone. The treatment may be a very simple matter, or may present considerable difficulties. The first point is to correct any displacement that may exist ; and the only direction that can be given for this is, that such manipulation is to be employed as may in each case be found most effectual. Sometimes the bone is brought into perfect line by merely pressing the soft parts into the interosseous spaces, anteriorly and posteriorly; and this should always be done, although it may also be requisite to correct an angle forward or back- ward, as well as to make some extension in order to disengage the fragments from one another, or from the torn interosseous ligament. As a general rule, the semi-prone position (with the thumb upward), is the best ; and if the patient is either a child or a restless or unruly adult, a splir.t extending from the middle of the upper arm to the ends of the fingers, with a right angle correspondins: with the elbow, will serve to secure it. My own preterence is for two smalhslips of wood, well-padded, and applied along the dorsal and palmar surfaces of the forearm, with very careful bandaging from the tips of the fino:ers to the elbow ; a piece of binder's board, cut so as to form an internal, angular splint, reaching down to the ends of the fingers, and with the forearm part broad, so that its lower edge can be turned up to support the whole ulnar side of the limb, may then be softened in hot water, moulded to the arm, and secured by a roller. For the first few days the con- dition of the fingers should be carefully watched, lest the circulation be interfered with by the compression ; a number of cases are on record in which HB-glect in this respect has cost the patients the loss of their arms, and even of their lives. Some surgeons are content with a mere trough, in which the semi-prore forearm is laid, and confined by means of a bandage ; but there can be do question that more efficient confinement is needed in many cases, and is safer in all. 1 X- n xT„ In compound fractures of the ulna the treatment must be essentially the same, although a gap should be left opposite the wound to allow of its being dressed. When the trough or angular splint is properly applied, the sling can hardly do anv harm by pressing one or both fragments toward the radius ; but it 7,8 better to have it of ample width. The hand should never be allowed to hang free, but should be well supported by the angular splint. When the appa- ratus is removed for the purpose of examining the limb, the utmost care should be taken to guard against any sudden displacement. I think it may even be better to leave the small splints in place for a week or two, and merely to ascertain by passing the fingers along the bone that the fragments are in their proper relation. Passive motion is in these cases wholly unnecessary, and would be very likely to do harm. At the end of about four weeks, the arm-part of the sup- » St. Bartholomew's Hospital Reports, 1870. FRACTURES OF THE BONES OF THE FOREARM. 161 porting splint may l)e left oft", and in a week more the hand may be set at liberty ; next the small splints may be removed, and then the api)aratus may be permitted to become loose, and so worn for a few days, when it may be finally dispensed with. Pseudarthrosis, when it occurs in the ulna, is not easy to deal with on account of the presence of the radius. Of sixteen cases collected by Muhlen- berg,^ live were treated successfully by drilling, and in one the plan failed ; four by resection, with one success, two failures, and the result in one not stated; three by frictions, with two successes and one failure; one successfully by tincture of iodine applied to the skin ; another by scraping the periosteum subcutaneously ; and another by mere mechanical pressure. From this it would appear that the methods which do not involve much disturbance of the parts are, in the case of this bone, the most effective. I may add that Le Fort^ has recently recorded a case in which he succeeded in obtaining union by means of electricity. Malgaigne quotes from Berard a case of comminuted fracture of the lower lourth of the ulna, with division, not only of the muscles, but of the ulnar artery and nerve ; he tied both ends of the artery, dressed the wound, placed the forearm first upon cushions and afterward in the ordinary apparatus for fracture of both bones, and succeeded in obtaining, at the end of sixty-eio-ht days, complete consolidation and cicatrization. ^ Fractures of the radius alone constitute a very large proportion of the whole number of fractures, not only of the upper extremity, but of the skele- ton m general. But this is due to the frequency with which the bone o-ives way at its lower part, close to the wrist ; the other portions of it are much more rarely broken. In illustration of this statement, I may quote the fio-ares ^iven by Agnew,3 derived from the registers of the Pennsylvania IIospitaL Out ot 648 lully recorded cases, 24, nearly 4 per cent., were in the upper third ot the bone; d3, a little over 8 per cent, in the middle third; and 571 about 88 per cent., in the lower. Hamilton's observations present a curious agreement with these ; out of 101 cases, 3 were in the upper third of the bone, 6 in the middle third, and 92 in the lower. Fractures in the upper third of the bone are generally, I think, the result ot direct violence. But in 1856 I saw a case under the care of Dr. Milton- berger, m Baltimore, in which the radius had given way very hio-h up as the patient was pulling very hard in driving a pair of horses. I do not know of any other recorded case of the kind, but the history of this one was clear, and the mechanism may be easily perceived ; the twist impressed upon the bone Dy the action ot the biceps was such as to overcome the strength of the tissue J^ractui^e of the neck of the radius, properly so called, may take place from direct violence, as in some cases of crushino; of the elbow ; althouo-h I think this bone IS more apt to escape by reason of its mobility and small size. But no instance is known to me in which it has been ascertained to be broken by itse . The specimen in the Mutter Museum, which has been sometimes said to illustrate this lesion, is, m fact, one of fracture through the tubercle and the displacement is such as to show the action of the biceps upon the upper as well as upon the lower fragment ; it is without history, which is much to be regretted Moore^ has reported a case in which the separation was clearly obferviJi Z v t ' 'IZ^ itself; and he refers to another. Observed by Parker, where there was luxation of the head of the bone, which * Agnew, op. cit., vol. i. pp. 768, 769, 770, 806. » Bull, et Mem. de la Society de Cliirurgie de Paris, 1882 Op. cit. vol i. p. 901. 4 London Med. Gazette, Oct. 17, 1845. V OL. W, — 11 162 INJURIES OF BONES. "was drawn considerably above the elbow-joint, by the cor.traction of the biceps muscle ;" reduction was accomplished, and the case is said to have *^°In ^-leakino- of the relative frequency of fractures in difterent portions of the radius if will be remembered that I quoted statistics from Agnew and Hamiiton in which the bone was considered as divided into an upper, middle, and lower' third. I venture to su^a;est that it would be better tor practical pur- BO'.es to stady these injuries accoi-ding as they aftect the shaft of the bone above or^below the insertion of the pronator teres, leaving fractures at or close to its lower extremity in a separate class. For there is no portion ot the skele- ton in the fractures of which the influence of muscular action i^pon the pro- duction or maintenance of displacement is more distinctly traceable than it is in those of the shaft of the radius. v Th- o-reat function of this bone is pronation and supination, as may be elearlv seen by a glance at the muscles which act upon it. One of these, the biceps, is indeed a flexor, but it is a supinator also The supmator brevis acts upon the upper portion-almost, if not quite, halt ot the bone--the supi- nator longus upon its lower end. The pronator teres is inserted into about an inch of its outer edge at its mid-length, while the pronator quadratus act-, in a supplementary way on the lower portion of the sha,ft _ If now the shaft gives way between the tubercle and the insertion of the pronator teres, it must be obvious that while this muscle wdl tend to rotate the lower fragment into pronation, and to drag it toward the ulna, the upper frao-ment wilt be rolled outward by the supinator brevis and biceps, the latter alsS tiltino- it up forward. The action of the supinator longus in opposition to the pronator teres will amount to nothing as soon as the continuity of the bone is lost; and the pronator quadratus will simply, by the contraction of its upper fibres, pull the lower fragment toward the ulna. If on the other hand, the shaft is broken below the insertion of the pro- nator teres, this muscle will draw the upper fragment toward the ulna, but its rotating action will be opposed by the supinator brevis and biceps; the pronator q°iadratus will act in the same manner as before, but more strongly, as the fragment will be shorter. Here the displacement produced will be an angle saliSnt toward the ulna, while in the former case there will be added a Son outward, as well as a tilting up forward, of the upper fragnient Clinical observation, as well as the testimony ot museum specimens, will be found to support these statements, the practical bearing ot which will pres- *"5[af"aSe S some curious facts as to the distribution of these fractures between the sexes. He found the radius broken in mnety-flve m£iles,_and in sixty-five females ;' but this proportion, three to two, was not maintained at all ages. The number of male cases to females is ten to one in infancy ; between fifteen and twenty it is fifteen to one. Thus up to twenty years of age this fracture is almost ex- clus vely masculine. From twenty to forty-five, it afl^ects women m pretty large num- bers twery'two, in a total of seventy-two. But, after forty-five, another change occurs, and the fr;cture displays a marked preference for the female sex ; there be.ng but twenty men to forty-one women." As to the causes of these fractures, they would seem to be sometimes direct violence, sometimes tails on the hand. Malgaigne quotes from \ an Nierop the case of a woman, aged thirty, who, after wringing out two large sheets, felt sharp pain in the I'orearm, when a fracture m the lower third of the > These figures include all fractures of the radius-not those of the shaft of the bone only, but those of its lower extremity also. FRACTURES OF THE BONES OF THE FOREARM. 163 radius was detected. O'Brien^ rei)orts that lie saw an oblique fracture of the bone, about three inches above the wrist, produced by muscular effort in aiding to lift a large cask. It is not improbable that cases of this kind are more frequent than would be supposed from the scantiness of the records. l*rominent among the symptoms of fracture of the shaft of the radius is always loss of power in the hand ; although the patient may still be able to flex the lingers, and perhaps to pull or lift in some degree. But from what was before said as to the function of the radius, and the action of muscles uiion it, it nmst be clear that the breaking of this bone cannot fail to render the hand useless, for want of pronation and supination. Deformity is usually present, the forearm having a curiously twisted, look ; and if the hand is grasped and rotated, there is an odd sense of looseness in the limb, the patient'experiences pain, and, unless the fragments are separated altogether, there is crepitus. I have, never myself seen a case in which the latter symptom was wanting. The injured part quickly swells, and the other phenomena become much obscured. In examining a forearm for the detection of this or any other fracture, the best procedure is for the surgeon, after noting the position in which the limb lies, to grasp the hand with his corresponding hand, and bring it into semi- pronation ; then to run the lingers of his other hand along the ulna, with some pressure, so as to determine the soundness of that bone."' ^"ext, applying his disengaged hand gently but closely to the upper part of the forearm, he rotates the patient's hand, with slight extension ; the fragments will usually be felt to rotate upon one another, and at one point the movement will cause pain. Greater certainty is given to this manoeuvre, if the thumb of the surgeon is applied to the head of the radius, which may often be felt not to lollow the motion of the hand as it normally should. The precise point of fracture may be determined by passing one or two fingers lightly but firmly along the bone ; a certain yielding, with crepitus, will be felt when the spot is reached, and the patient will experience pain. When the fracture is below the mid-point of the bone, it can be much more readily perceived than above, where the examination must be made- through a greater or less thickness of muscular tissue. When the symptoms are ordinarily distinct, there can be little or no difii- culty m the diagnosis ; but it may readily be imagined that if the periosteum should hQ untorn, and the fragments be thus held in contact, the fact of frac- ture might escape detection. Serious displacement would not under such circumstances be likely to ensue ; and especially if, notwithstandino- the absence of conclusive, symptoms, the case were treated as one of fracture. ^ I may mention that the rotation of the radius in an uninjured arm some- times gives rise to a sound somewdiat resembling crepitus, either by contact of the head of the bone witli the condyle of the humerus, or bv friction of the tendons in their sheaths. Any error thus induced would, however, be on the safe side. From what has already been said, it ^vill be perceived that the result of tracture of the shaft of the radius, if left to itself, would be likely to be the loss ot much of the usefulness of the hand. If the bone were broken above the insertion of the pronator teres, the upper fragment would be supinated, and the lower pronated ; the upper would be tilted forward, and the lower drawn inward toward the ulna. If the fracture were below that point, the upper frao-- nient might be but little rotated, but the lower would be drawn away from It, and Irom its shortness even more strongly pulled toward the ulna. And in either case the displacement of the upper end of the lower fragment would be favored at least by the action of the supinator longus muscle ; of this a » Atlanta Med. Register, 1881. 164 INJURIES OF BONES. Striking illustration is given by Malgaigne ' He says, "the styloid process Sis been drawn up to the level of that of the ulna, than which it is notably lower in the normal state of things." How this was done, he does not say; but it seems to me to be best explained by the action of the supinator longus. In treatinq these injuries, two objects are to be especially aimed at : to place nnd keep the fragments in their normal relation as to their axes, and to main- tain the inter-osseous space. Lonsdale, long ago, urged the importance of the former point, but I think that some later writers have in great measure lost sight of his views, and have given attention too exclusively to keeping the ^^PeAapsltTs not making too sweeping a statement to say, that in all frac- tures above the middle of the bone the forearm should be supmated while m all below that point the semiprone posture is preferable. For m the tormer case we want, to use Lonsdale's words, "to place the hand and forearm in such a position, that the lower portion of the bone may be supmated to the same eltent as the upper;" but in the latter the condition of supination ot the upper fragment does not exist. . „ , , . In any fracture of the radius, then, above the msertion of the pronator teres, I should advise the use of an anterior angular splint of wood, carefully padded; and on the dorsal (in this case the lower) surface ot the forearm I should place a narrow slip of wood, padded so as to act as a compress to f^^V^'^^ maintain the interosseous space. The angle of the splint may be about 90 , Ta little less if the upper fragment of the hone tends to be strongly tilted np K the action of the supinator longus muscle, drawing the styloid pro- cess of the radius upward, toward the elbow, be very marked it may be wel to apply slight but steady extension of the hand toward the ulnar side; meaT o^f dofng this will readily suggest themselves The best plan in my ^pinion would be to put on the hand a glove, with the fingers removed, and wTthtapr sewed toit by means of which it could be tied to the corner of ihe splint; or they could be brought up over a notch at that point, to be fastened on the upper surface of the board. To make this dressing effective, the lower part of the forearm, just above the wrist, must be steadied on the ulnar side - which may be done by means of a wide loop of adhesive plaster, both ends of which may be brought to the outside of the splint, on its upper or palmar surface, and there fastened. . ^ ^ ^ +1,^ When the radius is broken below the insertion of the pronator teres, the best appliance is an internal angular splint reaching from the upper part of the arm to the ends of the fingers, and with the part correspondmg to the hand so shaped as to draw the hand somewhat strong y downward, or toward the ulnar side. The forearm-part of this splint should be carefully and firmly pMded along the middle, especially toward the wrist; and a similarly padded dorXJuntf but much narrower, should be laid along the back of the fore- "Tefore applying the splints in any case, the fragments should be carefully resto ed to'^heir normal relation, and so held until the dressing is complete. The banda-ing should be done with the utmost care,_snugly, but not tightW ; and the su?gefn will do well to remember that he is dealing with a part in which ganfrene has repeatedly been induced by neglect or want of skill in rppTyinI apparatus. Frequent inspections should be made, and the state of circulation in the fingers watched; upon the slightest appearance of con- gestion, or complaint of undue pressure, the limb should be stripped and the dressing reapplied, with such modification as may seem to be demanded. Within three or four days it may be expected that the swelling will sub- I Atlas, PI. IX. Fig. 5. Translation, Fig. 50. FRACTURES OF THE BONES OF THE FOREARM. 165 fiide, and that the bandages will become inefficient; but in removing them care should be taken not to allow of any displacement of the broken bone. Compound fractures of the radius in its shaft may of course occur ; but I do not remember to have ever seen one, except from gunshot wound, and there are no special points which require comment in regard to the i)henomena or treatment of such a case. Fractures of ;rHE lower portion of the radius are among the most com- mon of accidents, and must always have been so ; yet it was not until the present century that they were distinctly recognized and accurately described. The history of the development of our present knowledge of these injuries is so curious us to merit some notice. ^ PoLiteaui had thrown out the idea that fractures of the radius in the vici- nity of the wrist, caused by falls on the hand, Avere " generally mistaken for sprains,^ for incomplete luxations, or for separations between the ulna and radius but the statement seems to have attracted no attention at the time. The same view was promulgated by Desault f but to Colles,^ of Dublin, is due the credit of having given the first clear and practical account of these in- juries and of their distinctive features. Dupuytren,^ Goyrand,^ Diday,^ and Voillenner,7 realized the importance of the fracture in question, althouo-h none _ot them seem to have been aware of Colles's paper ; and the same may be said of Kelaton and Malgaigne. Even Sir Astley Cooper makes no men- tion of Colles's name, and Fergusson barely alludes to his bavins: written on the subject. In fact, this first real investi2:ator of the matter would seem to have been forgotten until Prof. R. W. Smtth of Dublin, in his very valuable work,8 accorded him the credit to Avhich he was so justly entitled. At pre- sent, the name " Colles's fracture" is generally recognized by surgical writers, and employed to designate fractures of the radius close to the wrist, even if not corresponding exactly to the description Avhich Colles gave. Prof. Gor- don, ot Belfast, has published^ some researches which have shed further light upon the mechanism of these fractures, as well as upon their treatment ; his views have found confirmation in some interesting cases recorded by Cameron ot Glasgow. ^» ' In the United States, attention Avas first draAvn to the subject by Dr. John Khea Barton," of Philadelphia ; his views Avere based upon clinical observa- tion only, and not upon anatomical facts, yet they w^ere ingenious and Avell stated, and found extensive acceptance among the surgeons of this country. After this, no separate original American paper on this topic appeared for over thirty years, until Prof. Moore,!^ of Rochester, advanced the opinion that the fracture of the radius was a less important lesion than the luxation of the lower end of the ulna, Avhich certainly is often a marked feature of these cases, and suggested a plan of treatment based upon this vicAv. » (Euvres Posthumes, tome ii. p. 251. Paris, 1783. 2 (Euvres Chirurgicales, tome i. p. 155. Paris, 1813. « Edinburgh Med, and Surg. Journal, April, 1814. S''^^^'', l^^- ^^1^^°^^ the Injuries and Dise^ases of Bones" (Sydenham Society, 1847), which consists of selections from the above-named « Gazette Medicale, 1832, and Journal Hebdomadaire, 1836. « Arch. Gen. de Medecine, 1837. Ibid. 1842 ; article republished in his Clinique Chirurgicale, Paris, 1862. A Treatise on Fractures in the Vicinity of Joints, etc. Dublin and New York, 1854. (The preface to this work is dated 1847.) ^ m^?"^®^^^^® Fractures of the Lower End of the Radius, etc. London, 1875. ^ ^lasgow Med. Journal, March, 1878. ii Med. Examiner, 1838. « Iransactions of the Med. Society of the State of New York, 1870. 166 INJURIES OF BONES. Another essay which has attracted much attention, and which has shed additional light upon the mechanism and pathology of these lesions, has been published by Pilcher,i Brooklyn. I may perhaps mention also a paper of my own, read before the surgical section of the American Medical Association, in 1878,^ the views contained in which will be presented, together with those of the authors previously named, in the following pages.^ The brief sketch now given is that of a very great and important change in professional opinion. Luxations of the wrist, which were fornierly sup- posed to be of very common occurrence, and described in (Retail, in at least four varieties, have been relegated to a place among the rarest lesions ; while fractures of the lower portion of the radius are recognized as of extreme frequency. n- l- A careful study of the shape of the bone will render the study of its fractures much easier. In speaking of it, it will be supposed that the hand is hang- ino- by the side, with the palm looking forward, so that the anterior surface is the palmar and the posterior the dorsal, that the inner edge is the ulnar, and that the carpal articulating surface is downward. Adduction is bending the wrist so as to bring the band toward the median line, or the side of the little finger, abduction bringing it toward the outer or thumb-side ; in the former case, the angle on the ulnar side, between the hand and forearm, and in the latter, that on the radial side, is rendered more acute. Points to be noted are the projection of the radial styloid process, and the fact that it is normally at a lower level than that of the ulna ; the sudden swell of the bone dow^nward, just above the joint, so that there is an enlarged portion, as com- pared with the shaft, somewhat irregularly cubical in shape ; and the forward curve of the anterior wall of the bone, making a decided concavity in its outline if looked at from either side. This conformation is sometimes more and sometimes less marked. The fact that the most frequent cause of frac- ture of the radius, low down, is falling on the palm of the hand, may readily be seen to explain its comparative infrequency in childhood, as the weight is smaller and the leverage less than in similar accidents in the adult. In youth, epiphyseal separations, although not often met with, are not unknown; and at all later periods of life the bone gives way with great readiness. Both sexes are alike liable to these injuries. As already said, in a vast majority of the cases the cause is a fall on the palm of the*' hand ; in a few, however, the back of the hand comes to the ground, and the difference in the effect produced is of no small importance, as I shall try to show hereafter. Direct violence is, I think, still more rarely assignable as a cause ; Malgaigne quotes one case from Hublier, in which a young girl, whose wrist had been caught between a carriage-pole and a wall, had a transverse fracture of the lower part of the radius, the lower fragment being also split vertically into two parts. Authors have expressed very divergent views as to the lines of these fractures. Without quoting these at length, I may merely say that the practical result of the examination of cases and specimens seems to me to be that the lines of breakage are almost infinitely various. Sometimes the bone gives way almost exactly transversely, the fragments being, however, serrated or notched ; some- times the fracture is oblique from before backward, or from within outward, or part of it may run in one direction and part in another. Sometimes the separation takes place very close to the joint, sometimes farther from it. > Trans-actions of the Med. Society of the County of Kings, March, 1878. 2 Puhlished in the Am. Journal of the Med. Sciences, Jan. 1879. 8 The reader will of course understand that the above list is not intended to embrace all that has been written on the subject, which has been of course dealt with in systematic works, as well as in short articles containing reports of cases, suggestions in regard to treatment, etc. FRACTURES OF THE BONES OF THE FOREARM. 167 Sometimes the lower fragment is split or fissured in various directions, so as to constitute two or more fragments of very irregular size and shape. Occa- sionally the fracture begins at the articular surface, and runs up into the substance of the bone to a greater or less distance ; of this a notable example exists in the Warren Museum,^ and another is mentioned by Dupuytren.^ In another specimen^ in the Warren Museum, there is a double fracture, the result of direct violence ; it is described as " comminuted fracture of the lower end of the radius, just above, and into the joint, and a second fracture, two and a half inches above the joint." Dupuytren^ records another case, in which a woman, aged sixty-two, having rolled down about sixty steps, had " one fracture about an inch above the joint, and the other an inch and a half higher up. The ulna, which was dislocated inward, protruded to the extent of more than an inch through the skin."^ The Museum of the iS'ew York Hospital contains a specimen^ described as a fracture of the lower end of the radius " obliquely upward and backward, from within a quarter of an inch of the palmar edge of the carpal joint. The fracture was transverse and incomplete ; for a long narrow^ fragment passing up from the styloid process was still continuous with the shaft. This connecting bony bridge was slightly bent so as to permit the articular surface of the radius to be slightly rotated tow^ard the dorsal surface of the forearm." In the other foi-earm there was extensive comminution of the radius for the space of two inches, and the shaft is seen to be invaded by a longitudinal fissure running up from the fractured surface." Occasionally there is a separation of a lateral portion of the articular extremity. A number of instances are on record in which the styloid pro- cess has been thus broken off. Such a specimen exists in the Wistar and Horner Museum, and another in the Warren Museum ;7 Callender^ speaks of two in museums in London, and Hamilton thinks that he has made out the lesion twice in the living subject. One curious case is recorded by Butler,^ in which a boy of fourteen, by a fall from a height of thirty feet, had the styloid process broken off and drawn upward an inch and a half, where it became firmly united. In the IsTew York Hospital Museum there is a specimen^<^ in which " the only fracture of the radius consists in a chipping ofi" of a small portion of the lower extremity, so as to separate the articular facet for the ulna from the rest of the bone. One of the carpal bones is also broken." It is difficult to entertain any other theory of the mechanism of this lesion than that of direct violence. Gross^^ records the following: "In the case of a young man whom I attended along with Dr. Chenowith, the lower extremity ot" the radius was split in two by a transverse and an oblique fissure, the larger fragment being i Catalogue, p. 174, No. 1035. 2 injuries and Diseases of Bones, p. 126. » Catalogue, p. 174, No. 1038. « Op. cit., p. 127. 6 I am tempted to refer here to an instance reported by Mr. Godlee (Med. Times and Gazette, 1883), in wtiich a man, aged twenty, by a fall backward on his hands, sustained a compound fracture of the left radius at the junction of the middle and lower thirds, with displacement for- ward of the lower end of the ulna, which projected beneatli the skin. "An incision was made and the tendon of the flexor carpi ulnaris, which had slipped behind the bone, was raised up with a blunt hook ; but the ulna could not be replaced until first the styloid process and then the end of the bone had been sawed off." The mechanism of tliis injury seems to me to have been clearly the same as that in Dupuytren's case above mentioned, in which the removal of the end of the ulna was also practised, but not with so complete a restoration of the functions of the limb. 6 Catalogue, p. 80, No. 130. ' No. 4631. (Mentioned in a letter from Dr. Hodges.) 8 St. Bartholomew's Hospital Reports, 1865. » New York Medical Journal, 1867. 10 Catalogue, p. 79, No. 128. » Op. cit., vol. i. p. 970. 168 INJURIES OF BONES. completely detached and thrown inward and forward over the ulna, whence, as it w-as impossible to replace it, I removed it by incision. A good reco- very took place, with hardly any impairment of the functions of the wrist- joint." From what has been said, it is evident that the widest variety has been observed in the lines of breakage in the neighborhood of the wrist. Yet it is none the less true that in the vast majority of cases the lower end of the radius is fractured in a direction more or less transverse, and that the defor- mity produced is nearly the same in all. Mention has already been made of the fracture theoretically described by Barton ; and as his paper, the first one published on this special subject in America, had for a time a good deal of influence on professional opinion, it may be well to explain briefly what his views were. He says that in the act of falling " the hand is instinctively thrown out, and the force of the fall is first met by the palm of the hand, which is violently bent back^vard until the bones of the wrist are driven against the dorsal edge of the articulating surface of the radius, which, being unable to resist, gives way. A fragment is thus broken off from the margin of the articular surface of this bone, and is carried up before the carpal bones and rested upon the dorsal surface of the radius ; they having been forced from their position either by the vio- lence or by the contraction of the muscles alone." Again, he says: "It sometimes happens, also, though rarely, that fracture of a similar character to the one first described occurs on the palmar side of the radius, from the application of force against the back of the hand while it is bent forward to its ultimate degree." In the forty-five years which have elapsed since the publication of these views, there has not been, as far as I have been able to ascertain,^ a single instance placed on record in which they have been confirmed by dissection. Voillemier^ quotes one case from Lenoir, which may have been of this cha- racter, but is open to doubt ; and in most cases of comminution of the lower fragment, the dorsal portion has been broken ofl". But although a detached piece might be carried up before the carpal bones, there would not be, as he says, " on the palmar side a prominence w^hich is round and smooth, and difiering in this from similar projections formed by the fractured ends of bones."^ 'Nor is it. likely that, from a fracture merely of the posterior lip of the articulating surface of the radius, treated with ordinary skill or care, such bad results would often ensue as Barton enumerates : " A crooked arm, deformities, rigid joints, infiexible fingers, loss of the pronating and supi- nating motions." Yet consequences like these are frequently seen to follow the fractures just above the wrist. Fractures presenting such various conditions must, of course, be due to equally various mechanisms, is'evertheless, the vast majority of cases must be ascribed, I think, to the " cross-breaking strain" produced by over-extension of the wrist, as maintained by Callender, Gordon, and Pilcher. In other words, the hand being forced backward, an immense tension is put upon the anterior carpal ligament, and thus a leverage is exerted upon the lower end of the bone, beyond the resisting power of its structure. First the palmar wall gives way, then the columns or lamellse in succession, and finally, the dorsal wall. When the fall takes place on the back of the hand, the bone gives way in like manner, but in a reverse direction ; the mechanism is the same. That 1 Archives Generales de Medecine, Dec. 1839. FRACTURES OF THE BONES OF THE FOREARM. 169 this occurs, I think there is ample evidence, although it has been doubted by some writers. Fractures of the lateral margins of the articulating surface are less easily explained, but may be due to the sudden force brought to bear by violent contact of the carpal bones, and the same may be said of the rare instances of " stellate cracks." Upon the occurrence of transverse fracture in the way above stated, the area of the end of the upper fragment is less than that of the opposed surface of the lower ; and the force continuing to act, the former is driven down into the cancellous tissue of the latter, and may split or burst it into several lesser fragments, thus comminuting it. Or, if this splitting does not take place, the compact wall may penetrate the spongy texture of the lower fragment, constituting an impaction. Experiments on the dead subject have been many times made by difterent observers, and always with the same general result, in support of the above statements. With regard to the occurrence of impaction, writers have been greatly at variance. Gordon says that in Colles's fracture it is impossible. Callender says that thirty-six specimens in the various museums in London show de- formity in all clearly due to " the impaction of the proximal into the distal end of the bone." Yoillemier thought the impaction so marked a feature of the injury that he would rank it among what he calls " fractures by penetra- tion." R. W. Smith argues that the appearances which led Voillemier to this opinion were due to deposits of new bone. This question seems to me to have been discussed at greater length and with more zeal than its import- ance really warrants. It cannot be settled upon the evidence of specimens of old and long-healed fractures alone, but lesions of recent date must be examined also ; and from both together I think the conclusion is unavoidable that impac- tion occurs in some cases, while in others it is wanting. Deposits of new bone may undoubtedly take place in some cases, simulating impaction, or increasing its apparent extent. Probably the experience of most surgeons will confirm the statement of Pilcher, that a fall on the palm of the hand may be productive of a mere strain of the ligamentous structures, of bruising or even of Assuring of the hone, or of actual fracture with separation, according to the grade of the force brought to bear in over-extension of the hand. The symptoms of this fracture are, as a general rule, very decided. There is great pain, and instant helplessness of the hand ; the wrist is almost always deformed in a marked degree, and often both preternatural mobility and crepitus are present. Swelling comes on very rapidly, and, in some cases, there is ecchymosis, although, by reason of the thickness of the skin of the palm, this is not as apt to occur as in fractures in most other regions. The deformity requires special mention. It is such as might be expected from the bending backward of the lower extremity of the radius ; the back of the wrist is humped up, and there is a corresponding depression at the palmar side, with a sort of creasing of the skin. Sometimes the dorsal prominence is distinctly greater at the radial side, the part having a twisted appearance. By Velpeau the deformity was said to resemble the back of a silver fork, and the comparison is not an inapt one. Taken together with the pain and loss of power in the hand, it is often in itself conclusive as to the nature of the injury. Preternatural mobility may usually be detected by grasping the patient's hand (as if in shaking hands), and taking hold of the forearm ; then flexing and extending the Avrist. B}^ the same manoeuvre crepitus is apt to be elicited, but it may be very slight. In the case of decided impaction, both of these symptoms may be but slightly marked ; when they are very readily 170 INJURIES OF BONES. perceived, there is reason to suspect comminution. Maisonneuve^ records the following case : A woman, aged seventy, fell, striking the palm^ of her right hand. She had instantly great pain and tenderness of the wrist, and com- plete loss of power in the hand, which hecame swollen ; but there was no deformity nor crepitus. If, however, the hand was strongly extended, there was perceptible a yielding of the radius about an inch above the joint. She died on the fourteenth day, and the diagnosis of fracture was verified ; but the periosteum on the dorsal face of the bone was nntorn. The styloid pro- cess of the ulna had been wrenched off, and was adherent to the internal lateral ligament. Besides the silver-fork" deformity, there is in these cases an abduction of the hand, so that its radial border forms with that of the forearm an entering angle, and the ulna projects strongly on the other side of the wrist. This is due largely to the fracturing force, the hand being stopped while the weight of the body continues to drive the upper fragment downward and forward, and thus to push it into the cancellous tissue of the lower. It is easy to see that in the majority of cases the impact comes chiefly upon the radial side of the palm, in falls upon the hand, and hence that the penetration of the lower by the upper fragment would naturally be greater on that side. But this is in fact a shortening of the forearm on this margin by a change in the posi- tion and plane of the lower articulating surface of the radius, and the angle of the hand with the forearm must be correspondingly changed. The ulna does not move ; it cannot, by reason of its very close articulation with the humerus above. Hence, it seems to me incorrect to speak of luxation of the ulna as an element of this lesion ; it is the hand which, with the low^er frag- ment of the radius, assumes a new position with regard to that bone. And in strictness the ulna should not be said to project, although the expression may be retained as a matter of convenience. Perhaps I may best speak here of the views of Prof. Moore, of Rochester, who maintains that " luxation of the ulna" is the key to the pathology and treatment of the lesion in these cases. It has been already stated that there is often a twisting of the wrist along with the mere over-extension which breaks the radius, and when the change of angle between the hand. and fore- arm, just spoken of, takes place, there must of necessity be also a change in the relations between the carpal bones and the lower end of the ulna. And by entanglement in the annular ligament or a tendon (generally, I think, that of the extensor carpi ulnaris), the correction of this latter displacement may be rendered very diflacult. Admitting, however, that such a state of things exists, as claimed by Prof. Moore, in one-half of the cases, it seems to me that its absence in the other half certainly makes it secondary to the lesion which is always present. With all deference to his learning and practical ability, I am myself unable to accept his theory, to which I believe the above statement does justice ; of the treatment based upon it, which has some great merits, more will be said presently. It has been already stated that swelling takes place very rapidly after frac- ture in this region. When the lesion involves the articular surface, or in other words enters the joint, there is copious effusion into this cavity, and active inflammation may be set up. And in any case the sheaths of the ten- dons are thus distended ; besides which, although at a somewhat later stage, the subcutaneous areolar tissue becomes the seat of lymphization, and some- times, especially in feeble or aged persons, of oedematous fulneSs. Simultaneous fracture of both radii near their lower extremities has been observed in many instances, the reason of its frequency being obvious. 1 Clinique Chirurgicale, tome i. p. 164. FRACTURES OF THE BONES OF THE FOREARM. 171 i^'othiiig special iiee:ed fifty-five, made a miss in striking a back-handed blow. It must be obvious that force sufficient to break one of these bones w^ould be very likely to comminute it, and to inflict serious damage upon the soft parts also ; hence these fractures are very often compound. I once saw a separation of the palmar margin of the articular face of the first phalanx of the index finger, in a young lady, caused by a blow against the sharp, edge of a bedstead; the fragment was plainly to be felt. Ko serious inflammation followed, and union took place favorably. Most of these injuries are much more grave. A year or two since I was called into the street late at night to see a gentleman who, in going home, had slipped upon the icy pavement, and catching at a spiked railing, had impaled his middle-finger upon one of the points, splitting the first phalanx from end to 1 Philadelphia Medical Times, Oct. 16, 1871. 2 British Med. Journal March 28, 1874. FRACTURES OF THE LOWER EXTREMITY. 185 end. I had to cut through the soft parts of the side of the finger to liberate the hand. Amputation was unavoidable, and was performed the next day, with an excellent ultimate result. The symptoms need hardly be detailed, as they are those of fractures gener- ally, and from the small amount of covering of the bones are readily to be made out. On account of the strength of the flexors, the deformity is apt to be an angle, salient at the back of the finger ; but this rule is not uniform, as the fracturing force may drive both fragments toward the palmar surface. Occasionally these fractures are complicated with dislocation, but this, except in the thumb, is in general reducible without great difi&culty. Union almost always takes place without hindrance ; but I have reported* the case of a child three years old, who had two years previously sustained a fracture of the first phalanx of the thumb, with the subsequent formation of a false joint, and on whom an operation was performed with success. Necrosis of the fragments sometimes occurs, especially in compound and comminuted fractures ; and in these cases more or less thecal inflammation is very apt to ensue, and may travel up and even beyond the wrist. Under the most favorable circumstances some degree of stifl:ening and deformity is often permanent, although it may not interfere with the usefulness of the finger. Stoker^ showed to the Pathological Society of Dublin the skeleton of an index-finger, illustrating union of a fracture of the second phalanx. The first phalanx was entire and healthy ; the articulation between the first and the second had disappeared, and there was firm osseous union between these bones. Strong ligamentous union existed between the second and third phalanges. Occasionally patients find fingers which are thus stiftened so much in the way that they are anxious for their removal ; but in general they learn in time to disregard their presence. A far greater annoyance is sometimes caused by the twisting of a broken finger, so that it either crosses another, or constantly rubs against it in the movements of the hand. As to the treatment of these cases, a good deal of ingenuity has been ex- pended upon the devising of splints of various kinds. I believe that the best plan is to employ a piece of sheet zinc of suitable size, bent up so as to fit the palmar surface of the finger; this being very carefully padded and applied, may be secured by means of the best procurable adhesive plaster, or by a band- age imbued with a solution of silicate of potassium. If sheet zinc cannot be had, small strips of wood may be employed, carefully padded, and placed one on the dorsal and one on the palmar surface of the finger. As a temporary expedient this would answer perfectly. When no other means of solidifying the bandage can be had, flour and white of egg may be employed. The finger should be slightly flexed, but at the joints only. Passive motion may be carefully and gently made at the end of ten days or two weeks. In cases of compound fracture the question of amputation comes up, and must be settled on general principles. Excisions are not available here, and if any portion of bone must be lost, it is better to remove the finger. I have several times seen very unsatisfactory results follow the less decided course. Fractures of the Lower Extremity. These injuries differ from those of the upper extremity in some important respects. As a general rule, they involve the necessity of confinement, often keeping the patient in bed. The greater size of the bones renders the repair a more tedious process, and entails some additional dangers, as for example, 1 Am. Journal of the Med. Sciences, July, 1875. 2 British Med. Journal, Dec. 31, 1881. 186 INJURIES OF BONES. those of fat embolism and of pysemia. Extension is demanded in a larger proportion of cases, and by more powerful means. All the apparatus used must be on a larger scale. Arrangements must be made for the evacuation of the bowels and bladder, without disturbance of the broken bones. Often the risk of bedsores has to be guarded against. Yet the same general principles are to be observed — the same methods of study, the same rules as to diagnosis, and the same care for the avoidance of deformity. Fractures of the Femur. The femur, the largest bone in the body, and the most complicated in shape, is among those most frequently broken. The proportion varies in the experience of different observers, and even in the same hospital at different periods. Gurlt cites tables^ from which I derive the following statements : — Middeldorpf, among 325 fractures treated in the Allerheiligen Hospital, at Breslau, from 1849 to 1853, found 25, or something over 7 per cent, of the femur. Lonsdale, at the Middlesex Hospital, in London, between 1831 and 1837, found among 1901 fractures 181, or over 9 per cent. Gurlt, in the Hospitals and Surgical PolycHnic in Berlin, from 1851 to 1856, found 510, or less than 12 per cent, out of 4310. Blasius, in the Surgical CHnic and Polyclinic at Halle, between 1831 and 1856, found 97, or over 12 per cent, out of 778. Malgaigne, from the statistics of the Hotel-Dieu from 1806 to 1808, and from 1830 to 1837, embracing 2328 fractures, found that those of the femur were 308, or over 13 per cent. Lente, studying the records of the New York Hospital between 1839 and 1851, found that out of 1722 fractures there were 280 affecting the femur, or over 15 per cent. Matiejowsky gives from the Allgemeiner Krankenhaus, at Prague, from 1843 to 1855, 1086 fractures, of which those of the femur were 199, or over 18 per cent. Thus it appears that, from these seven sources, are derived results varying between 7 per cent, and 18 per cent.; a fact probably to be accounted for partly by the circumstances of the populations from which the patients were respectively drawn, and partly by the fact that, in some institutions, the general statistics are swelled b}^ the inclusion of walking cases, while in others these are referred to dispensaries, etc. From the statistics of the Pennsylvania Hospital for ei2:hty-seven years, from 1751 to 1838, Wallace gives, out of 1810 fractures, 291, or about 16 per cent, of the femur ; while Morris, for the period of twelve years, from 1838 to 1849 inclusive, found among 1441, 195, or over 13 per cent, of the lemur. This difference, although not very marked, is not easy to explain. On the other hand, it is readily seen why, out of the 316 cases of fracture before quoted from seven years' records of the Children's Hospital, in Phila- delphia, only 14, about 4 J per cent, affected the femur; for by reason of the unwillingness of parents to send their children to public institutions, a large proportion of these cases are treated at their homes. This statement is singularly at variance with that of Holmes,^ that " frac- tures of the shaft of the femur are among the commonest of all fractures in childhood;" and Gurlt's table,^ of 1383 fractures, arranged according to age, shows, among 330 below the age of fifteen years, 60, or a little over 18 per cent., in the femur. ' Op. cit., S. 6. 8 Surgical Treatment of Children's Diseases, p. 258. s Op. cit., S. 11. FRACTURES OF THE FEMUR. 187 The records of the Pennsylvania HospitaP show, out of 248 cases of frac- ture of the femur in which the age is noted, 80, or 32 per cent., under twenty years of age ; 47, or nearly 19 per cent., between twenty and forty years of age ; 71, or over 28 per cent., between forty and sixty ; and beyond sixty, 50, or 20 per cent. The influence of sex on the frequency of occurrence of fractures of the femur is strongly marked, but not equally so with regard to all portions of the bone. During childhood and youth, when the neck of the bone is almost exempt, the number of cases in males is very much greater than that in females. Afterwards, the ratio of the two sexes becomes more nearly equal ; but in old age, when the neck is the part of the bone most frequently broken, the proportion of women is in excess. The analogy which exists between the anatomical form of the femur and that of the liumerus obtains also in regard to their fractures. Thus, we have in the femur, fractures of the neck, of the trochanters, of the shaft just below the trochanters, of the shaft in other parts of its length, and of the condyles. But it will be noted that while the upper portion of the humerus, as stated in a previous part of this article, is less frequently broken than the lower, the converse is true of the femur ; and the anatomy of the neck of the femur is more complex than that of the condyles, while in the humerus the upper ex- tremity of the bone is much the simpler. The epiphyses of the humerus are far more frequently separated by violence than those of the femur. In fact, according to Holmes,^ separations of the upper epiphysis of the femur are " unknown, except, perhaps, in the foetus ;" this statement is too sweeping, but the lower is much ofteuer detached, as will hereafter appear. A correct knowledge of the external anatomy and internal structure of each portion of the femur is essential to the understanding of its fractures. The general mechanical principles concerned have already been laid dow^n.^ Fractures of the upper part of the femur are such as involve the neck of the bone, or the trochanters, or both. On examining a normal femur, it is seen that the neck, projecting upward from the oblique inter-trochanteric line, is set at an angle more or less obtuse with the shaft. In front, the surfaces of the two portions are nearly continuous, whereas posteriorly the line is a very marked ridge, and defines a deep hollow between it and the head. Hence, the greater trochanter projects backward, and the general shape of the neck of the bone is slightly convex in front, deeply concave behind. The angle at which the neck is set on to the shaft, is found, on comparison of femora from different subjects, to vary considerably. Ward says that it is on an average about 125°. Whether it changes in the same skeleton from youth to old age, has never been determined, although it has been so supposed by almost all writers on anatomy and surger}^ Sir Astley Cooper^ gives a very clear description of degenerative changes seen by him in old bones, and in the excellent illustrations accompanying his text, there may be perceived an arrangement of the cancellous structure, which, as I shall presently try to show, has much to do with the clinical features of all fractures in this region. But although these changes may undoubtedly occur, and are more frequent in old age, they are, I think, only parts of a degeneration which, in some individuals only, affects the entire skeleton. In many old bones no such change is to be noted ; the neck is at a very obtuse angle with the shaft, and its structure, like that of the bony system at large, resembles that of most 1 Surgery in the Pennsylvania Hospital, p. 280. 2 Surgical Treatment of Children's Diseases, p. 258. 3 See pp. 13 et seq. * Op. cit., pp. 134 et seq. 188 INJURIES OF BONES. bones at earlier periods of life. On the other hand, as shown by Gulliver/ such changes may occasionally occur as the result of injury in young persons and adults. Another point to be noted, which also varies in ditFerent individuals, is the constriction of the neck close to the head. Sometimes very marked, this constriction is in some bones scarcely present at all. When it exists, it must obviously influence the probability of fracture taking place at this point, especially if the nutrition of the skeleton becomes impaired by age or any other cause. The relation of the head of the bone to its neck also varies. Sometimes the neck extends more upward at the lower surface, so as to give the outline of its junction with the head, as seen either from before or from behind, an S -shape, and so as to lessen the relative length of the upper surface of the neck. Variations exist also in the actual length of the neck. It is in general proportionate to that of the shaft, but not always so ; as, for instance, in dwarfs, or short persons, it is longer, and in very tall persons shorter, than it would be according to such a rule. The antero-posterior is usually less than the transverse diameter of the cervix. A careful examination of vertical sections in the length of the head and neck of the femur shows, as pointed out by Ward, Wyman, and others, that a num- ber of the lamellae, beginning at the upper end of the inner wall of the shaft of the bone, close to the lesser trochanter, diverge upward to the concavity of the thin layer of compact substance covering the head, so as to receive the weight of the body upon their extremities. Another series of columns may be seen running outward from the same point, and meeting other colunms running up inward from the outer wall of the shaft ; these two sets of columns forming a series of groined arches culminating at the upper wall of the neck of the bone, a little to the inner side of the greater trochanter. By this arrangement, the shifting of the weight toward the outer or upper portion of the head is provided for, the pressure coming in greater degree on the outer wall of the shaft, the inner, however, receiving its share through the inner columns of the arches. The remainder of the lamellae run in various directions, not capriciously nor at random, but so as to afford in the aggre- gate a very strong support to the solid but thiii wall of the bone. The capsular ligament, properly so called, extends from the edge of the cotyloid ligament to the base of the neck of the bone ; that is, to the root of each trochanter, and to the ridges which connect them before and behind. When laid open, this is found to be lined by the synovial membrane, which is reflected from it to the neck of the bone, the line of reflection not corre- sponding, however, with that of the attachment of the capsule. A portion of the cervix is, therefore, surrounded only by fibrous tissue, the outer layer of which belongs to the capsular ligament, while the deeper is the perios- teum, the two being inseparable by dissection. I think that generally the distance between the reflection of the synovial membrane and the inter-trochanteric lines is about half an inch ; one or two pockets, however, existing, where the joint cavity is somewhat prolonged outward. One of these pockets is usually just within the gemelli muscles in the digital fossa, behind the greater trochanter. Differences exist between different individuals in regard to the precise relative extent of the synovial membrane and the neck of the bone. An arrangement of the immediate investment of the neck of the femur (called by Amesbury " the close coverings") which seems to have escaped the 1 Edinburgh Med. and Surg. Journal, July and October, 1836. FRACTURES OF THE FEMUR. 189 notice of writers on anatomy, is, I think, of importance. Under this portion of the synovial membrane are often to be noticed, raising it into longitudinal folds, several strong ligamentous bands.^ (Fig. 838.) Once, in a fresh sub- ject, a vessel of some size was seen by me running along one of these folds. Another subject, a woman, had in each hip-joint three such folds, directed obliquely (spirally) from left to right in that of the left side, and from right to left in that of the right ; these were in addition to the longitudinal bands above described. When these folds exist, they must obviously exert an influence in diminish- ing the chance of fracture of the cervix, and in the event of such fracture, Fig. 838. Fig. 839. Ligamentous bands beneath synovial capsule of Diagram showing lines of fracture in upper part of hip-joint. (After Amesbury.) femur. such of them as are unbroken must tend to prevent displacement. Possibly, vessels borne by them may be of importance in the nutrition of the pelvic fragment. The principal lines of fracture in the upper part of the femur are shown in the diagram. (Fig. 839.) The neck may be broken across just below the head ; or the fracture may begin below, just at or near the lesser trochanter, and run up obliquely across the neck, with more or less serration ; or the greater trochanter may be broken off. In not a few instances the latter lesion has been produced by the wedge-like action of the pelvic fragment, the main breakage being of the preceding form ; and sometimes the lesser trochanter also has been detached. Of course, in such a case, the fracture would be properly called a comminuted one. In the many and voluminous discussions bestowed upon this subject of fractures of the neck of the thigh-bone, it seems to me that certain facts, anatomical, mechanical, and pathological, have been too much disregarded. The anatomical facts have been set forth above, and the others will presently be mentioned. Authors have been generally agreed in c'.ividing these fractures into intracap- sular, extracapsular, and mixed. Under tne first head are those which separate * Called by Weitbreclit " Retinacula." They are spoken of hv Harrison, in the Dublin Dis- sector, and by Todd, in the Cyclopaedia of Anatomy and Physiology, Art. Hip-Joint. 190 INJURIES OF BONES. the neck in a direction almost or quite transverse ; under the second, those which involve the portion of bone close to the lesser trochanter ; and under the third, those which beo-in near the trochanter and run upward across the neck of the bone to a point close to the margin of the head. But unless the description above given of the extent and attachments of the capsular lig^ament is incor- rect, all these fractures are within the capsule. A more correct phraseology would be "intra-articular" for those which concern the part of the bone beneath the synovial membrane of the hip-joint, and "extra-articular" for those which are wholly outside of it. Of the latter class, I think, very few examples can be found, the great majority of cases being those in which the fracture affects the bone partly beneath the synovial membrane and partly beyond its limits. Bigelow says : " In lecturing upon this subject, I have been in the habit of dividing the injuries of the neck of the femur into the impacted fracture of the base of the neck and the unimpacted fracture of the rest of the neck, without regard to the capsule — a practical classification, embracing a majority of cases, and to which the other lesions may be regarded as exceptional." Viewed mechanically, the femur is a bent lever, arranged for the purpose of receiving the weight of the body, and of being moved so as to transfer it from place to place. Any force brought to bear upon the femur so as to tend to diminish the angle between the neck and the shaft, in other words, any force driving the head downward or the shaft upward, the opposite end being pre- vented from yielding, may cause a fracture beginning at the lesser trochanter, and tearing away the mass of lamellae described as radiating upward from that point tow^ard the head. This will only happen if the force is excessive, or if it bears upon the bony texture out of the proper line of transmission of the weight of the body. A blow upon the greater trochanter may do it, or a blow either in front or behind the base of the neck of the bone ; in either case the central point of the neck, as it might perhaps be called — the apex of the pyramid of columns — is the starting-point of the rending of the bone. This idea can readily be understood by any one who will carefully examine a vertical section of the upper portion of a well-developed femur. Moreover, such a section will show also how the greater trochanter may be split off. Out of a very large number of specimens of fracture of the neck of the femur which I have examined, every one which belonged to the " extracap- sular" class, that is, every one in which the fracture was not clearly within the limits of the synovial membrane, presented a long point running down close to the lesser trochanter, embracing the lower wall of the neck of the bone, and the pyramidal mass of columns already so often mentioned. And in this statement may also be included all those specimens which would be placed under the head of "mixed." In other words, I feel warranted in say- ing that all fractures of the neck of the femur are divisible into two classes : one in which the line of separation runs across the neck of the bone between the reflection of the synovial membrane and the margin of the head, the other in which the line begins close to the trochanter and runs up obliquely, and more or less irregularly, to the upper surface of the neck near the head. This long, wedge-like point is very apt to be driven into the cancellous struc- ture of the uppermost part of the shaft, and .may split or burst away several fragments of it, one of which will probably consist of the greater trochanter. By a mechanism not materially clifierent from that now described, fracture may be caused by any force acting upon the shaft of the femur as a lever, the head of the bone being fixed ; the enormous advantage aftbrded by the length of the shaft must be at once apparent. As to the production of the intra-articular fractures — those in wdiich the neck of the bone is broken nearly or quite transversely — they are generally due, I believe, to a twist impressed upon the part. In some cases this is very FRACTURES OF THE FEMUR. 191 obvious, as, for example, when the bone gives way hy reason of the patient tripping, or in merely turning around suddenly. Here the great leverage afforded by the length of the femur is almost doubled by the addition to^it of the length of the leg ; and it can scarcely be a matter of surprise that the neck of the bone should yield. The accidents which cause these fractures may be various: falls on the feet or knees, driving the femur upward, or falls or blows upon the trochanter, in whatever direction these may come. Sometimes it is difficult to tell whether the fall is the cause or the result of the fracture, in the cases especially of old people, and when the fracture is evidently within the joint. . I may, perhaps, anticipate somewhat here, by saying that in practice the distinction is not always easily drawn between the two forms of fracture. The differential signs so clearly laid down by authors may not exist, or they may be masked by swelling, or by the obesity of the patient. After what has been said of the mode of production of these injuries gen- erally, it will not be difficult to see how the capsular ligament and periosteum may be only partially torn, and may sometimes even remain entire. Under but slight stress, momentarily sustained, the fibrous structures may be only stretched. If they give way at one part only, that part will correspond to the greatest separation of the bone. Such cases are by no means rare. One instance is on record, and the specimen is preserved in the Warren Museum,^ of partial fracture or fissure of the neck of the femur. It was taken from a man aged forty-two, who had fallen through two stories of a building, upon a hard floor. The shaft of the bone was also broken trans- versely at about the middle. "The fissure involves about three-fourths of the circumference of the neck, the inner anterior portion only being spared ; and to a considerable extent it runs along very near to the head of the bone! It is quite closed, but there is considerable motion between the head and neck, when the head and shaft are grasped, and moved upon each other ; and the fissure would undoubtedly result in a perfect fracture if much force were used." Coulon is quoted by Holmes^ as having seen " the neck of the femur frac- tured m straightening a diseased hip, though no chloroform was given, and the extension so gently conducted that the child did not cry." The sym.ptom,s of fractures of the neck of the femur are very variable in the degree of their distinctness. Cases sometimes occur in which a mistake would be impossible, while in others the utmost care and skill cannot enable the surgeon to arrive at a positive conclusion. In well-marked cases there is loss of power in the limb, standino- and walk- ing are out of the question, and the patient cannot even raise the* knee as he lies m bed. The limb is drawn upward, or shortened ; this fact beino- appa- rent at a glance, and verified by measurement made from the anterior supe- rior spme of the ilium, or from the umbilicus, to the inner malleolus. Vari- ous forms of apparatus for making this measurement have been devised by Morton3 and others, but are scarcely available except in hospital practice, and equally accurate results may be arrived at with a good tape-line, carefully used. The patient should be laid perfectly straight, on a level surface, such as that of a hard mattress, or upon blankets folded and placed on the floor- and care should be taken to have the pelvis exactly transverse. I do not think It of any use to mark the points upon the skin, as is the practice of some surgeons, since such marks cannot but be movable. The tape should be T'^^'-P- .^""'.^^^-.l^.l'^^' Hamilton, pp. 98 and 396 ; and Mussey, Am. Journ. ot the Med. Sciences, April, 1857. 2 Surgical Treatment of Children's Diseases, 1st ed., p. 244. ® Surgery in the Pennsylvania Hospital, p. 288. 192 INJURIES OF BONES. carried from the upper point down along the inner side of the knee to the lower edge of the inner malleolus, on the shortened side first, and then on the normal limb. During this procedure the coverings should be all removed, and the parts concerned completely exposed ; although in women the genitals should be concealed by folding in the clothing over them. Sometimes the shortening, scarcely perceptible at first, becomes more marked within a few days, and, if uncorrected, continues to increase until it reaches its maximum. Sometimes it is suddenly produced, a week or more after the accident, by the disengagement of the fragments. Sometimes, again, it is at first very slight, but gradually augments as the injured bone undergoes atrophic change. Besides the measurement of the length of the limb, just mentioned, it is well to determine the distance between the trochanter and the anterior supe- rior spine of the ilium, and so compare it with that on the sound side. A result of the shortening, to which attention has recently been called by Allis, is the relaxation of the fascia between the trochanter and the crest of the ilium. As a diagnostic sign, it does not seem to me that this would be as valuable as an accurate measurement. To determine the position of the trochanter several methods have been sug- gested. iN'elaton's line is determined by carrying a tape from the anterior superior spine of the ilium, round the outer side " to the most prominent part of the tuber ischii. In the natural condition, the top of the trochanter in every position is in some part of that line."^ Bryant drops a vertical line from the anterior superior spine of the ilium to the mattrtss on which the patient lies, and then ascertains the distance, measured horizontally, from the top of the trochanter to this line. As a general rule, the foot is everted. So constant is this symptom, that the diagnosis may sometimes be settled in the surgeon's mind, in the case of an elderly patient, by this and the shortening exclusively. It would seem to be due partly to the fracturing force, partly to the weight of the foot and the natural shape of the limb, and partly to the action of the rotator muscles, the glutei especially. A number of cases, however, are upon record in which the foot, instead of being everted, w^as turned inward ,2 probably by reason of impaction of the fragments. Sometimes, as in a case under Stanley's care, recorded by Ormerod,^ the foot is neither turned outward nor inward, but remains straight, the explanation being the same. Ormerod says "the neck was broken irregularly, so that the lower portion was wedged slightly into the upper, and overlapped by it in front." Pain is rarely absent, although it varies in degree. Sometimes it is referred to the groin, a fact explained by the derivation of the nerves sup- plj'ing the hip-joint from the obturator nerve. On grasping the thigh and leg, and rotating the entire limb, it will often be found that the trochanter describes a less extensive arc than normally. This, however, is a fact not always easy to verify, and in the case of impac- tion the fragments may move together, the pelvic one rolling naturally in the acetabulum, so as to be altogether deceptive. Agnew recommends that during 1 Holmes's System of Surgery, 3d ed., vol. i. p. 1003. 2 Cooper, Dislocations and Fractures, p. 131, note, and Case Ixxxvii. p. 158. See, also, cases by Guthrie and Stanley, in the Med.-Chir. Transactions, vol. xiii. In Stanley's case the frac- tTire " extended obliquely through the middle of the neck of the femur, but entirely within the capsule." The inversion of the foot led to a suspicion of luxation, and to attempts at reduction. " A portion of the fibrous and synovial membrane on the anterior side of the neck of the bone had escaped laceration." R. W. Smith has recorded several cases. Bigelow mentions one in his work "On the Hip," and Hamilton has seen one. Another instance has recently been reported by Dr. Conklin, of Ohio, in the Columbus Medical Journal for November, 1882. 8 Op. cit., p. 44. FRACTURES OF THE FEMUR. 193 this procedure the thigh should be flexed to nearly a right angle with the body. The great leverage given by the leg (the knee being of course flexed also), should not be forgotten, as the fragments may be readily displaced, and damage done. Crepitus may be elicited by this manoeuvre, and is often perceptible even if the degree of impaction be considerable ; although in such a case it will be slighter and less distinct than if the fragments are freely movable upon one another. This and the preceding sign are apt to be in the same ratio of clearness. By Maisonneuve,^ and more recently by Levis,^ it has been advised that the patient should be laid on his face, and the limb lifted up from the bed in a backward direction ; if the cervix be intact, the movement will be very soon arrested. This procedure should be executed with the utmost gentleness, if at all, on account of the risk of doing mischief by separating the fragments bwelhngand ecchymosis, although Very apt to occur when the injury is the result of force applied over the trochanter, are sometimes wholly wantin^r when the bone has yielded to slight and indirect violence. The cowr^g of fractures of the femoral neck varies greatly, accordina; to the age and constitution of the patient and the character and severity of the local injury. In the old and infirm, there may be such a shock induced as to undermine the general health, and to lead to the extinction of life within a lew wrecks or months. Occasionally the fatal result is brought about by suppuration. McTyer^ recorded the case of a woman, aged fifty-six, who fell on her side, and had atterward a slight halt m walking. She was admitted to the Infirmary three months after the accident, for " ervsipelas in the thigh." A puncture was made, and a large quantity of pus evacuated; the discharge continued, and death took place on the eleventh day. The neck of the femur was broken within the synovial membrane ; " the abscess, which was situated in the thigh, communicated through the lacerated capsular ligament with the hip-joint. Reference has already been made^ to Hunt's ca^se of fracture of the neck of the femur in a man aged twenty-six, who died on the twenty- second day, of pelvic abscess and pyaemia. More commonly, in the old, the limb remains in a great degree useless, so that the patient becomes either bed-ridden or a crippte. The extent of the loss of power may be, however, but slight, especially if the fracture have been an impacted one. Even when bony union does not take place, there may be such a thickening of the capsule of the joint as to enable the weight of the body to be suspended, as it were, upon the fibrous band so formed. Perhaps the Y-ligament may add firmness to this support ; and it would seem that occasionally tliere are adventitious bands formed, as in an instance reported by Parkman,^ m which there were shown " certain bands of lymph pmceed- ing from the internal surface of the capsule to the broken surface of the upper portion or head of the bone." Morgagni^ states that in a case observed by Kuysch, ligamentous union had occurred betwen the broken surfaces and not, as asserted by Salzmami, through the periosteum alone; and numerous specimens of this kind may be found in museums. As to bony union between the fragments, there can be no question of its trequent occurrence m cases involving the base of the neck, close to the tro- chanters, or m what are commonly called extra-capsular fractures Some- times It IS very firm, and the accuracy of adaptation of the portions of the 1 Clinique Chirurgicale, tome i. p. 169. 2 Phiiadelpliia Medioal Times, Jan. 31 1874. 3 Glasgow Medical Journal, Feb. 1831. < See pacre 24 * Am. Journal of the Med. Sciences, Jan. 18521 ^ ^ Op. cit., Letter LVI. Art. 4. VOL. IV. — 13 194 INJURIES OF BONES. bone is sucli that the motions of the joint are very largely recovered. Thus Oanti records a case of impacted fracture of the neck of the femur, with slio-ht shortening, in which recovery took place w^ith firm union and a freely movable joint. I exhibited to the Philadelphia Academy of Surgery, a few years since, a man who had, when seventy-two years of age, sustained such a fracture by falling backward upon a pile of timbers ; he recovered so com- pletely that it w^as not apparent from his gait that any injury had ever been received. This man could lift either knee to his chin, could go up and down stairs, and in fact had no disability whatever. A very similar case was re- ported to Sir A. Cooper,^ in 1840, by Mr. Sheppard. The fracture, in a man in his sixty-fourth year, w^as thought to be within the joint; yet at tbe end of eighteen months he was able to resume his occupation as a mail-coach guard, climbing up and down from his box "with facility, and even dexter- ously." Although bony union may be obtained, and be perfectly firm, yet the mo- tions of the joint may be impaired by either one of two circumstances : the broken surfaces may be so displaced, either by impaction or by sliding past one another, that the extent of motion is limited in one or another direction; or there may be irregular deposits of new bone about the seat of fracture, and these may come in contact w4th the edges of the acetabulum, or even with the surrounding portions of the os innominatum. On the other hand, there may be absorption of some portion of the fragments, leading to a shortening, i:»erhaps extreme, of the neck of the bone, so that the head rests down against the upper end of the shaft, between the trochanters. A case was recently mentioned to me by Dr. Townsend, of Bridesburg, Pa., in which the neck of the femur was broken, and the shaft was strongly drawn upward. Union occurred between the pelvic fragment and the shaft below the trochanter, so that when the patient recovered he had not only great shortening of the limb, but its abduction was singularly hindered by the contact of the trochanter w^ith the ilium. The question has been often discussed, w^hether or not bony union could take place in cases of intra-capsular, or to speak more correctly intra-articular, fracture. A number of instances have been recorded as of this character, and from time to time others are likely to be brought forward. In 1867,1 published a paper^ in which I suggested w^hat still seems to me to be the true explanation of the majority of these cases, namely, that they are originally either wholly or in part outside of the joint, and become solidly united by bone ; after which a gradual absorption of the pelvic fragment takes place, allowing the head of the bone to settle down between the trochanters. (Fig. 840.) Since the publication of these views. Professor P. W. Smith has reported^ to the Patholo- gical Society of Dublin a case of bony union of a fracture, believed to have been within the capsule ; Shortening of cervix femoris con- and auothcr casc was reported by Dr. Senn, of Chi- secutive to fracture. cago, to thc Amcrlcau Surgical Association, in 1882.^ ^ Am. Journal of the Med. Sciences, July, 1866, from Med. Times and Gazette, April 14. 2 Op. cit., p. 566. 3 Am. Journal of the Med. Sciences, Oct. 1867. Three cases claimed to have been seen by Fabri (Ibid. Jan. 1863), had escaped my notice, but they are too meagrely described to be of any value. * Dublin Journal of Med. Science, Jan. 1873. 5 Medical News, June 17, 1882. FRACTURES OF THE FEMUR. 195 But it seems to me that the same explanation applies in these as in the other cases. I have seen, however, one specimen which I believe to have been unques- tionably an intra-articular fracture of the cervix femoris, united by bone. It was presented to the College of Physicians of Philadelphia* by Dr. J. M. Adler. The patient was an old lady of sixty-live, paraplegic, who fell out of bed. Her foot was inverted, and the limb shortened ; there was pain in the groin and .hip-joint, and crepitus. She died live months afterward, and the bone was removed and dried. On its presentation to the College, it was referred to a committee consisting of Dr. A. Ilewson, Dr. John Ashhurst, Jr., and myself. We carefully examined it, and reported unanimouslj^ that it was an impacted, intra-capsular (intra-articular) fracture, united by bone. Let me say that some time since, when in Cincinnati, I had an opportunity, by the kindness of Dr. IS". P. Dandridge, of inspecting one of the specimens reported and figured by Mussey,^ and that the line of fracture was readily traceable, extending down close to the lesser trochanter, according to the rule stated on a previous page ; thus proving in the case of that specimen that the fracture had not been entirely within the limits of the joint.^ Various causes have been assigned for the frequent occurrence of non-union in the intra-articular fractures of the cervix. One, which has been very generally regarded as the chief, is the want of nourishment of the pelvic frag- ment, which loses all connection with the vascular system except through the ligamentum teres. Another is the excess of synovia formed under the irrita- tion induced by the injury, by which the reparative material is continually washed away from the broken surfaces. Still another, and probably not the least important, is the readiness of movement between the pelvic and distal fragments, which indeed are, in some cases, completely separated. But, how- ever it may be accounted for, the fact remains, and !3ony union must be re- garded as practically unattainable by any care or foresight on the part of the sura-eon. very great difficulties. It is by no means always easy to determine whether the fracture is wholly within the joint, or wholly outside of it, or partly intra-articular and partly extra-articular. When, however, the patient is old and infirm, and the violence infiicted has been very slight, such as is caused by tripping in a fold of the carpet ; when the shortening of the limb is immediate and marked ; and when there is great mobility of the fragments upon one another, as shown by the ready rotation of the limb, the trochanter describing a small arc— the presumption is that the separation has taken place near the bead of the bone. When" the accident has been a severe one, such as a fall upon the hip ; if the patient is heavy, and especially if the age is such as to make it improbable that the bones have undergone such degenerative change as to w^eaken their texture ; when the shortening is but slight, and the fragments show no signs of free mobility upon one another, it may be regarded as probable that the fracture is outside of the joint, and that more or less impaction exists. Prof. R. W. Smith's assertion that " the extra-capsular fracture is always acconjpanied by a^ fracture of one or both trochanters" would, if proved, 1 a \ aluable diagnostic sign, as the mobility of the greater trochanter could in general be ascertained, and this, along with the other symptoms, 1 Summary of Transactions, in the Am. Journal of the Med. Sciences,- April, 1870. 2 Am. Journal of the Med. Sciences, April, 1857. 3 The reader who desires to examine further into this subject will find the references to the supposed cases of bonj union in intra-capsular fractures of the cervix femoris in mv paper, before mentioned ; also in Hamilton's work on Fractures and Dislocations. sometimes clear, may present 196 INJURIES OF BONES. would be conclusive. But, al though Prof. Smith adduces a large number of cases in support, of his opinion, there are many specimens of the fracture in question, in which the trochanter remains unbroken ; and hence this idea cannot form a ground for diagnosis.- The other lesions with which fracture of the cervix femoris may be con- founded, and from which it needs to be distinguished, are luxation of the hip-joint, and fracture of the acetabulum. Of the latter, an instance is recorded by Mr. Marsh ;^ the main symptoms were shortening and eversion of the limb, and the true nature of the lesion was only discovered upon examination after death. As to the means of distinguishing fractures about the hip from luxations of that joint, the foregoing discussion of the symp- toms of fracture leaves very little to be said. I may, however, again call attention to the fact, elsewhere referred to,^ that while in luxation there is limitation of passive motion in one or more directions, in fracture it is apt to be rather abnormally free. Great difficulties may, especially in persons below middle age, surround this question. In one instance within my knowledge, a man was twice examined, under anaesthesia, by four expe- rienced surgeons, who decided that he had a fracture of the cervix femoris, but after the swelling had subsided it was discovered that the head of the femur was resting upon the dorsum ilii, and there it remained, all attempts at reduction failing. After middle life, and in proportion to the development of the peculiarities belonging to advancing age, the chances in favor of fracture as against luxa- tion steadily increase, until in the very old the latter lesion is almost out of the question. The few instances of the kind on record should, however, inspire caution, and prevent too hasty a judgment. Malgaigne quotes with- out question the observation by Gauthier of a luxation of the hip in a woman of eighty -six, and Hamilton another in a woman of seventy-three, which was unreduced when she was seen thirteen years later. . Hence, in any case in which there is room for doubt, a careful and thorough examination should be instituted before pronouncing a positive opinion. The prognosis in these fractures is always grave. Although life may not be destroyed, the chance is that the patient will be a cripple for the remain- der of his days, and no surgeon should hold out hopes of complete recovery in such cases. At the same time, much depends upon keeping up the courage of the old and feeble, and it will often require tact and skill to do this. As to the treatment^ it must vary with the circumstances of each case. Sometimes all that can be done is to promote the comfort of the patient and to sustain his strength. Often the inconvenience and even distress caused by the application of confining apparatus, especially in cases of very old persons, will outweigh all the advantage derived from it. Yet there are manj instances, in those who may reasonably look forward to a considerable term of life, in which suitable treatment may do much to mitigate, if not to pre- vent, lameness. In the former class of cases, the knee should be supported on a pillow, and the limb placed in the easiest position, with the muscles relaxed. The patient should be allowed to lie as may suit him best ; sometimes a reclin- ing chair, enabling him to sit up and lie back alternately, answers an excellent purpose. Bed-sores must be carefully guarded against by cleanliness, by fre- quent washing of the prominent bony points with whiskey, and by the use of India-rubber air-cushions. Sometimes these cases are complicated by drib- bling of urine, especially in old men with prostatic enlargement ; and then the bladder should be emptied with the catheter at stated times. In cases of the other class, extension is called for, and may be best effected » British Med. Journal, March 18, 1882. 2 See p. 29. FRACTURES OF THE FEMUR. 197 by means of adhesive plaster, carried along the entire limb, and attached below to a cord running over a pulley and having a weight at the end of it. This weight need not be more than two or three pounds, and should never be sufficient to annoy the patient. The object is not so much to draw the limb down, as to steady it, and prevent any increase of the shortening. Sand-bags should be placed along the sides of the limb, and the foot should be supported as nearly upright as possible. By elevating the foot of the bed on bricks, the weight of the body is made to afford counter-extension. My own prac- tice is to direct the patient, after ten days or two weeks, to sit up in bed a little while each day, the extension being kept up ; thus preventing the hip- joint from becoming stiffened. Excision of the detached head of the bone has been proposed, but I know of but one instance^ in which such a procedure has been adopted, and in that the result was a useless limb. It seems to me that this operation could only be justified in cases in which suppuration had taken place, and that even then its advantage would be questionable. The same may be said of the operative measures proposed, and in a few instances carried out, for fastening the frag- ments together, and avoiding the non-union so apt to ensue after fractures in this region. Such a course would be useless in the old and feeble, and unne- cessary in younger persons, in whom fairly satisfactory results can be obtained by less difficult and less dangerous means. Fractures of the neck of the femur may occasionally be complicated with luxation of the head of the bone. Such a case was met with by Thornhill,^ who effected reduction, by means of pulleys, at the end of six weeks. Tunne- cliff^ has reported the case of a farmer, thirty years old, who was caught under a falling tree, and had a fracture of the cervix, the head of the bone being also displaced into the sciatic notch ; reduction was accomplished by manipulation on the thirty-eighth day. Another instance was recorded by Douglas.'* It was observed after death in the body of an old fisherman, who had twelve years previously sustained a hurt. The head of the femur was in the groin, under the middle of Poupart's ligament, "the femoral vein and artery being to its outer side and upon it ; " the neck of the bone was broken outside of the capsule. In these cases the luxation must have been first produced and then the fracture ; for otherwise there would not have been purchase enough to dislodge the head of the bone. Mr. Henry Morris^ recently reported to the Royal Medical and Chirurgical Society a case of impacted fracture of the neck of the femur, in an old man who had for years had an unreduced dorsal dislocation of the same thigh. Under examination the impaction was broken down, and union occurred with the limb in a much better position. Occasionally, but very rarely, the vessels sufier. Thus, Brainard^ mentions a case in which aneurism of the femoral artery was developed as a result of fracture of the cervix femoris produced b}^ a blow against a wheel ; the external iliac artery was successfully ligated. Robinson^ reported a similar case, in which an operation was proposed, but refused by the patient, who died. ^N'o autopsy could be obtained. Separation of the upper epiphysis of the femur may be mentioned here. It is very analogous to fracture of the neck of the bone close to the head, but • Howe, Med. Record, Nov. ]6, 1878. In the Index Medicus for May, 1882, there is a reference to a work by Wiesenthal : Ueber operative Behandlung intracapsularen Schenkelhalsbriiche durch Excision des abgebrochenen Gelenkkopfes. Halle, 1881. I have not had access to it. 2 London Med. Gazette, July 20, 1836. • Am. Journal of the Med. Sciences,' July, 1868. • London and Edinburgh Monthly Journal of Medical Science, Dec. 1843. « Lancet, Feb. 18, 1882. 6 Am. Jour, of the Med. Sciences, Oct. 1843. ' London Medical Gazette, June 28, 1834. 198 INJURIES OF BONES. occurs, of course, only in the young, the epiphysis uniting with the neck at about the eighteenth year. Another important difference, as appears from the recorded cases, is the much greater violence generally assigned as the cause of the epiphyseal disjunction. Six instances of this lesion may be found described by Hamilton, one of which he himself saw. Hutchinson^ met with one, and refers to two others. Stimson^ quotes a case in which the diagnosis was verified by dissection. Di\ J. M. Barton has recently^ reported the case of a boy of fifteen, in which he suspected a lesion of this character, but the evidence does not seem to me to have been conclusive. Far more may be expected from treatment, in a lesion of this kind, than in the fractures which affect the same region in advanced life. Such short- ening as exists, may be corrected by extension with the weight and pulley, and the joint may be immobilized by means of a well-applied plaster-of-Paris bandage around the pelvis and thigh. This confinement may be continued, with sand-bags on either side of the limb, and the extension kept up, for tw^o or three weeks in the case of a child ; a longer confinement would be advantageous in patients beyond the age of puberty. Cautious experiments should be made at first in allowing flexion of the hip-joint, but if they are productive of no pain or irritation, more and more freedom may be accorded to the patient, until be can move the limb without hindrance ; after which, with equal caution, he may be encouraged to put the foot to the ground, and to bear his weight upon it. A number of years ago, I had a patient, nineteen years of age, w^ho, by a fall from a very high wagon-seat, had sustained a fracture of the cervix femoris, the existence of which w^as verified, with the patient under ether, by Dr. Nancrede and myself. He was treated in the manner above men- tioned, and in six weeks was driving his wagon again, with scarcely any perceptible lameness in walking. My belief is, that the lesion was really a separation of the epiphysis. Fracture of the trochanter major is by no means uncommon as a complica- tion of fracture of the neck of the bone ; and it has been known to occur by itself, but the recorded instances are very few. Mr. Key's case, published by Sir A. Cooper,* which occurred in 1822, was the first, as far as I know. It was that of a young girl who fell in the street, striking the trochanter against a curb-stone ; the nature of the lesion was only discovered after the patient's death. Mr. B. Cooper^ gives an account of another case which was seen by him, and in which the diagnosis was justified by the symptoms as described, although the patient recovered, and hence absolute certainty could not be arrived at. The man's age is not stated. Stanley^ has reported two cases, but in regard to one at least there is room for doubt whether it was not really an ordinary extra-capsular fracture of the cervix, the trochanter also being separated. Bryant mentions one in a boy aged twelve, treated by Mr. Poland. McCarthy^ reports that a girl of eight, having fallen on her left side, had an abscess in the hip, and that this communicated with one within the pelvis ; she had also pyaemia, with pericarditis, pleurisy, and pneumonia, and the trochanter was found detached. Roddick^ saw a young man, aged sixteen, who had a strain while exercising, and a few days afterward symptoms of abscess about the trochanter, which was found necrosed and separated. 1 Med. Times and Gazette, Feb. 24, 1866. 2 Op. cit., p. 496 ; from Bull, de la Society Aiiatomique for 1867. 3 Medical News, July 14, 1883. * Dislocations and Fractures of the Joints, p. 186. 5 Ibid., p. 187. ^ Med.-Chir. Transactions, vol. xiii. 7 Trans, of the Pathological Society, vol. xxv. London, 1874. 8 Canada Medical and Surgical Journal, Nov. 1875. FRACTURES OF THE FEMUR. 199 Hamilton^ quotes from Clarke a ease of supposed comminuted fracture of the great trochanter, with the comment that it was probably ''an example of fracture of the neck without the capsule, accompanied with impaction and extensive comminution." He also candidly expresses a doubt as to au instance of the kind which he had himself recorded, and upon which he m now inclined to put a similar construction. F. W. Warren is reported^ to have shown, at a meeting of the Dublin Pathological Society, a specimen of fracture of the trochanter major, taken from the body of a male subject almost fifty years of age. ^ " It was without history ; but from the entire absence of signs of recent injury, and from the fact that the line of separation followed that of the epiphysary junction, the inference seems justified that it was really a case of epiphyseal detachment, dating hack perhaps thirty years." The cause of fracture of the great trochanter would seem to be invariably direct violence ; and the majority of the subjects are distinctly stated to have been below the age at which this epiphysis becomes united to the shaft. In such cases it may reasonably be supposed that the separation takes place through the cartilaginoid uniting substance, but that, as in separations of other'epiphyses, it may in part run through the true bone, detaching a layer of it of very irregular size, shape, and thickness. The syriiptoms of this lesion can scarcely be confidently detailed from the scanty experience recorded. Some of the symptoms, however, of the usual fractures of the cervix must be wanting; there cannot be shortening of the limb, and in rotating the thigh the trochanter cannot describe a smaller arc than normal, but will either "fail to follow^ the movements of the limb, or if the fibrous coverings are untorn, wdll behave as under normal conditions. Pain and disability of the limb must exist, the former being aggravated by pressure on the part ; but these symptoms, as well as swellnig and ecchy- mosis, would be equally likely to attend a mere contusion. When the tro- chanter is broken completely away from the shaft, it will probably be drawn upward, inward, and backward, by the action of the muscular fibres inserted into it ; and in such a case it will be transferred from its normal place to that occupied by the head of the femur in backward and upw^ard luxation. Stanley, speaking of the danger of confusion between these two lesions, urges " the positive resemblance of the fractured portion of the trochanter to the head of the femur, tlie former occupying the same place which the latter would in dislocation ; and if w^ith these circumstances there should happen to be an inversion of the injured limb, the difiiculty of the diagnosis must be considerably increased." Crepitus wx)uld of course be wanting in such a condition of things, and could only be elicited by bringing the fragment again into contact with the surface from w^hich it had been separated. The diagnosis has, perhaps, been sufiiciently discussed. As to the treatment of this injury, it need scarcely be said that the attempt should be made to bring back and to hold in place the fragment ; but as to the best means of so doing very little is known- Sir Astley Cooper's belt and pad, although theoretically very good, would be difficult to apply in practice, and, unless accurately adjusted, might increase the displacement it was intended to correct. I think that the object could be quite as well accom- plished with an ordinary compress, so arranged as to confine the trochanter in its proper position, and kept in place by bands of adhesive plaster. And if the diagnosis were clearly made out, a device, such as that suggested^ for keeping the fragment of the olecranon in place, might be employed ; a double ' Treatise on Fractures, etc., 6th ed., p. 429. * Dublin Journal of Med. Science, July, 1876. * See page 152. 200 INJURIES OF BONES. recurved hook, to be driven into the upper part of the separated portion, and attached by means of adhesive plaster to the skin of the limb below. From the slight data available, it would seem that some advantage might be gained by abducting and everting the limb, as suggested by Malgaigne, so as to make the shaft follow the fragment into the position into which the muscles are likely to pull it. It is very pi-obable that the lameness which might be mduced by the injury would not, after all, be so serious as to make it worth while to subject the patient to long and rigorous confinement. Fracture of the lesser trochanter is not described hy authors as a separate lesion, although sometimes, as in a case quoted from Guthrie^ by Sir A. Cooper,^ it is incidentally mentioned as an attendant upon other and more important injuries. In 1874 I saw, with Dr. Cohen, an old gentleman, who had slipped on an icy pavement, and in attempting to avoid falling, had met with a hurt about the hip. He could stand, but was unable to walk, and especially to draw the knee up toward the belly, although this position, with the hip-joint flexed, was the most comfortable to him. There was no shortening of the limb, no crepitus, and no aversion of the foot ; but there was pain in the groin, and tenderness at the inner and upper part of the thigh. After a time, he got about on crutches, and could even walk a few steps without them ; but he never fully recovered the use of the limb. He died five or six years after- ward, but no autopsy could be obtained. I thought at the time, and still think, that in this case there was a tear- ing ofi:' of the trochanter minor ; he was very thin, and I could feel the bone on^ the other side, but possibly the swelling and tenderness prevented my doing so at the seat of injury. I regret very much that the true state of the parts could not be determined by dissection, but feel that even without such completion the case is of sufiicient interest to be presented for what it is worth. Fractures of the shaft of the femur are in adults very common acci- dents. By some authors, those which aflect the bone just below the trochan- ters are placed in a separate class ; but although, like those of the surgical neck of the humerus, they present some special features, these are not so marked that they cannot be pointed out in the course of the discussion of the general subject. ^ The shaft is much more frequently broken in its middle portion than near either end ; and this statement holds good in regard to both sexes and all ages. Adult males are more liable to the accidents producing this injury than females or children, and hence afford a majority of the cases. Hofmokl has reported^ the case of a child, not rachitic, born with a united fracture of the femur, and I have known of more than one instance in which this bone ,has given way during the process of artificial delivery. When the accident is due to the use of the blunt hook, in breech presentations, the upper por- tion of the bone is for obvious reasons most likely to sutfer. Looked at from without, the shaft of the femur always presents a more or less marked curve, convex anteriorly, and a slighter curve convex exte- riorly. Very rarely it is found to be almost straight. On examination in section, the anterior wall is seen to be thinner than the posterior, where the bony substance is massed into a very thick and strong ridge, the linea aspera. Partly on account of this arrangement, and partly by reason of the bone's 1 Med.-Chir. Transactions, vol. xiii. 2 Qp, ^[^^^ ^ 2Y2. 3 Archiv fur Kinderkranklieiten, Bd. iii. S. 370. Stuttgart, *188l! FRACTURES OF THE FEMUR. 201 curved shape, the direction of fractures in this region is apt to be oblique from above downward and from behind forward. A few instances are on record of almost longitudinal fracture. Thus, in the Warren Museum, there i^^ a speci- men^ described as follows : The upper portion of the femur, showing a recent and very oblique fracture at some distance below the trochanters ; and from it a longitudinal split upwards, and through the great trochanter. Also a fracture of the neck, just above the trochanters." A specimen which is in the Lyons Museum, and photographs of which Mr. Morris showed to the Pathological Society of London, ^ is said to present a fracture extending "from the neck to the lower third, dividing the bone into two almost equal portions, which had united by a few narrow bands of bone." A case of very oblique, almost longitudinal, fracture in a lad, which became the occasion of legal proceedings, has been reported by Dr. Hunt.^ Spiral fractures have been sometimes observed, as well as fissures ; in either case the part affected is more apt to be either the upper or the lower than the middle portion of the bone."* Sometimes the bone is broken in two places, as in a specimen ^in the Museum of the Pennsylvania Hospital,^ in which "the upper fracture runs obliquely from within outward, and from below upward, about two inches below the trochanter major; the lower one being a jagged, slightly commi- nuted fracture about three inches above the condyles." Malgaigne mentions that in the Musee Dupaytren there is an example — the only one known to him — of a triple fracture. He does not describe it further. The causes of these fractures are very various. Direct and indirect vio- lence, and muscular action, have all been observed, the second perhaps rather more frequently than either of the others. Cases of so-called spontaneous fracture are more common in the femur than elsewhere, by reason of the great leverage afforded by the length of the bone. One of the most remarkable of these was recently reported by Rankine.^ It was the case of " a child aged six years, who, as the mothei' reported, was simply walking across the floor, wdien its leg doubled up, the child falling instantly to that side." The femur was found to be fractured in the middle third. The mother declared positively " that she was looking at the child walking over the floor at the time, and that there was no stumbling or any- thing, but only the leg seemed to double by the mere act of walking. It may be mentioned that the child did not seem to be in the best of health, althou2:h nothing very particular could be detected about it." Another case, in" a vigorous man aged thirty, is recorded by Gosselin.^ I have treated a man, about twenty-five years of age, who fractured the shaft of the femur in pull- ing on a boot ; he had done the same thing previously by stepping down from a chair ; there was no evidence whatever'of constitutional taint or disorder.® Humphry^ records a singular case in which a woman aged fifty-six was twice » Catalogue, p. 183, No. 1074. s Lancet, Nov. 5, 1881. ' American Journal of the Medical Sciences, Jan. 1879. * These spiral, spiroid, cuneiform, helicoidal, or screw-like fractures, as they have been variously named by the authors who have treated of them, are certainly interesting, but I must confess I have never myself seen a specimen of the kind in the femur. HoUhouse and Morris (Holmes's System of Surgery, 8d ed. vol. i. p. 1021) give a good description of them, with references to the somewhat scanty literature of the subject. From that source I derive the following : Gerdy, Chirurgie pratique, tome iii. ; Fere, Fractures par torsion de la partie inferieure du" corps du Femur ; RauUet, Des Fractures h^licoidales (These), 1880. 5 Catalogue, p. 31, No. 11355. 6 Lancet, March 31, 1883. 7 Clinical Lectures on Surgery, Stimson's Translation, p. 188. Philadelphia, 1878. 8 The reader will find an interesting paper "On Fractures of the Femur in Adults, without pre-existent Osseous Disease," by Clarence Foster, in the Med. Times and Gazette for July 17, 1880 ; and another by Vallin, in the same journal for Nov. 6, 1880, taken from the Gazette Heb- dom. de Med. et de Chir. (Paris), 10 Sept. 1880. * British Med. Journal, June 6, 1857. 202 INJURIES OF BONES. the subject of apparently spontaneous fracture of the femur ; the bone on the right side giving way in May, 1855, and that on the left in March, 1857. On both occasions the affected part had previously been the seat of sharp pains. Union had taken place favorably. But reference has already been made at sufficient length to this subject, in the general part of this article. The femur has been the seat of many of the so-called " spontaneous" frac- tures in cases of cancer. A remarkable instance of this kind has lately been reported by Mr. Hamilton.^ It was that of a woman aged Hfty-six, who had " a well-marked case of scirrhus," for which the right breast w^as removed, the wound healing well ; about three months afterward, she felt the right femur give w^ay, and fell to the ground. The curious fact in the case is that she ultimately had union, although with four inches of shortening — the latter having been due to her placing herself for a time under the care of an igno- rant bone-setter. Generally, a fracture produced under such circumstances fails to unite. Fracture seldom occurs, except as the result of direct violence, at any point near the middle of the femur. The reason of this would seem to be the fact that tlie mechanism in other cases is leverage, and that this can scarcely ever be applied so that just the same force shall be exerted on the two halves of the bone. Generally, there is a very great preponderance of force at one end, so that one arm of the lever is virtually much longer than the other. The immense strain put upon the femur by this leverage is shown by the occasional instances in wdiich even perfectly strong and well-developed bones are snapped under it. I have seen a case in which a man of remarkably robust frame, in running, caught his foot in a hole in the ground, and broke his femur in the middle third.^ But besides the mere leverage, irregularly exerted as before said, there is another force, a twisting, which cannot be left out of the account, although it is extremely difficult to estimate it w^ith any accuracy. Thus, in the last-mentioned case, the foot being arrested while the momentum of the body carried the upper part of the femur forward, the shaft of the bone was acted upon above through the cervix, while below, at the knee, the condyles were held more or less exactly transverse. Under ordinary stress, such a twist would make no difference ; but as the force applied is in- creased, the effect of the twist is to augment in a still greater ratio the actual resistance demanded of the bone. It can hardly be maintained that the large and powerful muscles surround- ing the femur, and acting upon it either directly or indirectly, are without influence in the productfon of its ordinary fractures, as they certainly have an effect in keeping up its displacements when broken. But in the former case their action is accessory only, and its degree is not easy to estimate. It probably varies in different cases. Fracture having once occurred, the fragments may act upon one another to produce still further damage; as in a case reported by Bennett,^ in which the femur gave way in its upper third, and it seemed clear that the lower fragment was driven into the upper, splitting and Assuring it. Another in- stance was communicated by Bryant to the Pathological Society of London;* > Lancet, June 2, 1883. 2 In illustration of the force exerted in such actions, I am tempted to quote from Dr. O. W. Holmes, the following passage : " Walking, then, is a perpetual falling with a perpetual self- recovery. It is a most complex, violent, and perilous operation, which we divest of its extreme danger only by continual practice from a very early period of life. . . . We learn how vio- lent it is, when we walk against a post, or a door, in the dark. We discover how dangerous it is, when we slip or trip, and come down, perhaps breaking or dislocating our limbs, or over- look the last step of a flight of stairs, and discover with what headlong violence we have been hurling ourselves forward." — (Atlantic Monthly, May, 1863.) 3 British Med. .Journal, June 26, 1880. * Transactions, vol. xxix. 1878. FRACTURES OF THE FEMUR. 203 it was the case of a man eighty -tliree years of age, who died on the twenty- fiftli day after the accident, when it was found that the shaft of the right femur "had been clearly fractured at the junction of the middle with the lower third, and the extremity of its proximal end was driven to the extent of an inch and a half into the shaft of the distal portion; this process of im- paction splitting the shaft of the distal extremity of the bone, and pi'oducing a second fracture of the bone above the condyles." The symptoias of fracture in the shaft of the femur are for the most part of a very pronounced character. Pain is not always present, although it is in- duced by any attempt at movement, whether active or passive ; but there is total loss of power. Deformity is apt to be very marked, the fragments being drawn up at an angle to one another, and the lower one generally rolled out- ward, the weight of the foot tending to throw it over on its outer side. Often the two broken ends are entirely separated at the anterior part, but posteriorly they are held together by the reinforcement of the periosteum by the strong intermuscular fibrous tissues attached along the linea aspera. This connection may be quite close, but sometimes even here the periosteum is stripped away to a considerable degree, so as to allow a good deal of play to the fragments, and admit of the occurrence of decided overlapping. Swelling quickly takes place, but from the great depth of the bone there may be but slight ecchymosis. Preternatural mobility at the seat of fracture is very perceptible; and crepitus is induced, of course, if the broken ends are rubbed together. Often a mere glance is sufficient to show the nature of the injury. The shortening of the limb, which strikes the eye at once from the position of the foot, may be verified by measurement between the umbilicus, or the anterior superior spinous process of the ilium, and the inner malleolus, as compared with that on the sound side. However carefully made, this measure- ment is very apt not to be absolutely correct, partly because of the mobility of the skin, and partly because of the difficulty of getting exactly the same bony points on each side. But the matter is really one of small consequence, and it is sufficient if the fact of shortening is made out. Ordinarily the dif- ference between the two limbs strikes the eye at once, and may be from an inch to two or three inches. In one case (the reference to which has escaped me), no treatment having been instituted, the ultimate loss of length was four inches. Cases are occasionally met with in which both femora are fractured, and here comparative measurement is, of course, valueless. One such, occurring to a sailor at sea, is reported by Surgeon H. Smith, U. S. N.^ Reference will be again made to this condition of things in connection with the modifications demanded by it in treatment. Sometimes the fever is repeatedly broken at the same point, as in an instance recorded by Humphry ,2 in which a woman aged sixty had in 1856 the fourth fracture at the lower part of the bone, the first having occurred in 1847. Firm union took place, but only after the lapse of eighteen weeks. Grosselin^ mentions a still more remarkable case, in which a young man of twenty had broken his left femur six times in the course of twenty months. Confinement for three months, with the use of phosphate of lime, was resorted to, and the accident did not again occur. Fractures of the shaft of the femur are seldom attended with any serious complications. Hammick^ says that in simple fracture of the thigh he has never seen the large vessels w^ounded so as to endanger the limb ; but he has once seen tetanus. " A filament of the anterior crural nerve was found * Am. Journal of the Med. Sciences, July, 1865. The same number contains an account of another case, in a child aged six, reported by Dr. A. Peter. * British Medical Journal, June 6, 1857. ' Op. cit., p. 192. 4 Op. cit., p. 74. 204 INJURIES OF BONES. stretched through a cleft in the bone, so tense as to resemble a violin-string. The patient had broken his thigh at sea, seven days before the arrival of his frigate in the sound." Burr, however, has reported^ an instance of occlusion of the femoral artery from fracture of the femur ; gangrene of the leg ensued, and amputation was performed. And Weinlechner met with a case^ in which the artery and vein were both ruptured, with hemorrhage and consequent gangrene ; amputation Avas submitted to on the third day, but death from septicaemia followed. Such lesions are much more apt to occur when the shaft of the bone is broken very low down. Thus, Travers^ relates that " a man broke his thigh; the bone protruded above the patella ; at the same time a diffused aneurism of the popliteal artery was produced by a spiculum of the fractured bone penetrating that vessel, though it was discovered only on the fourth day. The femoral artery was immediately tied by Mr. Bransby Cooper, whose patient he was. The ligature came away on the sixteenth day ; in another week the aneurismal swelling had disappeared, and the fracture was soundly united in six weeks." Another case is reported by Mr. B. Cooper,'* in which, the patient having been admitted into Guy's Hospital with compound frac- ture of the femur, there was so much tension of and injury to the soft parts, that it was thought unadvisable to put the limb in splints. During the night spasm came on, and the femoral artery was lacerated by a portion of the splintered bone coming in contact with it. A ligature was placed upon the vessel, and the fracture united so quickly that Mr. Key remarked of the case, that " the quickest way of producing union of fracture of the femur appeared to be by tying the femoral artery." Sometimes fractures of the shaft of the femur are complicated with luxa- tion of the hip, as in the case recorded by Murdoch,^ where the bone was broken in its upper third, and its head lodged upon the ischium ; the latter lesion was only discovered after death, which resulted from hemorrhage con- sequent upon an operation for non-union. Gayet is reported^ to have expressed the opinion that hydrarthrosis of the knee was very apt to ensue upon fracture of the femur. Oilier had seen the same in other joints, and thought it might be due to propagation of irritation through the bone. [According to Gosselin, the intra-articular effusion is due to irritation of the outer surface of the synovial capsule, by the extra vasated blood which gradually finds its way downward from the seat of fracture; hence this symptom may not be observed until some hours or even days after the reception of the injury.] The diagnosis of fractures of the shaft of the femur does not often present any difiaculty. Yet a case was reported, and the preparation shown to the Eighth Congress of the Deutsche Gesellschaft fiir Chirurgie,^ in 1879, of ampu- tation of the thigh in its upper part, by Langenbeck, for supposed malignant tumor, in a man aged forty-eight. There was found, however, only a simple fracture, with great separation of the broken ends, excessive growth of cal- lus, and a distinct false-joint, l^o history of traumatism could be elicited. Analogous cases are said to have been cited by Langenbeck, Martini, Roser, and Kuster. Such cases are certainly rare ; yet, while there can seldom be any trouble in ascertaining the mere fact of the existence or non-existence of fracture, it > Trans, of Med. Soc. of State of New York, 1873. ^ Quoted in the Index Medicns for March, 1883, from the Aertzl. Ber. der k. k. allg. Kranken- haus zu Wien, 1882. 8 A Further Inquiry, etc., p. 436. 4 Lancet, Dec. 5, 1840. 5 Trans, of Pennsylvania State Medical Society, 1878. 6 Med. Times and Gazette, Dec. 30, 1871. ' Verhandlungen, S. 30. FRACTURES OF THE FEMUR. 205 may be by no means easy to determine the character of the lesion or the di- rection of the line of breakage : and this obscurity is apt to be the greater, the further the fracture is seated from the middle of the shaft, either upward or downward. In fractures of ancient date it may be extreme. A child about three years old was some time since brought to me on account of a lameness strongly rcM^embling that of hip-joint disease ; but, on examination, I found that there had been, just below the trochanters, a fracture of the femur which had united lirmly with the fragments at an angle of nearly 90°. The child had, in fact, been\illowed to walk w^hile the callus was yet plastic, and the lower fragment had tilted up the distal end of the upper. The course^oi uncomplicated cases of fracture of the shaft of the femur is generally favorable, union occurring in six or eight weeks in adults, and somewhat earlier in children. Heydenreich^ has reported a case in which union was firm in thirty-five days, and Henderson^ one in which an oblique fracture near the middle, in a woman eighty-nine years old, had united solidly on the forty-fourth day. Lee^ saw a case of union of a broken femur in a man aged ninety-eight. False joint or pseudarthrosis has been met with, and is difiicult to rnanage on account of the great mass of muscle, making it very hard to keep the comparatively small ends of the broken bone together. Operative interference in these cases is attended with peculiar danger ; but this subject has been already spoken of in the general part of this article. Williams'* has recorded a singular case, in which a man, aged seventy, sustained from direct violence a fracture in the upper part of the lower third of the femur, about half an inch above the point of entrance of the nutrient artery. Union took place with overlapping ; the upper fragment was atro- phied and conical, the lower presented a good deal of callus, and was of full size. Union with deformity is of far more frequent occurrence, and, in fact, if all shortening, of what- ever degree, be considered as deformity, it may be said to he universal. When the fragments are kept wholly apart, they may altogether fail to unite, but it very seldom, indeed, happens that such is the case. A much more general event is tliat part of the periosteum remains untorn, and bridges across the interval between the fragments, which thus be- come connected by means of an intermediate for- mation of callus. (Fig. 841.) It is astonishing how strong a bone is when united in this way, and how little^inconvenience and deformity ensue, provided only that there is a parallelism of the long axes of the two fragments, and that there is no rotary dis- placement. Of course, how^ever, exact coaptation is far preferable when it can be secured. I shall have to refer to this matter again in connection with the subject of treatment, and hence it need not ^^.^^^^^ ^^^^.^^ ^ ^^^^^^ be dwelt upon just now. a bridge of caUus 1 Mem. de la Soc. de Med. de Nancy, 1882. (Index Medicus.) 2 London Med. Gazette, Jan. 13, 1843. 3 St. George's Hospital Reports, vol. iv., 1869. * Dublin Med. Press, April 17, 1844. 206 INJURIES OF BONES. From what has been said, it will be inferred that the j^rognosis will vary according to the circumstances of each case. It is certainly better for the surgeon to be very guarded in making promises or predictions as to the result, since the patient or his friends may be greatly disappointed at even a slight and unavoidable degree of deformity, A strong and serviceable limb is in the vast majority of cases obtained, but occasionally there is a permanent halt in the gait. The treatment of fractures of the shaft of the femur is a subject which has engaged the attention of surgeons for a very long time, and upon which much ingenuity has been expended. The end which has been most earnestly sought has been to devise means of making extension and counter-extension, for the purpose of overcoming the shortening which is the most obvious consequence of these injuries. Yet, by some this method has been wholly discarded, and the best results have been claimed from merely putting the limb in such a posture as to relax the muscles. At the present day, there are very able advocates for the use of lateral compression by means of solidifying bandages, to the exclusion of all direct extending apparatus. The adherents of these various plans have for the most part brought forward measurements, purporting to be accurate, of the limbs treated by them, in evidence of the completeness with which shortening was avoided. But I think that to speak of a shortening of an eighth, or even of a quarter, of an inch in the lower extremity, is a refinement beyond practical comprehension. I do not believe that ten, or even five, surgeons, examining a case inde- pendently, and without bias as to the method of treatment which had been pursued, would agree within an eighth or a quarter of an inch in their results. Hence I should decline to accept such statements implicitly, re- garding them as over-precise. Practically, if a limb is in good line and free from rotary displacement, a shortening of half or three-quarters of an inch is a matter of small moment. Extension and , counter-extension ought, in my opinion, to be carefully and eftectively made, and the length of the limb maintained as accurately as possible, attention being given quite as sedulously to the preservation of its proper line. It would occupy too much space to attempt to give here a full description of all the forms of apparatus which have been at various times proposed and employed in the treatment of fractures of the shaft of the femur, although the subject is really one of the most interesting in the history of practical surgery. I shall first describe the method of dressing these injuries which I myself use, and which is employed by many others, and then some of the modifications of it which may be required to adapt it to special cases. After- ward, I shall mention some other plans of treatment, and, lastly, will give briefly some historical points in^regard to certain portions of the" apparatus. When a patient with a broken thigh-bone has to be transported to a place where he is to be treated, whether to a private house or to a hospital, especial care should be taken to guard against needless disturbance of the fragments. A very good plan is to take a board about six inches wide, and long enough to reach from the axilla to the foot, and to place this on its edge along the side of the patient. The limb, having been drawn out as nearly as may be to its normal length, may be surrounded with a bundle of straw, or with a folded auilt or blanket, and then bound to the board with a number of broad strips of muslin or linen, the body being also confined in the same way. If another board is now slipped under the pelvis and lower extremities, the patient can be carried very comfortably. Arrived at the place of destination, a bed is prepared with a firm, hard mattress, perforated or not,i and the patient's clothes are removed. As far See page 56, FRACTURES OF THE FEMUR. 207 a.6 possible, the exact seat of fracture is now determined, and the amount of shortening is ascertained by measurement. A strip of good adhesive plaster, about three inches wide, and long enough to reach from the seat of fracture down one side of the limb to four inches below the heel, and up along the other side of the limb to the point of fracture again, is well warmed and applied, leaving a loop of eight inches below the sole of the foot. In this loop is placed a piece of thin board three inches square, and close to it, at either side, a small slit is cut in the plaster, thi-ough which a cord or strip of bandage may be passed. Three or four transverse strips of adhesive plaster, or a roller, may be applied to keep the longitudinal strips in exact contact with the skin. A pul- ley is now placed at the foot of the bed, either on a tripod with one long foot, extending under the bed, and two at right angles to it, or on a rod attached to the bedstead frame witli a clamp. An ingenious apparatus for attaching the pulley has been devised by Dr. Sheppard.^ One fok-ni of it is intended for cribs or beds with high foot pieces, the other for the ordinary iron bedstead in use in hospitals. I have sometimes screwed the pulley into the foot-board when the bedstead was so made. In the case of some iron bedsteads, a pulley may be made with a spool and a piece of wire, the latter being run through the former, and then bent up and curved into two hooks to catch on to the bar of the bed-frame. The patient is now to be placed in the bed, the foot of which is elevated a few inches by means of a couple of bricks ; the cord is passed over the pulley, and the surgeon proceeds to make extension and to adjust the fragments. Sometimes the services of assistants are required in doing this, and occasion- ally anaesthesia must be induced. If the limb be a very muscular one, and the displacement great, one assistant may grasp the foot and another the upper part of the thigh ; the force used must be very gentle and gradual, and, while it is exerted, the surgeon carefully handles the fractured part, and coaxes the broken ends into their normal relation. Sometimes, in old people, or in persons of no great muscular development, the adjustment is readily made, and as easily kept up by moderate traction. But in the strong, or in those whose nervous systems are excitable, a good deal of power has to be exerted. The weight to be used depends greatly upon these circumstances ; sometimes it is but small — perhaps two or three pounds — and again it may require ten or tw^elve pounds to overcome the muscular resistance. One, two, three, or four bricks may be thus used, or bottles of sand, or regular weights placed in a frame ; the latter device is adopted in some hospitals. Sand-bags, to give lateral support to the limb, are of great service ; they are made of muslin, are long enough to reach, one from the heel to the peri- neum, the other from the heel to above the crista ilii, and should be ten or twelve inches in circumference. They ought not to be too tightly stuffed, hut should be capable of adaptation to the outline of the limb. Whenever the patient is restless, or if there is a tendency to angulation of the thigh forward or outward, or both (it very seldom bends inward or backward), one or more ^' coaptation-splints" maybe employed. Binder's board or felt answers best for this purpose, a piece of suitable size being soft- ened hi hot or cold water, and moulded to the normal shape of the thigh ; after which it is to be carefully padded, and applied with a roller, or with three or four w^ide adhesive strips.^ If the foot shows any tendency to dis- placement, whether outward or inward, this must be carefully corrected, as it indicates rotation of the lower fragment ; and the proper position must 1 Medical News, Jan. 7, 1882. * The plaster should always be cut for this purpose in the length of the piece, and not across it, lest it should yield and stretch. 208 INJURIES OF BONES. he secured by a loop of bandage around the foot, fastened to the sand-baff or the side opposite to that toward which the foot inclines. Certain details must be attended to in making all these arrangements, in order to the effective working of the plan. The adhesive strips must be smoothly fitted, and not allowed to wrinkle, lest the skin should be irritated ; the circular pressure should not be tight enough to obstruct the return of venous blood along the limb; the pulley must be placed at the proper height, and exactly in the line of the long axis of the limb. Should the con- stant pressure on the heel give rise to any soreness, a mass of carded wool or cotton may be placed a little above, so that the limb may rest on a different point ; it is better, however, to guard against any such trouble by protectino- the skin with a patch of soft kid spread with soap plaster. The proper adap- tation of the w^eight to the necessities of each case is a matter of much conse- quence. It will be perceived that in this plan of treatment the counter-extension is exerted by the weight of the body, by reason of the elevation of the foot of the bed, a device credited by Hamilton to Dr. Van Ingen, of Schenectady. The w^eight and pulley, distinctly described by Gui de Chauliac in the four- teenth century, was brought forward in modern times by John Bell, in 1801, and in this country, in 1824, by Dr. Luke Howe, and again in 1829, by Dr.' Daniell, of Georgia.^ Its most prominent advocate, however, was the late Dr. Gurdon Buck, of ^ew York, whose name has been generally attached to the method since he revived it in 1861.^ To show how thoroughly developed it had formerly been, however, I may perhaps quote the following passage from Le Clerc : — ^ " To hinder the Patient from turning cross and sliding down toward the Feet of the Bed, you must plant a Stake into the Floor, underneath the Bed, and pass it through the Matting and Bedclothes, so that it may be between the Patient's Legs. This ought to be as thick as the small of the Arm, and covered with some Stuff or other, that it may not hurt the Patient. And for greater security, let it be ty'd with an equal Girth to the Patient's Thigh above the Knee ; and let each Branch or Tail of the Girth pass on each side the Knee, exactly on the middle, and over two Bullies (fastened at the end of the Bed's Feet), and at the end of them let there be two Weights suspended to draw the Thigh, and keep it in a streight Posture. The Thigh must be wrapt round with a Bolster'^in the Place where the Girth is, that it may not hurt it." When the fracture is very high up, just below the trochanters, there is apt to be not only the drawing upward of the lower fragment, but a tilting up- ward and forward of the upper one, by contraction of the psoas and iliacus'mus- cles. Perhaps this fragment is also rotated outward by the glutei and other rotator muscles at the back of the hip ; but I have never seen this distinctly. Under such circumstances there is so little purchase upon the upper fragment, that it is apt to remain in its abnormal position in spite of every effort to bring it down ; and the result is that when union takes place the limb is not only permanently shortened, but deformed and seriously disabled. I believe that in such a case the only resource is to make the lower fragment follow the upper, by raising the knee and flexing the whole thigh upon the pelvis. This may be done by means of the double-inclined plane in some form, or perhaps even by the single inclined plane, as the latter would produce no tension upon the muscles of the front of the thigh. The double-inclined plane is merely a framework, generally hinged so that the angle can be 1 The reader will find an excellent article on the history of this subject, by Dr. E. Hartshorne, in the American Journal of the Medical Sciences for April and July, 1869 2 Arn(!rican Medical Times, March 30, 1861. 3 The Compleat burgeon, etc. London, 1727. FRACTURES OF THE FEMUR. 209 changed at will ; one part of it is intended to support the thigh, while the leg rests upon the other, the angle occupying the bend of the kiiee. Exten- sion may be made by means of a pulley attached either to the apparatus itself, a frame being added for the purpose, or to a standard lixed at the foot of the bed. The single inclined plane, as its name imports, is a board inclined at an angle, upon whicli, properly padded, one or both of the patient's lower limbs may rest. Extension may be made by means of a pulley fixed at the upper end of the board. One objection holds against both these forms of apparatus ; there is much difficulty in preventing the patient from w^orking his body up on to the inclined plane, so as to neutralize its effect more or less completely. Possibly this object might be accomplished by having a perineal block, or a well-rounded upright arranged at a suitable point. But it would perhaps be better to have recourse to one or other of the suspensory splints to be pre- sently described. Dr. Swinburne, of Albany, advocates^ the treatment of fractures of the shaft of the femur by simple extension, using a perineal band attached to the head of the bed, and fastening, the lower part of the limb to the foot of the bed, by means of adhesive plaster and a cord. Without disputing Dr. Swinburne's statements as to the results obtained by him in this Avay, I can- not but think that the less rigid methods are at the same time more com- fortable to the patient, more adaptable to the varying circumstances under which fractures occur, and more likely to be satisfactory in the hands of most practitioners. Plastcr-of-Paris bandages were strongly recommended a few years ago by Dr. Sands,2 of I^ew York. They were applied during complete extension, and sometimes under anaesthesia. Whether acknowledged or not, the efficacy of this method must have largely depended upon the extension made against the swell of the leg below the knee, and the counter-extension against the upper portion of the thigh ; and the lateral compression must have been at once lost if the thigh. itself diminished in size, as it naturally would do fron:k total inaction. My own experience of this plan is limited to a very few cases in children, in which it afforded good results. It seems to me that here, where there is but slight muscular power to be counteracted, and the small size of the bone makes the leverage on the fragments but trifling, the plaster- of-Paris or other solidifying dressing, especially the silicate-V-potassium, is much less objectionable than in the case of adults. Hamilton, however, holds the opposite view. He says : " If I have been unable to give my ap- proval to the treatment of fracture of the shaft of the femur in adults with plaster of Paris, or to any other form of immovable dressing, I am still less able to give it my approval in fracture of the same bone in children." He then relates a case of gangrene in a boy four years old, treated on this plan ; but, according to the account, there was unpardonable neglect on the part of the surgeon, and nothing is proved against the treatment" if carried out with ordinary skill and judgment. The method devised by Dr. Nathan Smith, and improved upon by his son, the late Dr. i^athan R. Smith, of Baltimore, has had a wide popularity in this country, especially in the Southern States. As at first made, the appa- ratus consisted of a wooden splint, cut so as to fit along the front of the entire limb, from the groin to the toes, the hip and knee being each flexed to about 135°. To the under side of this splint the limb was carefully band- aged, and then slung by means of two staples driven into its upper face, one ^ Treatment of Fractures of Long Bones by Simple Extension. Albany, 1861. 2 New York Medical Journal, June, 1871. VOL. IV. — 14 210 INJURIES OF BONES. above and the other below the knee. By changing the point of suspension, a more or less considerable degree of extending force was applied to the limb, the weight of the body upon the bed giving the counter-extension. Afterwards, this splint was modified by substituting for the wooden splint a wire frame, suspended by means of wire loops. One advantage of this is that it may be bent so as to suit limbs of various lengths. The cord attached to the splint runs through the loop of another cord, which passes over a pulley fastened in the ceiling, or in a frame over the bed ; and this latter cord is passed through what is known as a tent-block, by means of which it may be tightened up or let out, so as to raise or lower the limb at pleasure. (Fig. 842.) . Fig. 842. Smith's anterior splint for treatment of fractured thigh. By the late Dr. Hodgen, of St. Louis, a somewhat similar splint was used, but, instead of being bandaged to it, the limb was suspended in it by means of strips of muslin, so that it formed a sort of cradle. (Fig. 843.) With both these forms of apparatus good results have been obtained in a very large number of cases. Yet in one instance seen by me, that of a man treated by an experienced surgeon, and an enthusiastic advocate of Smith's method, the fragments had united at an angle backward, and such pressure had been made upon the sciatic nerve as to give rise to very serious symp- toms, only partially relieved by an operation. 1 may mention that Dr. J. R. Taylor, of 'New York, has recently^ published an account of a " saddle" attached to an iron brace, and fitting into the peri- neum, for the purpose of making counter-extension, extension being made by means of a coiled spring. Dr. Brownrigg, of Tennessee, has described^ an apparatus of his own, in which counter-extension is made by means of a ^ .lounial of Am. Med. Association, Sept. 1, 1883. 2 Trans, of Mississippi State Med. Association for 1881, quoted iu the College and Clinical Record for August 15, 1883. FRACTURES OF THE FEMUR. 211 jacket of stout muslin. Neither of these plans seems to me to possess any advantages over other methods more generally known. Fig. 843. Hodgen's suspension splint for treatment of fractured thigh. Mention has already been made, in a previous part of this article, of certain forms of apparatus known as fracture-beds. These contrivances, of which the best known perhaps were Earle's, Amesbury's, Crosby's, and Burge's, were mostly on the principle of the double-inclined plane, but some of them were arranged for making extension with the limb straight. They were all com- plicated and expensive, and liable, when used in hospitals, to become iniested with bugs. At the present day, I think that they may be said to have been abandoned. Vertical extension has been recommended in cases of children, by Klimmel,^ who applies adhesive plaster in the manner before described, and keeps the leg in the vertical position, with the corresponding side of the pelvis suspended by means of a cord fixed to the loop of plaster, and either attached above to some object over the bed, or slung over a pulley, with its free end support- ing a weight. A curious eftect of this treatment, in female children, is the occurrence of vaginal catarrh, which, however, soon yields to appropriate measures when the extension is no longer kept up. Bryant recommends ver- tical extension of both the sound and the injured limb. A few words may now be said as to the development of the present methods of treating fractures of the shaft of the femur, and especially in regard to certain points. Benjamin BelP describes an apparatus, invented, he says, by Gooch, and improved by Aitken, which promises to be of the greatest utility in oblique fracture of the thigh." It consists of two leather straps, one buckled around the upper part ot the thigh, the other around the lower part ; two or three steel splints, connected with the straps, pass from one to the other in such a manner, that by means of them the straps can be forced asunder," thus making extension and counter-extension. If such an apparatus could be borne by the patient, it would seem that there would be great danger of undue pressure, Avith serious consequences. Besault's splint extended from the crista ilii to the sole of the foot. It was ' Am. Journal of the Med. Sciences, July, 1882 ; from Berl. kliu. Wochenschrift, No. 4, 1882. * System of Surgery, vol. vi. London, 1788. 212 INJURIES OF BONES. notched at either end, and the upper and lower turns of the bandage con- fining the limb to it were cast through these notches, so as to make an im- perfect and inefficient extension and counter-extension. Phjsick lengthened this splint both ways, extending it up into the axilla, and downward beyond the foot ; he also contrived a gaiter to be placed over the ankle, in place of the figure-of-8 bandage previously employed, and introduced the perineal band, afterward padded by Coates, for counter-extension. Hutchinson added a block on the inner side of the long splint, below the foot, over which the extending 'band passed, thus bringing the force into line with the axis of the limb. The iiitroduction of adhesive plaster for securing the extending band to the limb, an invention the paternity, of which has never been satisfactorily established, but which is certainly of American origin, was a great step in advance. By Gilbert^ the use of the same material for counter-extension was strongly advocated. Yet the extension and counter-extension, however carefully made, were apt to become relaxed, and various means were tried with the view^ to make them constant. I myself employed an India-rubber accumulator f and the same idea was subsequently brought forward by Buckstone Brown^ and others in England. It was not, however, until the revival of the old weight- and-pulley extension that the problem was solved ; although, indeed, the sus- pension splint of Dr. i^athan Smith, before mentioned, may be regarded as capable of answering the same end. In the foregoing slight sketch, many things have been omitted which would deserve description in a history of the developmicnt of the treatment of these fractures. Such are, for example, the inside splint of Physick's apparatus, and the splint-cloth by which it and the other splint were connected ; the various forms of apparatus in which it was attempted to " make the sound limb act as a splint for the injured one;" the different arrangements of screws for making extension; and the perineal block for counter-extension. All these devices have been so completely superseded that it seems to me need- less to enter into detail with regard to them. After the descriptions now given of elaborate contrivances for the treat- ment of fractures of the shaft of the femur, and the importance evidently assigned by surgeons to the prevention of shortening, the reader may well be surprised to know that there have been advocates of the use of a simple roller bandage in these cases. This plan, which is a good deal more than a step beyond that with the plaster-of-Paris or starched bandage, was first proposed by an English surgeon named Eadley. Dr. Dudley,^ of Kentucky, claimed great merit for it, but without succeeding in gaining for it the favor of the profession at large. It would certainly be a difiacult matter to convince a jury, if a dissatisfied patient should seek for damages in a case so treated, that due care had been exercised to obtain the best possible result. Bryant, however, tells us that, in St. Bartholomew's Hospital, both Paget and Callender were in the habit of treating all cases of fracture of the shaft of the femur, in children, without splints or other apparatus ; " the child being laid on a firm bed, with the broken limb, after setting it, bent at the hip and knee, and laid on its outer side." Bloxam^ makes a similar statement. It may serve as an additional illustration of the diversity of views that may be held on practical subjects, if in contrast with those given on the fore- 1 Am. Journal of the Med. Sciences, Jan. 1858, and April, 1859. 2 Ibid., July, 18G2. » Lancet, Oct. 10, 1874. 4 Am. Journal of the Med. Sciences, Nov. 1836 ; from Transylvania Journal of Medicine, etc., April, 1836. 6 St. Bartholomew's Hospital Reports, 1867. FRACTURES OF THE FEMUR. 213 going pages, as to the necessity of extension and counter-extension in the cases in question,! quote the following: Winchester' lias advanced the opinion that muscular contraction "is, if rightly understood, a natural power of in- estimable value, supplying the exact amount of forcible contact between the broken surfaces necessary to excite healthy reparative action in the most speedy and perfect manner, accurately adjusted to the functional capacity of each individual case." When union has taken place with the fragments in had jposition^ in fractures of the shaft of the femur, the correction of the deformity is highly desirable, since, if left to itself, it entails upon the patient a lameness which not only is unsightly and mortifying, but may be a very serious hindrance to his gainilig a livelihood. Generally, the best procedure in such cases is forcible refracture under anaesthesia. Numerous instances of this kind have been recorded. Xorris^ gives references, asid more or less of detail, in regard to some twenty- five cases, all but three of which were successful. One, operated on by Bon- tecou, is recorded among the experiences of our late war.^ Fayrer^ gives two, in one of which the bone was broken at two points — at the middle and in the lower third. The patient, an English boy fourteen years of age, had. met with his accident at sea. Both cases did well. Buck* has recorded five. A very remarkable case of multiple fractures, one of which, in the femur, united with deformity and was corrected by re-fracture, is recorded by Tifiany.® I myself had occasion, some years since, to rectify a fractured femur in a boy nine years old, which had been badly treated in the country, and had united with marked overlapping as well as slight angle outward ; the callus gave way readily under ether, and the little fellow recovered so as to walk without any perceptible limp. It is well to bear in mind that in conducting a procedure of this kind a good deal of force may be saved, by not only bending the bone, but giving it a slight twist also. Extension should be cautiously made in these cases, lest if it be suddenly and too strongly efi:ected, damage should result to tliQ soft parts, and especially to the vessels. I have seen death caused in this manner. Subcutaneous osteotomy may sometimes be resorted to witli advantage, as in a case reported by Verneuil,^ this plan being preferable when the bone is afiected near a joint, or when the injury is of such ancient date that union is probably very firm. The details of the operation are much the same as when it is practised in other cases, and the after-treatment does not difter materially from that of accidental fractures. Resection through an open wound, a procedure attended with much greater risk, was many times prac- tised, and with a considerable degree of success, by the older surgeons.^ It is now almost wholly abandoned in favor of the improved method just mentioned. Occasionally, when the callus has not yet become thoroughly solidified, it may be bent into proper shape by firm but gentle pressure applied by means of well-padded splints and compresses, or by bands attached to the bedstead. A case so treated with success at the tenth week, extension and counter-ex- tension being also used, has been reported by Michener.^ > Lancet, Aug. 22, 1863. 2 Contributions to Practical Surgery, pp. 112 et seq, * Med. and Surg. Hist, of the War of the RebeUion, Part III., Surgical Volume, p. 651. * Indian Medical Gazette, March 1, 1872. * Transactions of N. Y. Acad, of Medicine, 1855. 6 Trans, of Medical and Chirurgical Faculty of Maryland, 1874. 1 Bull, de la Societe de Chirurgie, 5 Dec. 1882. « See Norris, op. cit. 9 Am. Journal of the Med. Sciences, Jan. 1848. 214 INJURIES OF BONES. Com.'pound fractures of the femur are always of serious importance, involving a good deal of shock, and presenting sometimes great difficulties in their treatment. When amputation is not indicated, the surgeon has to choose, among the various plans already described, the one which seems best adapted to the circumstances of the case. Often the plaster-of-Paris bandage, fene- strated so as to give access to the wound for the purpose of dressing it, and combined with suspension, presents great advantages. But in the majority of cases, the ordinary arrangement for extension, by the weight and pulley, will answer quite as well, allowing the wound to be dressed and the limb com- pletely supported. I believe this method, carefully carried out and properly watched, to be the best, except in cases of very restless patients, as for exam- ple those who have delirium tremens; for such the plasrer of Paris, with moulded splints, may be temporarily employed with great benefit. Much depends upon the situation, size, and depth of the wound ; and no general rules can be laid down which shall cover the various conditions presented by even a small number of cases. Fractures of the lower 'portion of the shaft of the femur are by no means as frequently met with as those higher up in the bone. They have, in most of the recorded cases, affected adult males. Opinions have varied as to their causes; Sir A. Cooper says^ that they happen " when a person falls from a considerable height upon his feet, or is thrown upon the condyles of the os femoris with the knee bent." Hamilton concurs with him ; but Malgaigne says, " These fractures seem to me to be chiefly produced by direct causes." Probably the experience of different surgeons, or of the ?ame surgeon at dif- ferent times, may differ in regard to this point as upon many others. Mal- gaigne had seen only two cases from indirect causes, but seven from direct. Among the former cases is perhaps included one previously published by him,2 to which, however, he makes no reference in his work ; the fracture was due to rotation of the knee in an attempt to reduce a luxation of the hip-joint. How^ever produced, these injuries present very various conditions, differing materially from those of other portions of the bone. At its lower portion, the femur broadens toward the knee, and just above the condyles swells out quite abruptly. Its cancellous structure resembles that of the lower portion of the radius, except that the downw^ard direction of the lamellae is more dis- tinctly marked ; and I think that sometimes the " cross-breaking strain" must be admitted as the true mechanism of its fractures also. Generally, the principal direction of the fracture is obliquely downward and forward ; but Hamilton mentions an instance in which it ran dow^nward and backward, and in which gangrene of the foot occurred, apparently from pres- sure of the lower end of the upper fragment upon the vessels. In one case, recorded by the same author, both femora were broken just above the condyles, by a fall from a fourth-story window, the patient alight- ing upon his feet. A very singular specimen, in the Museum of the Pennsylvania Hospital, is thus described :^ " An oblique fracture, which commences at the linea aspera, about six inches above the condyles, and extends spirally inward and down- ward, completely circling the bone until it reaches within an inch of the con- dyle. The beginning and end of this line of fracture are united by two other lines of fracture extending upward from the lowest point until they reach the upper end of the spiral fracture. These have separated a bony fragment of the > Dislocations and Fractures of the Joints, p. 244. 2 Gazette des Hopitaux, 15 Fev. 1838. 3 Catalogue (Supplement), p. 37, No. 114116. FRACTURES OF THE FEMUR. 215 outer part of the shaft from the remainder, and thus completely severed the condyle-portion from the upper part of the bone." The patient, a man aged iifty-nine, had fallen from the height of a ladder. Another specmien in the Hanie museum,^ taken from a man aged thirty-five, who had also fallen from a beio-ht, shows a fracture about two inches below the trochanter major, Lesides " a jagged, slightly comminuted fracture about three inches above the condyles." Sometimes, as in two cases recorded by Ilamdton,^ the long anterior point of the upper fra2:ment projects so as to give trouble; in one of Hamilton's case& resection was required in order to effect reduction. Spence^ has published an account of a very similar ca^^e, the sharp point of the upper fragment pro- jectino-, covered merely by the skin, and with the patella apparently locked between it and the condyles. Reduction was attempted in vain, and the patient died on the fourth day, having sustained other grave injuries. It was then found that the bone had penetrated through the vastus externus and crureus muscles, and the edge of the tendon of the rectus, on dividing which transversely, reduction became possible. The condyles were found to be separated and comminuted. Occasionally , the lower fragment is tilted down backward, as mentioned by Boyer, and observed much more recently by Erichsen, Bryant, and others ; the displacement is ascribed by these surgeons to the traction exercised by the o;astrocnemius muscle, which, it has been proposed, should be relaxed by division of the tendo Achillis. Three cases so treated have recently been placed upon record by Treves.-* I believe the cause of this rare displacement to be the upward pull of the muscles at the back of the thigh, forcing the lower fragment against the upper, by which it is again pressed backward. I have "cited from Hamilton a case in which the circulation was interfered with by the pressure of one fragment upon the vessels ; Laurent^ quotes a case in wdiich a popliteal aneurism was thus developed, necessitating ligature of the femoral artery. Injury to the peroneal nerve from like cause has lately been reported by Lauenstein.^ The symptoms and diagnosis of fractures of the lower part of the shaft of the femur need hardly be dwelt upon at much length. Pain, helplessness of the limb, swelling^ deformity, and crepitus may be looked for. The main difficulty will be to determine the exact extent and direction of the lesion of the bone, and whether or. not it involves the joint. For it must be remembered that even if an arthritis be not set up, there will still very probably be some effusion, and that this, along with the rapid swelling of the neighboring soft parts, will obscure the precise condition of the bone. I think that the degree of lateral mobility of the leg upon the thigh (the real point of motion being, however, above the knee)* may be, to some extent, relied upon as indicating the state of the condyles ; if it is very free, they have probably suffered. Anaesthesia should always be induced for the pur- pose of making this examination, which should be cautiously and gently conducted ; and if the question is not readily settled, it is far better not to be 1 Catalogue, p. 31, No. 1133*. « Op. cit., p. 489. 8 Am. Journal of the Med. Sciences, July, 1848, from Monthly Journal and Retrospect of Medi- cal Sciences (Edinburgh), May, 1848. 4 British Med. Journal, Feb. 17, 188a. ^ Op. cit., Obs. XXI. p. 36. 6 The quotation is thus given in the Index Medicus for February, 1883 ; Bruch des Obersch- enkels oberhalb der Condylen, Dislokation des unteren Fragmentes nach der Knie-kehle, mit Ver- letzung des N. peroneus ; Befreiung des Nerven durch Resektion des vorspringenden Knochen- fragmentes (Fracture of thigh just above the condyles, displacement of the lower fragment toward the°ham, with injury to the peroneal nerve ; freeing of the nerve by resection of the projecting portion of the bone.) Centralblatt fiir Chirurgie, Leipzig, 1882. I have not had access to the original account of this case. 216 INJURIES OF BONES. too curious, but to assume that the condyles are involved, and to act accord- ingly. The ireatmeMt of these injuries consists, first, in allaying inflammation by the ordinary means, keeping the joint immovable .by placing it on a well- padded back-splint, and employing extension by the weight and pulley from the very outset. After all swelling has subsided, and the parts are again in a healthy condition, the limb may be laid on a pillow, and the extension kept up until the fourth or fifth w^eek, when passive motion may be veiy care- fully tried. Union generally occurs favorably, and, in many cases, a perfect recovery has ensued. Yet it must not be forgotten that there are chances of grave constitutional disturbance, and that in all injuries of large bones, especially in the neighborhood of joints, there are risks which cannot safely be ignored. Separation of the lower epiphysis of the femur is a rare accident, although perhaps it sometimes occurs without being recognized. It belongs, of course, to the period of life in which consolidation with the shaft has not yet occurred, that is to say, before the twentieth year (sometimes as late as the twenty-fifth). As far as I know, in all the recorded instances the patients have been males, and none of them have been over sixteen years of age. The epiphyseal line is just above the boundary of the knee-joint, and when a separation takes place exactly through it, that cavity will not be involved, although it may become so secondarily. Holmes says:^ "A reference to such of the published cases of 'separation of epiphysis' as are accompanied by anatomical examination, will satisfy the reader that most of them have been of this nature, viz., injuries in which the line of fracture has been close to the epiphyseal line, and generally, in all probability, corresponding with it in more or less of its extent ; but accompanied with fracture in almost all cases, and, therefore, as IvTelaton has truly observed, presenting identical symptoms with those of fracture." Sometimes, as in a specimen figured in the work just quoted (Fig. 43, p. 261), another line of breakage extends down between the condyles. The cause of this injury has been in almost every case, I believe, indirect violence. Madame Lacliapelle is quoted by Malgaigne as having seen the lower epiphysis of the femur and the upper one of the tibia separated at once by traction on the foot in aiding delivery. CouraP has observed in a boy of eleven years, whose leg was buried in a hole up to the knee, while his body was thrown forward, a separation of the femoral epiphysis ; the upper fragment was carried backward, and on proceeding to amputation, which became necessary, the condyles were found in front of the shaft, and so tilted that the articular surface was directed forward. In several^ cases the injury was the result of entanglement of the leg in the spokes of a wheel. Eobson* has reported three cases. In one, in a boy of fifteen, hurt in a colliery acci- dent, the lower end of the diaphysis projected into the popliteal space, tightly stretching the large vessels and nerve ; in another, in a boy of six, the same deformity w^as observed ; and in both, amputation was necessary. In the third, in a boy of fifteen, caught in a belt and carried around a shaft, there was the same displacement; union occurred, and excision of the knee was ulti- mately performed with success. In the Museum of the Pennsylvania Hospital, * Surgical Treatment of Children's Diseases, first ed., p. 259. 2 Fontenelle, Archives Gen6rales, Oct. 1825. 3 One seen by Hamilton, and two quoted by him. Callender published another in the St. Bartholomew's Hospital Reports for 1873. * Liverpool Medico-Chirurg. Journal, July, 1883. FRACTURES OF THE FEMUR. 217 there is a specimen* of separation of the condyloid epiphysis, along with transverse fracture in the middle third of the hone, in a boy run over by a railroad car; also another of the former lesion only, without history. Even in this small list of cases, the course and results presented a marked variety. Sometimes amputation became necessary, once excision ; in Hamil- ton's case there was anchylosis of the knee-joint, and some shortening of the limb. Callender's patient did much better ; union took place in six weeks, and sixteen months later there was no sign of atrophy. Another very favor- able result occurred in a case treated by Puzey.^ A boy aged sixteen was playing leapfrog, and alighted with his legs farther apart than usual ; he fell, and was taken to the hospital with one leg at an ande of about 130° with the femur — looking, it is said, like genu valgum. Under ether, the joint was found all right. "The lower end of the thigh was now steadied, and by gently pushing the leg toward the middle line, the limb was straightened, and in so doing there was clearly felt the soft crunch and crepitus which is generally noticed in straightening out a greenstick fracture ; further exami- nation made it evident that what had occurred was a separation of the con- dyloid epiphysis, not quite complete at its upper aspect." Eight months after the accident, this patient w^as seen again, with a good straight limb and perfect movement of the knee-joint. As to the diagnosis in these cases, very little can be said. The age of the patient, and the characters of the fracture — its want of obliquity, its nearness to the joint, and the smoothness of the fragments — will be the chief points to be relied upon in distinguishing this lesion from ordinary supra-condyloid fracture. The treatment must consist in thorough reduction, and then in placing the limb at complete rest in an easy position, especial care being taken to pre- vent eversion or inversion of the foot. Extension may be called for if syno- vitis of the knee should ensue, but need not be as energetically made as in fracture of the shaft. Minute directions need hardly be given as to the means of following out this course, as they do not ditfer from those employed in other cases. Fractures of the condyles of the femur are not very seldom rnet with as the result either of direct violence, as from railroad or machinery accidents, or of indirect, as from falls on the knees. They generally occur in male adults, and present numerous varieties according to the seat and direction of the fracture, the amount of bone involved, the degree of comminution, and the severity of the damage done to the soft parts. The majority of these injuries atfect hoth condyles, and many of them are T-fi'actures, the bone being broken across transversely, and the lower fras;- ment split down into the joint.- I shall speak first of fractures of this kind, and afterward of those which concern one condyle only. Sometimes the transverse fracture is quite low down, sometimes much higher. Thus in the pathological cabinet of the IN'ew York Hospital there is a specimen^ " from a man who had had his right knee jammed betw^een the side of a ship and a box of two tons' weight, a'few days previous to the am- putation of the thigh. The shaft was fractured very obliquely a couple of inches above the condyles, the inner one of which, moreover, had been crushed inward toward its fellow, and was traversed by several gaping; fissures, which incompletely separated it into several fragments." Another* is described as follows : " Fracture of the femur, four inches above the knee, accompanied ^ Catalogue, p. 31, No. 1132. a Catalogue, p. 97, No. 177. 2 British Med. Journal, Oct. 21, 1882. * Ibid., p. 98, No. 181. 218 INJURIES OF BONES. by a separation of the two condyles from each other by a line of fracture up at right angles into the one first named. The condyles have united by porous bone situated between their opposed surfaces, while the fracture of the shaft has not united at all, owing, as was found on dissection, to the interposition of a portion of muscle between the fragments." In the Museum of the Pennsylvania Hospital, there is a specimen^ showing a transverse fracture an inch and a half above the joint, and a longitudinal fracture completely separating the condyles from each other. In this case the patient, a man, aged nineteen, was caught between two railroad cars ; there w^as great contusion about the knee, and the popliteal artery was ruptured, necessitating amputation. Again, in the Warren Museum, there is a specimen^ with the following description: " An oblique fracture just above the condyles; and a second between these two into the knee-joint. The upper fragment is drawn down- ward in front of, and two inches below, the knee-joint ; its pointed ex- tremity being far advanced in the process of separation, and showing finely the contrast between the living and dead bone. A considerable quantity of new and soft bone connects this upper fragment with the shaft above the inner condyle. From an intemperate man, aged thirty-seven years, who slipped and fell with the whole weight of his body upon this limb. On entrance into the hospital (December 20, 1844), there was a shortening of two or three inches. Considerable swelling and emphysema about the knee,, and a protrusion of the upper fragment nearly an inch, with great pain and, considerable bleeding. The fracture was reduced, but the bones could hardly be kept in place ; and on the third day, the extension being discontinued on account of the pain and sw^elling, the limb was simply laid in a fracture-box. Suppuration and sloughing followed. February 5, the limb was much shortened, and the upper fragment seemed to have penetrated the knee-joint beneath the patella. On the 11th of March it protruded below this bone, and on the 11th of April the man died." Occasionally there is scarcely a distinct transverse separation, but rather a double oblique one, the upper fragment being obtusely pointed in front, and seeming as if it might have acted" as a w^edge in bursting apart the condyloid portion of the bone ; and I think that this may sometimes be accepted as the true explanation of the mechanism of the lesion. Or, possibly, first one con- dyle and then the other may have been detached, the end of the shaft being thus, as it were, denuded ; such it seems to me was the rationale of Bichat's case, quoted by Malgaigne, in which a man broke the condyles by lighting on his feet. It will readily be seen that whether the force producing the fracture be direct or indirect, it is scarcely possible for it to act alike on both sides of the bone. Hence, as in some of the instances above cited, one or the other con- dyle must suffer more severely ; and hence there must result a change in the position of the limb, so that an angle will be presented between the shaft of the femur above, and the leg below. Sometimes this angle will be open out- wardly, sometimes at the inner side of the limb ; and, slight as it may be, it will be so far indicative of the character of the lesion. In two cases recorded by Callender,^ the patella had sunk into the space between the fractured condyles, and was so wedged there that its extrication was impossible ; the patients recovered slowly, and in each case the knee was rendered permanently stiff. The symptoms are pain, loss of power, deformity, often rendered very ob- 1 Catalogue, p. 33, No. 11381°. 2 Catalogue, p. 197, No. 1118. 3 St. Bartholomew's Hospital Reports, vol. vi. 1870. FRACTURES OF THE FEMUR. 219 scure by the swelling from effusion into the periarticular bursfe as well as into the joint itself, lateral mobility just above the joint, and crepitus. When the case is seen very early, the diagnosis may present no great diffi- culty ; but from the extreme rapidity with which swelling comes on, and the complexity of the parts involved, the surgeon is rarely able to pronounce upon the nature of the injury without reserve. The gravity of these cases may be at once perceived. The knee-joint is of necessity involved, and must become the seat of inHammation, so that there is a great risk of anchylosis if the immediate dangers to life arc surmounted. Hence a carefully guarded prognosis only should be given. The treatment must be directed in the first place to the rectification of any obvious distortion, and then to subduing inliammatory action. During the few hours succeeding the accident, indeed, there may be a very marked col- lapse, and this must be met as in any other case, bearing in mind the proba- bility of the occurrence of severe reaction in a succeeding stage. Complete immobilization of the joint, with moderate extension and coun- ter-extension, will I think commend themselves to the judgment of every one as the cardinal principles of the local treatment in these cases. As to the exact means to be employed, there may be room for the exercise of choice. My own preference would be for a well -fitted back-splint, and suspension in either Smith's or Hodgen's wire-frame ; but I cannot speak from experience, having never treated a case of this kind except complicated with other inju- ries which proved speedily fatal. Theoretically, I should think that the corn- fort of the patient, as well as the retention of the fragments, would be pro- moted by a slightly flexed posture of the knee, while in the event of anchy- losis this would insure a better gait than could be obtained with the limb entirely straight. Should suppuration unfortunately occur, it would be neces- sary to decide between evacuating the pus and washing out the joint with carbolized water, and amputation ; or in young subjects the propriety of ex- cision might be considered. Fracture of one condyle, although more rare than that of both, has been repeatedly observed. All the cases have been in males, and the result of direct violence. Malgaigne says that this lesion "consists in a nearly vertical division of the bone, striking the articular face near one or the other of the condyles, and directed from before backward, which goes up along the bone, deviating inward or outward, according to the condyle affected, and terminating two, three, or even four inches above the joint; the detached fragment forming a sort of pyramid, with the condyle for its base." The external condyle was broken off* in two cases recorded by Sir A. Cooper ;^ in both, however, the shaft of the bone was also fractured across. In another instance, reported by Crosby,* the separation of the condyle was due to a twist of the leg, and the fragment Avas removed by incision some months afterward. Here there may be, perhaps, a question as to the correctness of regarding the force as direct, but I am inclined to think that it was so. Hamilton mentions the case of a man aged forty, seen by him three months after the receipt of the injury; the fragment was then distinctly movable, and he was in doul)t whether the fracture had involved the joint. Such a lesion would be analo- gous to fracture of the epicondyle of the humerus. Kirkbride^ saw the ex- ternal condyle separated by the kick of a horse. 1 Dislocations and Fractures of the Joints, pp. 241, 242. * New Hampshire Journal of Medicine, 1857. ' Am. Journal of the Med. Sciences, May, 1835. / 220 INJURIES OF BONES. Brookes^ has published an account of a boy, aged eleven and a half years, " who had his leg entangled in a wheel, and sustained a compound fracture of the femur, extending obliquely downward through the external condyle, which was movable with the lower portion, projecting through a wound in the popliteal space. The leg was twisted inward, much hemorrhage had taken place, and the patient was in a state of collapse. On further examina- tion, the capsular ligament was found to be lacerated, and synovia escaped — the wound in the popliteal space being as large as a five-shilling piece. There w^as also a simple fracture of the lower third of the same thigh-bone. Ampu- tation having been refused, the limb was put up in the straight position, with a splint extending from the hip to the ankle on the outer side, and a concave one on the inner side of the thigh. Complete union had occurred by the end of the sixth week." At the time of the report the knee could be bent to a right angle, and the entire use of the limb had been recovered ; there v^^as no shortening perceptible. Three other cases are cited by Malgaigne:^ one seen by himself, another published by Gerdy, and a third, the specimen from which, without history, is found in the Musee Dupuytren. The inner condyle has been observed to be fractured in the following in- stances : Wells^ saw a thick scale of bone detached from the inner part of the condyle, the tibia being at the same time luxated outward and backward; the patient could only state that he had fallen. Malgaigne quotes from Boyer* a case the account of w^hich is too meagre to be of much interest. The internal condyle w^as separated, the line of fracture running only a short distance up- w^ard ; there was no displacement, but manifest mobility of the fragment. Consolidation took place without difficulty, and without apparent deformity. The patient could not walk for three months, and two months afterwards he still limped. Two other cases are cited in the same article,^ one seen by Mal- gaigne himself, and the other by Lisfranc. Curtis^ has published an account of a case seen by him, in which, from the statement made by the surgeon first called, the fragment was displaced backward, the outer side of the limb appearing normal ; the joint could not be flexed by reason of the pain caused by bending it. Reduction was easily accomplished, and a good recovery ensued, the joint, however, remaining enlarged. Hamilton quotes a case reported to him by Dr. Eiggs, in which, by the kick of a horse, " the internal condyle of the right femur was broken ofi^", carrying away more than half the articulating surface of the joint ; the tibia and fibula were at the same time dislocated in- w^ard and upward, carrying w^ith them the broken condyle and the patella. The displacement upward was about two inches, and the sharp point of the inner fragment had nearly penetrated the skin. There was no external wound." Great difficulty w^as experienced in the reduction, but the case ultimately did well. Two instances are cited by Morris,^ as follows : " M. Dubue has reported the case of a man aged sixty, who fell while ascending a ladder, and broke off very obliquely the whole of the internal condyle of the femur, and the supe- rior external angle of the patella. Prof. Yerneuil had a case in which a large cube of bone, consisting of the inner condyle, w^as broken off by the falling of a quantity of earth upon a man aged twenty-eight." » London Med. Gazette, March 10, 1848. 2 Revue Med.-Chirurgicale, April, 1847. '* Am. Journal of the Med. Sciences, May, 1832. * Traito des Maladies Chirurgicales, tome iii. Paris, 1845. This case does not appear in the earlier editions of Boyer's Treatise. 6 Revue Med.-Chirurgicale, April, 1847. 8 Am. Journal of the Medical Sciences, Oct. 1866. ' Holmes's System of Surgery, 3d ed., vol, i. p. 1023. FRACTURES OF THE PATELLA. 221 The symptoms of these cases would seem, as far as they have been recorded, to resemble in many respects those of fractures of both condyles ; there is the same pain, loss of power, swelling, and crepitus, and in some cases, especially where the bone has been broken'higher up also, there would seem to be like deformity. But if one condyle alone is separated, and the case is seen before the parts have been masked by swelling, it may be possible to grasp the frag- ment by itself, and to move it upon the rest of the bone, so as to gain some idea in regard to it. The diagnosis, however, is extremely difficult in injuries of this portion of the femur ; and for my own part, I should be unwilling to make a positive assertion as to any case in which the examination w^as made after swelling had taken place, unless either the detached fragment was thrown off, or an opportunity for dissection had occurred. I may say that I have seen several cases in which there was reason to believe that one or other condyle had been separated, but it was impossible to arrive at anything approaching to certainty. Theoretically, it is easy to point out what it seems ought to be the signs of one or other lesion ; but in practice the matter is far more per- plexing. The course of these cases varies very much; sometimes excellent results have been obtained, but in other cases, either from the previous bad habits of the patients, or from the severity of other injuries, the loss of the limb, or even of life, has ensued. When recovery has taken place, the use of the limb has generally been in very great measure restored, and sometimes the cure may be said to have been perfect. As to the treatment, no precise directions can be given, but the general course to be followed is the same as that advised for fractures involving both condyles. Fractures of the Patella. According to most observers who have furnished statistics, the patella is affected in s'omething less than 2 per cent, of all the cases of fracture. Gurlt,^ in the tables before quoted, cites from the record of the Klinik and Poly- klinik at Halle, given by Blasius, the statement that out of 778 cases there were 20, or over 2 J per cent., of the patella. On the other hand, at the AUerheiligen Hospital at Breslau, Midcleldorpf reported but 3 fractures of the patella out of 325 cases, being less than 1 per cent. By far the larger number of the subjects of fractured patella arc adult males. Agnew^ says that, in the Pennsylvania Hospital, out of 106 cases 96 were in men and only 10 in women ; only one case was seen under twenty years of age, the largest number, 36, occurring between twenty and thirty. Fractures of the patella do not appear at all in the seven years' tables of the Children's Hos- pital in Philadelphia, already several times cited. Malgaigne's figures are not quite as striking as the above ; out of 45 cases, 37 were in men to 8 in women. Of 20 cases observed by himself, only 4 w^ere in women. But 1 of the 45 w^as in a person under seventeen years of age ; one of his own cases, however, was that of a boy of eleven. He calls attention to the fact that in women, from the seventeenth year to the fifty-fifth, there were but 3 fractures of the patella; there were 5 beyond this period. Rare as this injury is in children, it has been observed in them. Haniilton mentions the case of a boy of five, in whom, by a direct blow, a small piece of the mai'gin of the bone was broken oft'. Dr. Samuel Ashhurst has reported to the Academy of Surgery, in Philadelphia, the case of a child four years old, J Op. cit., Bd. i. S. 6 und 7. « Op. cit., voL i. p. 971. 222 INJURIES OF BONES. who, by a fall, striking the knee against a glass "marble," sustained a frac- ture of the patella downward and inward. The patella may be broken either by direct force or by muscular action, or by both these causes combined. The mechanism by which the bone is made to yield in the first case, is plain enough, as its spongy and easily crushed texture would ill lit it to resist a sudden blow — such, for example, as the kick of a horse. Muscular action does not produce the effect by tearing the bone apart, but by the pull exerted upon the upper portion of the bone, v/hile its lower part is fixed by the ligamentum patellae, and the resulting leverage over the lower end of the femur. According to this theory, which has re- ceived the sanction of most of the leading authorities, this fracture is due, like so many others, to " cross-breaking strain." Malgaigne suggests that in some of these cases the bone has been weakened by previous injury, and that in some there have been pains, or other indications of pathological change ; but there have certainly been many instances in which nothing of the kind has been known to have occurred. Perhaps it is too obvious to need argument, that in many cases the muscles are in a state of tension when direct violence is applied to the bone, and that this condition aids materially in overcoming the resistance of its structure. Desault^ relates the case of a patient who was cut for stone, and who, in a consequent convulsion, broke both patellae at once. Marcy^ reports that a woman, aged thirty-eight, in an effort to save herself from falling, met with the same misfortune. Sir A. Cooper^ mentions another case, and Johnston* another. Callender^ has recorded one, to be again referred to, and one was seen by Beauvais.^ Callender has recorded^ two cases in wdiich a different mechanism was thought to have obtained : — " I. M., aged 45, laborer, fell 20 feet, from a ladder, on his knees. There was great effusion into the right knee-joint, with fracture extending througli the condyles of the femur, and comminuted fracture of the patella, without mu6h displacement of its pieces. The injury was treated on a double-inclined plane, and the patient was discharged with a useful knee-joint. We had no doubt but that this patella was broken after ^fracture of the femur, by displaced fragments being driven against the articular surface of the bone. In the museum of St. George's Hospital is a transverse fracture of the patella, without laceration of the fibrous covering of the bone, produced by violence acting from within, in a case of compound fracture of the lower end of the femur, one of the fraf^- ments of the femur being driven against the deep surface of the sesamoid bone." The line of fracture may be almost exactly transverse, or it may be more or less oblique, and in a few instances it has been seen to be longitudinal. One specimen, without history, in the Musee Dupuytren, has been accepted as an example of incomplete fracture, involving only the articular cartila2:e and a small portion of the underlying bony structure, and not extending to the lateral edges of the bone.^ It does not seem to me to be unquestionably of the character claimed for it. Sometimes the bone gives way at more than one point. Bryant mentions a specimen, in Guy's Hospital Museum, in which there were four fragments, united by ligamentous bands. There is one in the museum of the Pennsylvania Hospital,^ described as follows : " The bone has been fractured into five fragments, which are all bound together by a thin, ' Treatise on Fractures, Luxations, etc. Edited by Bichat. Caldwell's translation, p. 299. Philadelphia, 1817. 2 Boston Med. and Surg. Journal, October 8, 1874. I Op. cit., p. 230. 4 Lancet, November 8, 1873. 5 St. Bartholomew's Hospital Reports, 1870. 6 Medical Times and Gazette, Oct. 9, 1880 ; from L'Union Medicate. ' St. Bartholomew's Hospital Reports, 1870. 8 Holmes's System of Surgery, 3d ed., vol. i. p. 1028. 9 Catalogue, p. 35 ; No. 1146. FRACTURES OF THE PATELLA. 223 broad layer of fibrous tissue. The distance between the upper and lower frao-ments is fully ^ inches, the three other fragments occupying interme- diate positions. The surfaces of the fragments have been a good deal rounded off, but are still quite irregular." The patient in this case v as known to have twice fractured the bone. Gross' figures a specimen in the museum of Prof. Joseph Paucoast, in which there are three fragments, with intermediate bands. Xo history of double fracture or of re-fracture is given. Lonsdale speaks of having seen a man who "fell and struck his knee ao*ainst the edge of a curb-stone ; the fracture took a direction so as to leave the lower portTon projecting angularly upwards, fitting into the upper." In comminuted fractures, there is not unfrequently a line of separation more or less transverse, and the lower fragment is again divided by one or two splits running downward from this main fracture. An anatomical point of importance is well set forth by Tillaux^ in regard to the connections of the patella. He describes the "lateral ligaments" of the bone as continuous with and arising from the ligamentum patellae. Strongly attached to the lateral borders of the patella, where they (the liga- ments^ are very thick, they pass backward, surround the condyles, and are inserted into the fibro-cartilaginous capsule with which the gastrocnemii are connected. These lateral ligaments, be says, "constitute a powerful protec- tion for the front of the knee, and play an important part in fractures of the patella, according as they are more or less torn. When they are but slightly torn, or not at all, as happens in fractures by direct violence, which, indeed, are the rarest, they hold the fragments together ; if, on the other hand, they are much lacerated, the unopposed quadriceps muscle drags the upper frag-^ ment upward, until it may be separated from the lower by several fingers' breadths. This ^toint must be taken into the account in estimating the value of different methods of treating these fractures, since in the one c-ase the frag- ments remain in contact, of themselves, while in the other it is difficult to control them even with the best contrived means." When transverse fracture of the patella occurs, the lower fragment remain.s in place, being attached to the tibia by the very strong and unyielding ligamentum patelke. But there are two agencies by which the upper fragment may be separated from it, so that there exists a perceptible^ gap between them. One, already alluded to, is the contraction of the quadriceps muscle ; the other is effusion of serum, and sometimes of blood also, into the knee-joint. Both of these, it must be obvious, will be limited in their action by the lateral ligaments of which I have just quoted Tillaux's description ; but the muscle'may be powerful enough to tear the ligaments, and thus to produce the displacement. Indeed, it may well be doubted whether it is not in this way that laceration of the ligaments always occurs, since they can seldom be directly ruptured by the fracturing force except just at the edges of the bone ; yet having given way here, thei«r further tearing can scarcely require any very great force. Once torn, how- ever, the greatest obstacle both to muscular action and to effusion into the joint is removed ; and separation of the fragments will very soon take place. It must not be forgotten that the strength of these ligaments varies in different individuals ; and it is doubtless for this reason, as well as because of the varying degree of the violence sustained, that in some cases there is at once a wide gap between the portions of the bone, while in others the frag- ments remain almost in contact until inflammatory effusion occurs in the joint. Mr. Jonathan Hutchinson^ maintains that the quadriceps extensor muscle ^ System of Surgery, vol. i. p. 1000. ' Med.-Chir. Transactions, vol. lii. 1869. ^ Anatomie Topographique, p. 1103. 224 INJURIES OF BONES. is singularly inactive in cases of transverse fracture of the patella, and that the separation of the fragments is due largely to fluid pressure from within the joint. He says that the muscle occasionally undergoes marked and per- manent atrophy. Vertical or longitudinal fractures of the patella are always due to direct violence, and differ from the transverse in the much less separation of the fragments. Dupuytren^ gives four cases of this kind, in one of which it is stated that the bone was divided into two nearly equal portions. He speaks of having treated several other cases at the Hotel Dieu, and thinks them less rare than they have been generally supposed to be. Lonsdale, Cooper, and others, have met with them in the dead subject. The literature of the sub- ject is very scanty, and I know of no recent reports of such cases. Rupture of the prepatellar bursa is very apt to occur, whether the bone gives way to direct violence or to muscular action; in the former case it is by bursting, in the latter by tearing of its posterior wall. It is not of any im- portance as compared with the lesion of the bone. The symftoms of this fracture are generally well marked ; the patient falls — and sometimes it is difficult to say whether the fall is the cause or the result of the injury to the bone ; there is pain, aggravated by the strain upon the fibrous structures surrounding the bone which must attend any attempt at movement; there are swelling and deformity, and, unless the upper fragment has been dragged away entirely from the lower, crepitus is very easily elicited. These syniptoms are by no means always equally clear. Tresoret^ has pub- lished an account of a robust man of forty -five, who struck his left knee in a fall. He kept at work for three weeks, and then, examining his knee on accoun\ of its being swollen, he thought that the bone was broken. Two months after the accident, he applied for advice, when a transverse fracture between the middle and lower thirds of the bone was easily detected. A cyst (?) had formed at this point ; iodine was injected, and a month after- ward the patient was considered as cured. Morris^ mentions the case of a young woman who struck her knee forcibly against a chair: ''for part of two days she got about the house and up and down stairs, moving, hoM^ever, with great difficulty and much pain," w^hen an oblique fracture of the patella was detected. Tillaux* mentions a source of error in the diagnosis of fracture of the patella, which, he says, he has several times witnessed: "An efitision of blood in the prepatellar bursa may give rise to crepitation, and the clots may even cause a sensation exactly like that of separation of the fragments." He is of opinion that this may have been the real state of things in some cases in which fracture has been supposed to exist, and in which it has been claimed that a perfect cure with bony union was effected. When there is doubt as to the existence of fracture, Mr. H. Morris recommends* " fixing the bone between the finger and thumb of one hand, and then pressing all around the circuinference of it with the index finger of the other." Hupuytren^ cites a case seen by Breschet, in which it was very difficult to determine the nature of an injury, sustained by a patella which had been fractured twelve years previously ; the joint had become almost entirely anchylosed, and the conclu- sion arrived at was that the union had given way. The course of these cases is very various, but that which is most usually observed is a gradual subsidence of the inflammation in and about the joint, and the formation of a ligamentous connection between the fragments. If 1 Diseases and Injuries of Bones, Syd. Soc, TransL, p. 225. 2 Gaz. des Hopitaux, 11 Aout, 1881. ^ Holmes's System of Surgery, 3d ed., vol. i. p. 1029. " Op. cit., p. 1124. 6 Lqc. cit. 6 Op. cit., p. 228. FRACTURES OF THE PATELLA. 225 there is no displacement, as occasionally happens by reason of the fibrous envelop and hiteral lii^anients remaining intact, this fibrous band may be exceedingly short, so that the fragments are very close together. But cases are upon record in which the separation, at first only slight, has been in- creased upon the use of the limb being resumed ; and it is, I think, the rule that in every case some such increase takes place, unless tiie fragments have been united by bone. For bony union does sometimes occur; there are several specimens of it in the Miitter Museum of the ( 'ollege of riiysicians of Philadcl[>hia,and one is figured by Malgaigne; several are mentioned by Mr. 11. Morris.' In such cases the usual rule obtains, that on the articular face of the bone thei'e is rather a loss of substance than a deposit of callus, so that the line of fracture is marked by a shallow groove. T. C. Smith has re- corded* a case of fracture of the patella by a fall on the knee, the outer con- dyle of the femur being also broken off. There was no separation ; firm osseous union ensued in about six weeks, and no observable deformity was left from either fracture. Sometimes, as in a specimen figured by Morris,^ it seems unquestionable that there has been a new formation of fibrous tissue, developed from a plasma, just as in some instances of like union between other bones; but this is not always the case, for there may be only an expansion of pre-existing liii'an lentous substance. When the fragments have been tilted, the attach- ment of these fibres may be somewhat changed, as in another example given l;y Morris.* Kirkbride* has reported a case in which the fragments had be- come united at their inner part by a round fibrous cord, the remainder of their extent being unconnected ; with the knee in the straight position, they were two inches apart at the outer side and one and a half at the inner, while on flexion of the knee the distances were increased to three and three-fourths and two and a half inches. The patient had good use of the limb, and walked without any perceptible limp. Irregular i)ressure by apparatus, or perhaps the unequal yielding of dif- ferent [)ortions of the ligamentous structures, may give rise to lateral tilting of the fragments, so that the gap between the latter is wider on one side than on the other. And sometimes there are irregular deposits of bone in the uniting medium, showing an effort at the establishment of bony union, lioth these points are illustrated in a preparation in the museum of the Pem>- sylvania Hospital:^ ''The fracture has been transverse, about the middle of the bone ; the fragments are covered by a thick membrane ; a broad, fibrous layer, an inch and a quarter w^ide, unites the two fragments, being attached to their anterior surface. There is also a strong but thin band passing between their posterior surfaces. At the outer side of the patella there are two bony nodules springing from each fractured surfiice ; these are evidently new-formed bone, and are almost in contact with each other, though no bony union has occurred between them; they were, however, firmly bound together by ligament. The degree of separation at the outside of the joint is not more than half an inch ; at the inside it amounts to fully an inch." This speci- men was taken from the body of an old negro, who had sustained the fracture eleven years previously. Hamilton^ makes the extraordinary statement that in the case of a young man of nineteen, with a transverse fracture caused apparently by a direct ' Loc. cit. 2 Am. Journal of the Med. Sciences, April, 1873. » Loc. cit., p. 1031 ; fig. 175. * Ibid., fig. 176. * Amer. Journal of the Medical Sciences, May; 1835. 6 Catalogue, p. 35 ; No. 1145. ^ Treatise on Fractures, etc., 6th edition, p. 502. VOL. IV. — 15 226 INJURIES OF BONES. blow, ' the ligament subsequently gave way completely on the outside, and u new patella formed in the very ng.uch elongated ligament on the inner side." It must be clear that in so far as the separation "of the fragments is due to eftusion within the joint, it must lessen as the fluid is absorbed; and this phenomenon has been strikingly described by Malgaigne, as noted by him in two of his own cases. But the contraction of the quadriceps muscle can only induce a progressive increase of the interval, and may thus act, if unopposed, for a long time. Malgaigne says that the greatest separation within his knowledge was one observed by Sir A. Cooper, which amounted to four inches ; but Cooper him- self says,i"the bone may be drawn five inches upward, the capsular ligament and tendinous aponeurosis covering it being then greatly lacerated; and this, with one exception, is the greatest extent of separation which I have seen." And Mol-ris^ says that "in St. Thomas's Hospital Museum are two specimens in which the ligamentous union is six inches or more in length." A curious shortening of the ligamentum patellae sometimes occurs ; and though it is not generally of great extent, yet it contributes somewhat to the ultimate amount of separation between the fragments. Perhaps this is due in some degree to pressure by apparatus, which certainly often has the effect of causing the gap to be greater at the anterior surface than at the posterior. Callender^ has noted the occasional occurrence of hypertrophy of the fras;- ments, as well as the fact that the opposite condition has been met with, the broken portions becoming atrophied. He also mentions a specimen, in the museum of the Middlesex Hospital, in which the lower fragment has become united by bone to the tibia, so that the fibrous band between the fragments had come to represent the ligamentum patellae. ^ In one or two recorded instances, the upper fragment has contracted adhe- sions to the femoral condyles, but without any direct influence in impairing the usefulness of the limb. Refracture of the patella is not a very unfrequent occurrence. Sometimes, but rarely, the bond of union gives way. More frequently the bone separates at another point ; and this, I think, is to be accounted for on the ground that as the use of the limb is acquired, one or other of the fragments comes to bear, as the original bone did, over the lower extremity of the femur, this portion then giving way under a "cross-breaking strain." I have myself reported' a case in which, under the use of Malgaigne's hooks, I had succeeded in getting extremely close union of a transverse tracture, and the bone gave way, apparently at the same point, four months afterward, under a sudden slight strain. But instances of this kind are not common. Little^ has re- corded a case in which, ligamentous union having occurred, a second fracture, half an inch higher up, took place niue months afterward ; so that when the patient finally recovered, there were three fragments and two clearly defined fibrous bands. Parson^ published an account of a case in which (in Decerii- ber, 1874) the left patella was fractured at the junction of the middle and upper third ; io October, 1880, the same bone gave way at the junction of the middle and lower thirds, and in August, 1882, it was again broken at the same point. Lloyd^ saw a patella broken by direct violence, which gave way again twice at intervals of twelve months. Bryant mentions a case seen by him, in which one patella had been broken tw^ice, and the other three times. It is not very diflicult to see why fracture of one patella should occasion 1 Dislocations and Fractures of the Joints, p. 224. 2 Loc. cit., p. 1030. 3 St. Bartholomew's Hospital Reports, 1870, p. 49. * Am. Journal of the Med. Sciences, Oct. 1861. -f ' ^ ^ 6 Med. Record, March 4, 1882. 6 Lancet, May 19, 1883. ' liirmingliam Medical Review, March, 1883. FRACTURES OF THE PATELLA. 227 ally be followed by a like misfortune to the other. The patient will natu- rally spare the limb which has already suffered, and in case of a slip, or any demand for effort, will be likely to put a severe stress upon the better one, which yields as its fellow did. The interval between the fractures is some- times a long one. I have now under treatment at the Episcopal Hospital a robust and healthy man with fracture of the right patella, in whom the bone of the left side was broken about two years ago, and is united by a short fibrous bond. He was not aware of any lameness or weakness of either limb. When re fracture occurs, the damao:e done is sometimes far more serious than that of the original accident. Thus King^ met witli a case in which, five months after a fracture of the patella, union having taken place with the fragments about half an inch apart, the whole knee was burst open, a wound seven inches long being produced, and the fragments separated an inch and a quarter. Suppuration ensued, but the patient made a good recovery ; the amount of motion in the knee, if any, is not stated. Charles Bell^ mentions a very similar instance. The bone had united by ligament, and this ligament had incorporated with the skin in such a manner that it lost much of its pliancy. The poor man w^as carrying a burden and fell backward, the knee sank under him, and the whole fore})art of the joint was laid open by laceration. The case terminated in amputation of the limb." ^falgaigne, after referring to this case, says : " I have seen a nearly similar instance ; the rupture of the fibrous band was attended with enormous ecchy- mosis, gangrene ensued at about the fifth day, and death closed the scene. M. Seutin quite recently sought in vain to save a limb thus affected ; after four months of suftering, am[)utation of the thigh became the only resource." Thomson^ reported to the surgical section of the British Medical Associa- tion, a case of old fracture of the patella, in which suture of the fras^ments liad been practised; a year later, the knee being stiff', the patient tripped, and burst open the whole joint. Resection was performed, with a good result. lie refers to other like cases seen by Bell, Poland, and Pelletan, in all of which amputation was deemed necessary. A very similar instance has been placed on record by Mason,* and another, but with a far more fortunate issue, by Roberts.* Necrosis of a portion of the fractured bone has been observed in a very few instances. One of these is given by Erichsen,^ as follows: "The patient, a middle-aged man, had met with an ordinary transverse fracture of the patella, which united by ligament two years after the accident; and without any fresh injury he came to the hospital, with necrosis of the outer half of the upper fragment, which was completely detached, and lying in a cavity bounded and shut off' from the joint by plastic matter. 1 cut down upon and removed the necrosed fragment, which appeared to constitute about one- quarter of the patella. Xo cause could be assigned for the necrosis, except defective vascular supply to this part of the bone." Another instance is briefly referred to by Lawson,^ " in which a portion of the patella was chipped off", necrosed, and fell into the joint, there setting up inflammation, which caused death." Hulke^ says that a partially detached portion of one of the fragments may die and be gradually exfoliated, as in Liston's patient, a sailor, aged twenty-four, who died seven weeks after the injury from hectic fever following extensive suppuration in and around the knee-joint. ' Dublin Med. Press, Dec. 8, 1847. * A System of Operative Surgery, 2d Am, ed., vol. ii. p. 361. 1816. » British Med. Journal, Aug. 26, 1882. ♦ Med. Record, March 20, 1875. 6 Bryant's Surgery, 3d Am. ed. 6 Science and Art of Surgery, Am. ed., vol. 1. p. 381. 1873. ' British Med. Journal, June 9, 1877. • Holmes's System of Surgery, 3d ed., vol. i. p. 1028. 228 INJURIES OF BONES. A fact of much importance, as will be seen when the subject of treatment comes under discussion, is that the usefulness of the limb after recovery from fracture of the patella is not necessarily in proportion to the closeness of apposition of the fragments. I have seen a number of persons who had had this injury, and in whom very great separation remained, who yet were able to walk, to go up and down stairs, and even to mount, as for instance into a chair, as well apparently as ever. One very large and portly man, well known for years in Philadelphia, had had fracture of both patellae at different times, with very lengthy ligamentous union, and yet he walked about freely, and showed no peculiarity of gait beyond what might have been perfectly natural to him. Such, however, is not always the case. Callender^ says : I note in April , 1866, the case of a poor fellow who had fractured either patella some years previously, and who was admitted for some other trouble. He had lost all power of recovering himself when the body was bent back from the knees^ and thus he constantly fell whilst moving about. In his case the interval between the two fragments of bone on each side was less than two inches and a half, but then both knees were damaged." My belief is that much depends upon the confidence felt by the patient ; and it is very probable that in a case of simultaneous fracture of both bones, the loss of power would be apt to be greater and more persistent than if the injury should be sustained first in one limb, and at some later period in the other. When fracture of one patella has taken place, and even when, as in an instance recorded by Hamilton, ^ the fragments are separated to a distance of four and a half inches, and no bond of union can be detected, the rule is that in a greater or less length of time, with judicious management, the strength and usefulness of the limb are in a very complete measure regained. Hence it seems to me that the i^'^ogiiosis of these cases rnay be favorable, so far as the ultimate result is concerned ; but the patient should not be led to think that his recovery will be speedy, not only lest he should be disappointed, but also lest he should by imprudence sustain further damage. As to the treatment^ a great deal of ingenuity has been expended in the endeavor to devise means of holding the fragments in apposition, or as nearly so as possible ; and a vast number of appliances for this purpose, many of them very similar in principle, and varying only in trifling details, have been described, each with its inventor's name. I shall not attempt to give a com- plete list of these, but propose to state the objects to be aimed at, and the chief methods by which they may be attained ; not omitting any practical suggestions, but not being careful to mention all the curious and complicated mechanisms which have been from time to time recommended, without acquiring more than a transient and local reputation. Surgeons have difiered as to the best position in which to place the limb, some advocating the flexion of the hip-joint, others deeming it of little im- portance. Callender^ says : " I hope the old fashioned plan of raising the limb on an inclined plane for the treatment of fracture of the patella is quite obsolete. Fractures of this sesamoid bone are now treated in St. Bartholo- mew's by rest simply, the limb lying in the horizontal position." On the other hand, Mr. Croly, of Dublin, is said^ to be ''content to obtain good fibrous union by simply elevating the limb, so that a line drawn from the toe wall pass on a level with the patient's nose, the chest and shoulders being raised by a bed-rest, and subduing all inflammation by ice and evaporating lotions." ' Loc. cit., p. 49. 3 Loc. cit., p. 46. 2 Op. cit., 6tli ed., p. 527. 1880. < Lancet (editorial), March 31, 1883. FRACTURES OF THE PATELLA. 229 While it is very probable that the importance of flexing the limb strongly upon the body may have been overstated by some writers, it seems to me that surgeons generally would be unwilling to forego the advantage gained by complete relaxation of the muscles on the front of the thigh. I3ut in order to secure this, it is not necessary to place the limb at an angle of less than about 130° with the axis of the body. It is, however, essential that the knee should be kept in the extended position, and this becomes very irksome from stretching of the posterior muscles, if the hip-joint is strongly flexed. So o-enerally has the propriety of this posture of the knee been recognized, that almost all suro-eons have included a back-splint in their appliances for dealniii- with fractures of the patella. By some the ordinary single-inclined plane "is used, so arranged that the degree of elevation of the foot may be altered at the will of the attendant. Others have employed a trough of tin, iCutta percha, binders' board, or some like material ; while many prefer a board, either sloped ofi:' above and below, or padded, so as to All up the hol- low of the ham. If such a board is used, it should be of suitable width for each portion of the limb, very slightly hollowed out along the middle, and at its ends the edges should be carefully bevelled oft' so as to make no pressure upon the skin. Plaster-of-Paris bandages have been used by some surgeons, and the starched bandage is highly recommended by Erichsen; but neither of these can, in my opinion, be safely employed, except in the later period, when the patient is beginning to weary of confinement, and union has so far progressed as to be inli measure assured. Hamilton quotes several cases in which the injudi- cious use of plaster of Paris, or of a silicate bandage, seemed to be the clearly assignable cause of very imperfect results, and one has been recorded^ in which gangrene ensued, and amputation had to be performed. I will merely mention that some surgeons on the Continent of Europe have resorted to what must, I think, be regarded as an unjustifiable practice— the aspiration of the knee-joint for the removal of the eftused liquid, by which it is ai)t to be distended for a few days after the accident. Such interference is not only theoretically attended with risk, but it has been actually proved so. I do not refer to the rare cases in which a formidable arthritis has already been set up, and in which there is an existing danger from the products of inflammation within the joint, although as to even these there are conserva- tive surgeons who would hesitate to adopt such measures ; but to those cases in which the eftiision is a mere temporary inconvenience, and in which nature will, do the work of relief as surely and much more safely, if not as promptly, as any surgical instrument. For a few days, then, until the swelling of the joint has subsided, the best course is to place the limb at rest on a back-splint, and to employ suitable means for allaying the local irritation. Evaporating lotions, lead-water and laudanum, or hot water-dressing, may be made use of, the choice being determined according to the age and strength of the j^atient, the season of the year, and perhaps other circumstances. Upon the disappearance of the eftusion into the joint, means must be adopted for approximating the fragments. Should the tendency to separa- tion be very great, an attempt should be made to control it even from the outset; for although the bringing of the fragments together may be impos- sible, and even inadvisable for fear of injury to the joint, yet the subsequent coaptation may be rendered easier. The best way of doing this is by means of a compress of folded lint, having around it an envelope of adhesive plaster, the adhesive surface outside ; this being placed on the skin just above the • Am. Journal of the Med. Sciences, Feb. 1840; from the Gaz. Medicale, 1839, No. 28. 230 INJURIES OF BONES. upper fragment, and the middle of a strip of bandage laid over it, the ends of the bandage may be gently drawn upon, and secured to pegs or nails at either side of the splint, at such points that the tension shall be exactly in the direc- tion desired. The aim of most of the inventors of appliances for the treatment of these fractures has been to act on both fragments, forcing them together. But, in fact, the lower one is not displaced, unless by the shortening of the ligamen- tum patellse, before spoken of; and it is very doubtful whether this is not actually promoted by pressure brought to bear upon it in some methods. Various devices for circular pressure were used at a very early date ; Mal- gaigne speaks of splints perforated in the centre, and kept in place by a ban- dage (the patella being received into the opening, by the edges of which the fragments were held together), as known to Albucasis, Guy de Chauliac, and others. This plan, he says, was still employed at the Hotel Dieu in the latter part of the last century. Another development of the same idea w^as the rino- or cap, Avhich has been revived in modern times by Knight,^ Gibson,^ Eve,^ Blackma'n,'' and perhaps others. Its simplicity is its only recommendation, and although it may answer well where there is little or no gap between the fragments, and where mere support is required, it is not likely to take the place of appliances which admit of greater adaptation to the circumstances of each case. A positive objection may be made to it on the ground of its interfering with the nutrition of the bone. Gross^ quotes Manning as having " observed by dissection that the vascular arch of the upper fragment is situated at the precise spot where the greatest amomit of pressure is nsually made by the retentive apparatus ; and that the lower fragment experiences a similar fate when, as not unfrequently happens, the internal superior and inferior arteries arise from a common trunk." By Thomas,^ also, the importance of non- interference with the circulation of the patella is urged. By a great many surgeons, the use of pressure by bands, with or without compresses, and arranged in various ways, has been relied upon. Thus Dor- sey used a Dack-splint, with tapes fastened to it, which were brought up above and below the broken bone, so that they should draw the fragments into place ; the lower one passing above, and the upper one below, crossing one another at each side. A somewhat similar arrangement, but with pegs for tightening the bands, is recommended by Agnew.^ ""Perhaps it need hardly be pointed out that by changing the points of attachment of the tapes or bands, the traction may be brought more or less parallel with the long axis of the limb ; and that the further apart they are, the more directly will the fragments be drawn together. Hamilton uses a moulded trough, and figure-of-S turns of a roller. Sir A. Cooper laid tapes along the limb on either side of the fractured patella, and then applied a roller, leaving the patella uncovered. By drawing up the ends of the tapes, and tying the corresponding ones together, the turns of the roller above and below the knee were approximated, and with them the fragments. The obvious objection to this plan is the circular constriction which it of necessity involves. Gerdy's method was somewhat similar to this. A much better device, but still subject to the same inconvenience, was afterward used by Cooper f it was a leathern band buckled round the thigh just above ' Am. Journal of the Med. Sciences, July, 1860. 2 St. Louis Med. and Surg. Journal, Oct. 1866. This author claims to have obtained bony- union by means of the ring. 3 Nashville Journal of Medicine and Surgery, Feb. 1867. * Western Journal of Medicine, May, 1868. 5 Op. cit., vol. i. p. 999. 6 Med. Press, and Circular, Oct. 11, 1882. ' Op. cit., vol. i. p. 974. » Op. cit., p. 229. FRACTURES OF THE PATELLA. 231 the patella, and drawn down by another strap passing down from it, around the sole of the foot, and then up along the other side of the leg. An appa- ratus, very similar in principle, has lately been proposed by Levis, of Phila- delphia.^ A plan Avhieh has in my hands proved very satisfactory, is known as ban- born 's. Its peculiarity consists in the use of a strip of adhesive plaster along the upper surface of the limb, leaving a free loop just over the patella. Com- presses having been applied, and the ends of the strip secured by transverse strips and a roller, the loop is twisted up by means of a bit of stick passed til rough it, until the compresses are so drawn together as to bring the frac- tured ^surfaces as nearly as possible into contact. The stick is then secured by tyino- its ends with a strip of bandage passed round under the back-splint. Of course the pressure can be increased at any time by twisting the loop up tio:hter, and can be lessened by untwisting it. "a number of appliances have been proposed, and a few of them have been extensively used, with semicircular or crescentic plates of metal, arranged to press ai>:ainst the upper and lower edges of the fragments, and to push them togethei'. Of these, Lonsdale's^ was the lirst ; his plates were carried on arms attached to the back-splint, and by means of screws and nuts could be adjusted so as to produce the desired effect. I need hardly enumerate the other forms of apparatus based upon this idea, as they can be found described in readily accessible works, and have mostly had but an extremely limited use. Some of them are complicated, and others inefficient. Perhaps I may be permitted here to digress for a moment, and to say that this subject of the treatment of fractures of the patella affords a striking illus- tration of the fact that in surgical appliances and methods what is wanted is not power, not mere brute force, but exact adaptation. Much ingenuity has been expended upon the invention of apparatus to overcome resistance which it is far better to evade than to oppose, to coax than to compel. An apparatus employed at the ^liddlesex Hospital,^ in London, seems to me to possess very great advantages, and I will quote the description of it in full :— " A broad piece of moleskin plaster, cut out at one border, somewhat horseshoe- shaped, but with the ends oV the curve prolonged, is fixed to the thigh, so that the curved edge is level witli the normal position of the patella, and is retained by means of a few turns of roller. Next the limb is fixed upon a well-padded Mclntyre or simple wooden back-splint having a foot-piece. Then the lower fragment of tlie patella is fixed by means of a pad of lint and broad strip of adhesive plaster applied figure-of-8 fashion around limb and splint ; and the bandage which confines the foot and leg to the splint is continued upward as far as this pad, which it assists in fixing. To the pro- longed ends of the moleskin plaster are sewn pieces of bandage (pieces of moleskin plaster of different sizes cut to the right shape, and having the pieces of bandage fas- tened on, are always kept ready) which are attached in turn to India-rubber accumu- lators, one on each side of the leg ; eacli of the accumulators at its lower end is fastened to a piece of bandage, and these are tied togetlier below the foot-board of the splint. With a pad of lint at tlie upper border of the superior fragment of the patella beneath the free edge of the moleskin, the requisite amount of tension is obtained by tightening the tied pieces of bandage." I am at present using this plan in two cases in my wards at the Episcopal Hospital, and find it satisfactory. A very elegant, but very complicated arrangement for the use of weights and pulleys in coaptating the fragments of the broken patella, the invention ' Agnew, op. cit., vol. i. 980. • Treatise on Fraetures, p. 427. * Holmes's System of Surgery, 3d ed., vol. i. p. 1032. 232 INJURIES OF BONES. of which is ascribed to Dr. Burge, of Brooklyn, is figured by Agnew. Callen- der/ Hornibrook,^ and Grant^ have suggested simpler devices for merely drawing down the upper fragment by means of a weight and pulley. I think that instruments of this kind would scarcely be available in practice, unless with extremely tractable patients. Malgaigne's hooks, intended to act directly upon the bone itself, and to keep the fragments in exact apposition, have been by some surgeons regarded with great favor, while by others they have been strongly condemned. The instrument, as used by its inventor and by others, myself among the number, consisted of a pair of steel plates, each carrying a pair of strong recurved hooks, and having on its upper face a block perforated with a female screw ; the hooks having been inserted through the skin so as to catch, one the upper edge of the upper fragment, the other the lower border of the lower one, were brought toward one another by turning a male screw through the blocks, and the fractured surfaces were thus forced together. Within a few years, Mor- ton and Levis* have employed these hooks, detaching them so as to make them into two independent pairs, or into a set of four movable hooks. The question with regard to them, however, is not of their efficiency, which is obvious, the modifications suggested being merely for convenience in appli- cation ; it is whether their use is or is not attended with danger. On this point Agnew^ says : — " Once have I seen death follow the use of this infernal machine, from an erysipe- latous inflammation exteiiding into the joint, and giving rise to abscesses, both within and without the articulation. No advantage whatever results from the close contact of the fragments accomplished by the instrument ; it is rather a disadvantage, as the ten- dency to refracture is increased by the very closeness of the union, the intermediate bond not being as strong as the ordinary fibrous tissue which fills the gap when the pieces of the bone are a short distance apart. Three times have I seen the union broken a few weeks after the patients treated by this method had been discharged from the hos- pital." Hamilton^ quotes from Volkmann: " That Malgaigne's hooks have caused ulceration of the joint and death of the patient in a number of cases, is only too true ; I, myself, know of two which occurred in the practice of friends, and which were never published, and another sad experience was met with in my own clinic a number of years since." On the other hand, De Morgan,^ speaking from his experience with the hooks in the Middlesex Hospital, says " there is no method of treatment which, with so little trouble to the surgeon or irksomeness to the patient, will produce such satisfactory results." Hamilton, while he says that " several cases have been reported of danger- ous or disastrous inflammation induced by the hooks," thinks that " in cases in which the original separation exceeds one or one and a half inches, and especiallj^ in cases of a refracture or rupture of the fibrous band, accompanied with great separation," the plan is entitled to a further trial. In "the case recorded by me,^ in which the hooks were used, they caused no inflammation of any moment, and by experiment on the dead subject I afterwards satisfied myself that there could be no risk, with ordinary care and skill, of wounding the knee-joint in their application. With the excep- tion of the cases referred to by Agnew and Volkmann, and one reported by » Practitioner, March, 1875. ' Canada Lancet, Jan. 1876. 3 Edinburgh Med. Journal, Oct. 1876. 4 Medical News, Jan. 7, 1882. See, also, Surgery in the Pennsylvania Hospital, p. 274. 6 Op. cit., vol. i. p. 980. 6 Clinical Lecture, Med. News and Abstract, April, 1881. 1 British Med. Journal, May 24, 1842. ^ American Journal of the Medical Sciences, April and October, 1861, FRACTURES OF THE PATELLA. 233 Mr. Royes Bell,^ I do not know of any distinct statement of damage done by this plan of treatment; and if the obtaining of very close apposition of the frag- ments were the only condition of restoring the usefulness of the limb, I should reo-ard the employment of the hooks as not only justifiable, but an imperative diUy. Such, however, is not the case ; very many patients, as has been before stated, are able to walk, climb, and run, with the fragments connected by tibrous bands of considerable length ; and it seems to me that the question is, therefore, one which may be left to the individual judgment of each surgeon. Those who use the instrument are not to be adjudged foolhardy, and those who al)stain from employing it are not necessarily timid or over-cautious. Trelat is said by Stimson^ to have applied the hooks through the medium of plates of cratta-percha, moulded to the anterior aspect of the limb above and below the knee ; thus avoiding the wounding of the skin, and, of course, placing the joint beyond all risk of harm. Similar plans have been advo- cated by Spence^ and by Gant.* But whether the instrument is not deprived of its efficiency by this change, may be seriously questioned. ^ Of late years, even bolder procedures have been advocated and practised, with a view to securing apposition of the fragments in transverse fi'actures of the patella. Operations similar to those mentioned in the early part of this article^ as performed in cases of non-union of other bones, the exposure and wiring together of the broken portions, have been resorted to, and in many cases with success, notwithstanding the unavoidable risks from the neighborhood of so large a joint as that of the knee. The idea is not altogether a new one. Hamilton^ says: " Severinus, an Italian, proposed to make an incision into the joint, exposing the fragments, and then to freshen the broken surfaces and bring them together. This was nearly three hun- dred years ago, when surgeons did not pretend to have any specific for pre- ventiiig infiammation after wounds of large joints, such as Mr. Lister thinks we possess to-day." Malgaigne also refers to this proposal, but only to con- demn it. According to Byrd,^ Dr. George McClellan, of Philadelphia, adopted such a course many years ago, in one instance, and as an experiment, which is said to have proved successful ; but no account of this case was ever pub- lished, and it certainly seems as if more would have been known of so bold a procedure, and as if the surgeon would have had imitators, if the result had been favorable. It was also among the achievements of Prof. Cooper,^ of San Prancisco. As has been before remarked, the gravity of fractures of the patella depends in no small degree upon the involvement of the knee-joint ; and the same may be said of these operations. By the advocates of Listerism, it is claimed that antiseptic precautions" diminish the risk of opening the joint-cavity.^ Rose^° reported to the Medical Society of London, two cases of fracture of the patella » Lancet, April 29, 1882. 2 Op. cit., p. 561. ' Practitioner, March, 1875 ; Med. Times and Gazette, Aug. 21, 1875. < Lancet, April 29, 1882. 6 See pp. 62 et seq. 6 Clinical Lecture in the Med. News and Abstract, April, 1881. ' New York Medical .Journal, May, 1876. • As claimed in a letter from him, quoted in the Medical Times and Gazette, Nov. 2, 1861. The original report I have been unable to find. 9 Lister himself is reported (Lancet, Nov. 22, 1879) to have said that "the risk a patient incurs in having his knee-joint opened antiseptically is not greater or so great as that attending the removal of an ordinary fatty tumor without antiseptic treatment." I have no hesitation in saying that such a claim is unsupported by the experience of the profession at large. Perhaps I may say here that there is often a confusion between safety and impunity. The fact that an operation has been done with success, does not by any means show that it did not involve great risk. Persons have fallen from great heights, sustainiug only slight injuries ; but they certainly were in most imminent danger. w Lancet, Jan. 22, 1879. 234 INJURIES OF BONES- in which he opened the knee-joint, drilled the fragments, and fastened them together with silver wire. The operations were done with antiseptic precau- tions ; no bad symptoms ensued, and the final result in each case was satisfac- tory. Cameron^ gives the case of a man, aged thirty-five, in whom the broken patella had formed a wide ligamentous union, the fragments being, in exten- sion of the knee, three inches apart, and in flexion admitting the breadth of the hand between them ; he sutured them with thick silver wire, under anti- septic precautions, leaving a drainage tube in the joint. The result was satisfactory ; eight months afterward the man had difiiculty in flexing the knee, owing to the shortening of the parts in front.^ Other instances have been recorded, , without a distinct statement as to the fact of interference with the joint. Thus Barling^ showed to the Midland Medical Society an adult patient who by a fall had torn the ligamentous union of an old fractured patella. By a longitudinal incision over the bone, the fragments had been laid bare, refreshed, and then approximated by a sin- gle silver wire suture, which was cut ofl:" short and left. The operation had been performed some weeks before, and the fragments were in good position. In course of time. Dr. Barling hoped that solid osseous union would take place." Holmes* records the history of an attempt to obtain bony union in a case in which the fragments were connected by fibrous tissue ; an incision w^as made with antiseptic precautions, and a suture applied ; the patient's life was seriously endangered by suppurative inflammation. Other cases have been reported in various journals.^ One instance in which very little good seems to have been accomplished is recorded by Lloyd.® The fracture was caused by direct violence ; the knee gave way about twelve months afterward, and again twelve months after that. Malgaigne's hooks were then used, but without success, arid incision^ resection, and suture were employed, with division of the quadriceps tendon, of the tissues at either side of the bone, and of the ligamentum patellae. The suture was allowed to remain ; the fracture, however, w^as still ununited. Lund^ has proposed a plan of treatment combining the idea of Malgaigne's hooks and that of suture of the fragments. He advocates keeping the limb extended, on a back-splint with a foot-piece, and slightly raised ; a cold evap- orating lotion, or ice, is applied to the knee until nearly all eflusion has sub- sided. Then, under anaesthesia, a strong screw-pin is driven into each frag- ' Glasgow Medical Journal, April, 1883. 2 In the Index Medicus for August, 1883, I find the following title : Henzelt, Ueber die Behand- lung der subcutanen Querfracturen der Patella mit besonderer Beriicksichtigung der Function des Gelenkes und der Knochennaht. Dorpat, 1883. (On the treatment of simple transverse fractures of the patella, with reference especially to puncture of the joint and suture of the bone.) The work itself I have not seen. 8 British Med. Journal, April 14, 1883. * St. George's Hospital Reports, 1879. 6 Ward (British Med. Journal, June 9, 1883) records five operated on in the Leeds Infirmary, three having been cases of simple and two of compound fracture. I find also in the Index Medicus the following : — Weinlechner, Eine durch Verschiittetwerden erzeugte Fraktur der Fatella, welche das Gehen wegen weiten Abstandes der Bruchstiicke und unwollstilndiger Streckung des Unterschenkels behinderte, kam nach sechsmonatlichem Bestande durch Resection und Naht der Bruchstiicke zur Heilungmit normaler Function. (A fracture of the patella by direct violence which hindered walking by reason of the wide separation of the fragments and inability to extend the leg ; after six months the normal function was restored by resection and suture of the fragments.) Aertzl. Bericht der k. k. allgem. Krankenh. zu Wien, 1882. Sacre, Fracture ancienne de la rotule droite ; avivement ; suture osseuse ; guerison avec anky- lose. (Old fracture of the right patella ; freshening of edges ; suture of the bone ; cure with anchylosis.) Journal de Medecine, Chirurgie et Pharmacie, Bruxelles, 1883. Wahl, Naht einer Patella-fraktur. (Suture of a fracture of the patella.) Deutsche med. Wochenschrift, Berlin, 1883. 6 Birmingham Medical Review, March, 1883. ^ Lancet, April 29,1882. FRACTURES OF THE PATELLA. 235 meiit so as not to injure the articular face, and a double-acting screw-instru- ment is ap[)lied so as to bring the fragments together. Then a coil of very thin copper wire is firmly wound around the pins, and the screw-instrument is removed. Occasionally, very bad results have followed these heroic measures. Wyeth^ relates a case of long standing in which the fragments were sutured ; the joint suppurated, and amputation became necessary. It has been proposed by Oilier, VV^yeth,^ and others, to insert fresh marrow cells between the fragments ; and the [)lan has been adopted in a few instances, but I believe with only negative results. The theory of such a procedure is difficult to understand ; it would seem to be needless if the fragments were close together, and useless if they were widely separated, to say nothing of the want of a physiological ground for expecting any advantage from it in the way of bone-formation. Dietfenbach^ made a subcutaneous section of the ligamentum patelh^, and of the rectus femoris about three inches above the patella ; he then rubbed the fragments together, and kept them in contact by means of an apparatus for i)arallel pressure ; it is said that there was " complete hardening of the interposed substance," and that the patient's condition was markedly im- proved. One cannot help asking, however, whether the mere solidification of the patella would not be somewhat dearly bought at the expense of a length- ened and weakened ligament, and a muscle impaired by the substitution of a cicatrix for a portion of its substance. It will now be necessary, in order that the reader may not be only embar- rassed by the foregoing enumeration of methods and appliances for the treat- ment of fractures of the patella,^ that I should give a brief and practical summary of the subject. Here, as elsewhere, the great aim of the surgeon is, and ought to be, to restore, as nearly as possible, the normal state of things ; and it has, therefore, been thought desirable to obtain bony union betw^een the fragments. But that this is not essential to a good cure has been shown in the facts stated as to the value of limbs in which the fragments were con- nected only by a fibrous band of considerable length. Hence it may well be questioned whether it is not a mistake to concentrate all our attention upon merely forcing the fragments together, and especially to run any risk of doing greater mischief by the very means employed to this end. Whenever the fragments have already been forced apart, a tearing of the fibrous tissues surrounding^ the bone, and in the neighborhood, must have occurred. To prevent any increase of this rending, by properly securino- the upper portion of the bone, is manifestly indicated ; and in doing this^it is equally clear that interference with the nutrition of the bone and of the limb should be avoided. I think that it is sound surgery to use mild means first ; and hence should advise the relaxation of the quadriceps muscle by extend- ing the knee, and fiexing the hip-joint by elevating the foot. As soon as the inflammatory symptoms of the first few days have been subdued, the upper fragment should be brought down, but not with any great force, and a com- press applied above it, with pressure in such a direction as to oppose the upward pull of the quadriceps muscle. For this purpose any of the simpler means above described will answer ; I think that the elastic traction of the Mid- dlesex-Hospital plan is perhaps the best, but it should not be too vigorously applied. At the end of six or seven weeks, it will be found that the tendency > Med. Record, June 22, 1882. 2 ibid., May 11 1878 » Casper's Wochenschrift, Oct. 2, 1841. ' * The list might have been still further extended, but I have not thought it worth while to include a number of contrivances, which, although published as new, are really only modifi- cations, and often very trifling ones, of existing plans or instruments. 236 INJURIES OF BONES. to separation of the fragments no longer exists, and the patient may be allowed to lie in bed with merely a back splint on the knee, and with the limb otherwise unconfined. A week later he may be permitted to sit up, and to move about in a wheel-chair ; after which the use of the limb may be graduall}^ resumed, the back splint being left off. It may very probably be that the uniting medium will be found to stretch, and the gap between the fragments to be thus widened ; but in time the parts will acquire firmness, and the result will be satisfactory. In the rare instances in which this does not happen, but the limb remains weak and useless, the propriety of resorting to more energetic means may be considered. I do not myself think that any great risk is run in using Malgaigne's hooks, but I do not think that any great gain is effected by them. And, although much is claimed for the graver procedures, the resection and suture of the fragments, I think that a faithful trial should first be made of the reparative powers of nature, aided by frictions, shampooing, and well- regulated exercise, before the patient is subjected to the hazards which they cannot but involve. Everything else failing, and it being clear that the want of union between the fragments is the sole cause of the disability, extreme measures may be taken ; but the patient should be made fully aware of the extent of the dangers attending them, and of the chances of anchylosis, or of still worse evils. As to section of the quadriceps or its tendon, it seems to me to be merely the substitution of one evil for another. If incomplete, it is useless, while, if complete, it must almost of necessity involve the w^ounding of the knee- joint. Compound fractures of the patella are always of grave importance, largely increased if the knee-joint be directly involved. . These injuries are always due to direct violence, and the bone is often comminuted. The arthritis which is so apt to ensue upon simple fractures may be looked for in even a higher degree in the cases in question, and is much more likely to assume the suppurative character, as it will almost certainly do if the synovial cavity is laid open to any extent. Gross^ mentions a case followed by abscess, necrosis, and removal of the patella, the knee-joint becoming partially anchy- losed. Levergood^ records an instance in which, the patient having been inefiaciently treated, and having left his bed four weeks after the accident, suppurative arthritis ensued, and the joint was emptied by incision ; ampu- tation was proposed but refused ; recovery took place, and the patient was dismissed with " slight anchylosis." Poland,^ among 85 recorded cases, found that 20 proved fatal ; suppuration occurred in 63, and anchylosis more or less complete resulted in 31 out of the 65 in which recovery took place. The symptoms are generally sufficiently clear. The diagnosis is only obscure, in some instances, in regard to the involvement of the knee-joint, which may be but slightly punctured ; sometimes the opening is large enough for the finger to be readily passed in, and in any case the escape of synovia, if abun- dant enough to be distinctly perceived, is conclusive. The progn.osis^ it need hardly be said, is to be carefully guarded. If the immediate danger of shock is surmounted, there remain too many chances against both the limb and the life of the patient to warrant the surgeon in presuming upon success. Yet it does sometimes happen that complete recovery takes place, even under apparently adverse circumstances. The treatment is not materially different from that of ordinary simple frac- » Op. cit., vol. i. p. 1004. 2 Am. Journal of the Med. Sciences, Jan. 1860. * Med.-Cliir. Transactions, vol. liii. FRACTURES OF THE BONES OF THE LEG. 237 tures, except that the wound must be dressed. If small, an attempt may be made to close it ; but if large, and if the joint-cavity be opened, I think that thorouo;!! washing out with carbolized water should always be resorted to. Afterv\^ird, the closure of the wound ought again to be aimed at, as it may be obtained unless suppuration ensue, in Avhicli case experience teaches that effective drainage gives the best results ; this may be accomplished either with a tine rubber-tu1[)e,"with horse-hair, or with a few strands of carbolized silk. As dressing's, lead-water and laudanum, carbolized water, or an ice-bag (in hot weather especially) may be employed. Irrigation has. been preferred by some surgeons, but cannot always be conveniently arranged so as not to wet the clothing and bed, on account of the position of the limb. The question" of amputation or of excision of the joint must sometimes come up when the patient is young, and the local injury very severe, but it can hardly be appropriately discussed here. Perha[)s it is in these cases that the use of Malgaigne's hooks, or the resort to the suture, is most available; yet I cannot but think that other means should lirst be tried, and that they will often be found efficient. Very generally, after the tirst stage of the case, and especially if suppura- tion is established, a stimulant and supporting treatment is obviously demanded, and must be kept up during a long and tedious convalescence. Fractures of the Bones of the Leg. All authors agree that these injuries are of very common occurrence ; but there are some curious differences noticeable between the statistics derived from different sources, as will appear from the following data, chiefly ob- tained from Gurlt : — Lonsdale, out of 1901 cases, gives 289, or about 15 per cent, of the leg. Gurlt, among 1631, found 283, or over 17 per cent. Blasius, out of 778, found 139, or nearly 18 per cent. Middeldorpf, out of 325, gives 59, or a little over 18 per cent. Matiejowsky, among 1086, gives 293, or nearly 27 per cent. Agnevv, among 8667, found 2315, or nearly 27 per cent. Malgaigne, out of 2328, found 652, or 28 per cent. Lente, among 1722, gives 579, or nearly 34 per cent. If the reader will take the trouble to compare these statements with those quoted on page 186 from the same sources, but in reference to fractures of the femur, he will see that the figures given by the different institutions, for the latter bone, are not in the same ratio to one another as those above quoted for the leg. But these discrepancies can only be stated as facts, difficult, it seems to me, of explanation. Fractures of the leg are divided into those which affect both bones, those of the tibia alone, and those of the fibula alone. These again are found to differ in frequency ; both bones being involved far oftener than either bone singly. These differences are marked enough to warrant their presentation in a table as follows — 1 The percentages in this table have reference to the fractures of the leg only, and in stating them they are given approximately, neglecting fractions. 238 INJURIES OF BONES. Lonsdale Gurlti . Blasius . Middeldorpf Matiejowsky Agnew . Malgaigue Lente . Both bones. Tibia alone. Fibula alone. 197 or 68 per cent. 41 or 14 per cent. 51 or 17 per cent. 173 " 61 " 36 " 13 " 42 " 15 94 " 67 " 30 21 15 " 11 40 " 68 " 8 " 14 " 9 15 230 " 78 " 33 " 11 30 " 10 1441 " 61 437 " 19 " 437 " 19 515 " 79 " 29 " 4 " 108 " 15 442 " 73 " 45 " 8 " 92 " 16 Among the 316 cases derived by me from the records of seven years at the Children's Hospital, there are stated to have been 7, or a little over 2 per cent., of the leg; they are not classed as above, but fractures of either bone by itself are of extreme rarity during childhood, as, indeed, may almost be said of fractures in this region in general. Probably the reason of this may be found in the very slight leverage afforded by the bones of the leg at this period of life, whereas the femur, which is so often broken in children, yields by reason of its slenderness. I have, however, myself repeatedly had occa- sion to treat fractures of the leg in children in private practice. It may easily be seen why the proportion of fractures of both bones should be so large. Any force applied to the part, sufficient to break one bone, will l3e likely to act on both; and if one of the bones gives way, the other, losing its support, will be very apt to give way also. Fracture of the leg may occur at any age, and in either sex; but the great majority of its subjects are adult males, simply because these are espe- cially exposed to the violence by which the injury is produced. Agnew says that he has twice seen intra-uterine fracture of both bones ; and two other cases have been referred to elsewhere.^ On the other hand, Meachem^ has reported the case of a woman aged ninety years, who broke her leg in the lower third ; union had occurred by the twenty-eighth day. _ For greater convenience, fractures of both bones of the leg; will first be con- sidered, then those of the tibia, and lastly those of the fibula. Feactures of both bones of the leg may be produced either by direct vio- lence, as by blows, kicks, or falls— the leg striking against resisting objects— or by indirect, as when a man falls from a height, alighting on his feet, or when the foot is caught, and the impetus of the body is exerted upon the upper part of the leg. It is not always easy to explain the mechanism of these injuries with exactness, although the general principles of their produc- tion can be readily understood. The whole limb constitutes a mechanical system ; and if force be brought to bear upon it in such a way that the lever- age is through the lower part, for example, of the leg, the foot being fixed, and especially if there be any twist impressed upon the bones at the same time, the bones will give way either where the stress is greatest, or at the weakest point of their structure. Muscular action has in a very few instances been assigned as the cause of fractures in this region. Agnew^ says: ''A colored man was brought into the Pennsylvania Hospital with a fracture of the tibia and fibula, four inches above the ankle, which was caused by the violent muscular effort made to recover his equilibrium after slipping upon an orange-peel. He was thirty years of age, of an excellent constitution, and without any evidence whatever of pre-existing bone-disease. He had never before had a fracture." Gross > Gurlt, in his statistics, gives fractures of the malleoH separately; they numbered 32, and thus would be 11 per cent, of his 283 fractures of the leg. Middeldorpf gives 2, which would be about 3.5 per cent, of his 59 cases of fracture of the leg. 2 See p. 21. 3 Am. Med. Times, Jan. 5. 1861. 4 Op. cit., vol. i. p. 981. FRACTURES OF THE BONES OF THE LEG. 239 mentions that " an instance of fracture of both bones of tlie leg by. muscular action, in a man forty-two years old, has been recorded by Ilevlliard d'Arcy." Hamilton says "Eight times I have found the bones broken by muscuhir action alone." It does not often happen that both bones are fractured at the same level ; very generally the fibula yields at a higher point than the tibia. Sometimes the fractures are very far apart, so as really to constitute separate lesions, as in two specimens mentioned by Stoker.^ Here the tibia was broken low down, and the tibula high up, the obliquity of the two fractures being in con- verse directions. These cases, rare as they are, are not without analogues in the forearm. _ Occasionally the leg is broken in more than one place, when the violence is very great, as in some machinery accidents. Bransby Cooper^ saw a case in which both bones of the left leg were fractured in three distinct l)laces ; the patient, a niaii aged forty-eight, had had his leg crushed over the side of a boat by the falling of a heavy weight ; amputation was proposed, but he declined to submit to it, and although for a time his symptoms were very threatening, he ultimately did well, his convalescence being considered established by the eleventh week. In a specimen without history, in the Museum of the Pennsylvania IIospital,3 " the shaft of the tibia presents three nearly equidistant, slightly oblique fractures, and several small frao;ments have been broken off from the bone. There are also three equidistant frac- tures of the shaft of the fibula, the upper two of which are oblique, the other tnins verse." A similar specimen is in the Pathological Cabinet of the Xew^ York Hospital." The fibula is " broken near its upper end, while the tibia has been traversed by several very oblique fractures at and below its middle, separating the shaft into four fragments, all of which are firmly united bv bone deposited between the opposed surfaces and in the cavities left by pro- jecting angles." Fractures of both bones of the leg at their upper part are always due to great direct violence, such as the passage of a wheel, the caving in of eartn, entanglement in heavy machinery, etc. These fractures may or may not in- volve the knee-joint, a^nd tlieir exact mechanism is often difficult to determine. When the knee-joint is involved, it sometimes seems probable that the tibia first gave way across its long axis, and then that the lower or shaft portion was forced mto the upper, bursting it into tw^o or more fragments. The line of separation is seldom exactly transverse, but it is not often very oblique. Occasionally the fibula escapes ; but this is a matter of small moment, not affecting the gravity of the injury, or influencino; the symptoms. ^ In the i^ithological Cabinet of the Xew York Hospital, there is a specimen* from a man, aged thirty-two, who had a compound fracture of the left tibia, caused by a blow from a heavy piece of iron. " Both tuberosities are sepa- rated from the shaft by a line of fracture running across the bone an inch or .so below the joint, {ind a small portion of the internal tuberosity is still fur- ther separated by a fracture running from the first one up into the joint." \Vhen both bones are broken in the upper thirds of their shafts, the frac- aires are as a rule oblique, and they are apt to be more nearlv on a level with each other than when the injury is lower down. In the latter case, as before stated, the fibula is generally broken higher up than the tibia. ^ By far the largest number of cases, however, afiect the bones of the le^ either at or below the middle. I have said that the line of breakao-e is most generally oblique ; yet it is not always so, and one or two specimens of » British Med. Journal, Dec 24, 1881. 2 Hospital Reports, vol. i. 1836. 3 Catalogue, p. 42 ; No. 1174. 4 Catalogue, p. 122 f No. 243. . * Catalogue, p. 116 ; No. 226. o > ^ , 240 INJURIES OF BONES. almost exactly transverse fracture in this region have come under my obser- vation. Tillaux says that one reason why the tibia is apt to break below the middle, is that it has there its least diameter ; another, that it there assumes a cylindrical instead of a triangular form ; and he mentions a third, " a pecu- liar arrangement of the bony tissue, pointed out by MM. Fayel and Duret ; the cancellous structure of the tibia is, according to these authors, disposed in two independent systems of vertical columns ; the one occupies the upper two-thirds, and the other the lower third, so that the minimum of resistance corresponds to the junction of the two systems." In the middle, or indeed anywhere in the extent of the actual shaft of the bone, if force is applied to the tibia sufficient to break it, and especially if it be indirect, the fibula can scarcely escape : the exceptions being perhaps slight torsion, and such force as the kick of a horse, or any pressure brought sud- denly to bear upon the tibia, for an instant only ; in such cases the elasticity of the fibula may allow it to yield, and to spring back into shape. Some- times, indeed, the slenderness of the fibula may exempt it from direct force which breaks the tibia. If the leg is strongly bent between the knee and the foot, both bones may give way at once, or the tibia may be first broken, and the fibula may yield secondarily from the stress put upon it when it is no longer supported by the larger bone. Holmes^ figures a specimen in the Museum of St. George's Hospital, show- ing " the lower epiphyses of the femur and tibia, and both epiphyses of the fibula, separated in the same injury ; the shaft of the tibia is also fractured.'' He quotes also Prof. R. W. Smith's account of a case of separation of the lower epiphysis of the tibia, observed in a boy, aged sixteen, who recovered. The symptoms of this injury are often very distinct. As a general rule, there is immediate loss of power, and the patient falls ; but to this there have been noted numerous exceptions. Ormerod^ mentions the case of a man aged thirty-two, admitted into St. Bartholomew's Hospital in 1843, who had sus- tained, by the kick of a horse, a transverse fracture of the right tibia a little below the middle, with fracture of the fibula in its lower third. He had walked to the hospital, consuming about four hours in, so doing, with a crutch about the length of a walking stick ; his leg was very crooked at the time of his admission. Bryant says, " I have seen more than one patient walk upon the fractured limb directly after the accident, and in one case a man went up a whole fiight of stairs to his ward with but a slight limp. In another, under care in 1874, a woman with a fractured tibia and fibula went about for a week." A case is recorded^ of a patient walking about for twelve days after sustaining a fracture of the leg. Pain is very seldom absent, and may be very severe ; there is always ten- derness over the seat of injury, or if the limb is grasped above and below, and stress put upon the fractured portion. The deformity is sometimes very slight, but may be extremely marked ; its character depends chiefly upon the fracturing force. When this has been great, the limb may be wrenched entirely out of shape, bent, twisted, and perhaps shortened. But, as will be further detailed hereafter, in some very grave fractures there may be scarcely any change of form. Preternatural mobility is another symptom which varies greatly in degree in diff'erent cases. Sometimes the lower part of the limb dangles in the loosest way, but sometimes the fragments are held together by interdigita- tions, so that there is very little movement between them. 1 Surgical Treatment of Children's Diseases, 1st ed. p. 259. 2 Clinical Collections and Cases in Surgwry, p. 50. London, 1846. 3 Am. Journal of the Med. Sciences, Oct. 1845, from Recueil de Mem. de M6d., de Chir., et de Phar. Militaires. FRACTURES OF THE BONES OF THE LEG. 241 Crepitus is rarely wanting, and is in general developed by the slightest handling of the injured limb. Swelling occurs'very rapidly, and may mask the other symptoms in a great deo-ree. Ecchymosis also attends almost every case, by reason of the tearing of die periosteum ; it often takes place only gradually, and increases for some days. T have repeatedly seen the discoloration of the skin outlast the period of consolidation of the bone. Along with the eccliymosis there is very apt to be a formation of huWee or blebs, containing a more or less bloody scrum ; but these, if carefully let alone, will dry away without trouble. They are apt to be a source of great alarm to the patient and his friends, and to inex- perienced pnictitioners. Gross^ says that a symptom which is seldom absent is " a spasmodic twitch- ino; of the lini]), coming on soon after the accident, and frequently lasting for several days, or even" weeks, much to the annoyance and distress of the patient." I have never had my attention called to this phenomenon unless other symptoms of disorder of the nervous system were also manifested. The covrse of these fractures is subject to like variations. In some cases, after the first dressing, there is no pain, union takes place promptly, and the l)atient s only inconvenience is in the contiiiemeiit necessarily imposed upon him. Sometimes, however, very grave symptoms manifest themselves. Mr. Green^ reports a case of simple fracture of the leg followed by gangrene, for which amputation was performed, with a fatal result ; the autopsy showed no wound of the vessels, which may, however, have been pressed upon by one of the fragments. The patient w^as a man aged forty-seven. Another case is rei)orted by Trask.^ Dupuj'tren'* records six cases in which arteries were wounded by the fragments, the anterior tibial, the posterior tibial, and the peroneal being known to have thus suffered. Three times amputation w^as called for, and twice ligation of the femoral. Leigh^ records the case of a man, aged forty-eight, who fell from a height, and fractured both bones just l)el()W the knee. On the twentieth day he was thought to have an abscess, whirh was punctured, but only blood escaped ; two days afterward the Avound was oi)ened,and the anterior tibial artery was found torn across. The vessel was tied, but death occurred in a few hours. Borcheim^ has published an account of a case of fracture of both bones, in which an aneurism of the l)osterior tibial artery was formed, and the femoral was tied at the apex of Scarpa's ti'iangle ; union was not interfered with. Edwards^ has reported to the Pathoiogical Society of London, the case of a woman, aged sixty-three, who was run over, sustaining a fracture of the right tibia at the junction of the middle and lower third. On the third, day some bullae appeared on the foot ; on the fifth day the foot was cold ; amputation was performed, but death ensued. " The anterior tibial vessels had been occluded by being nipped between the fragments ; and a large blood-clot w^as found in the pressing on the posterior tibial vessels." Stimson® says that I\'epveu in a recent pa})er,® cites more than fifty cases of fracture involving injury to various vessels in the leg. Occasionally the nerves are likewise injured. Callender^'* records four cases of this kind, in which bull?e, causalgia, glazed skin, and the other phenomena recognized as due to nerve-lesions, were present. > Op. cit., vol. i. p. 991. « St. Thomas's Hospital Reports, vol. i. 1836. * Am. Journal of tlip Med. Sciences, Oct. 1850. * Lesions of the Vascular System, ete. ; Syd. Society's Translation. * St. George's Hospital Reports, vol. iii. 1868. « Medical Record, Dec. 30, 1882. 7 Med. Times and Gazette, May 26, 1883. * Treatise on Fractures, p. 568. ^ Bulletins de la Soc. de Chirurgie, 1875. " St. Bartholomew's Hospital Reports, 1870. VOL. IV. — 16 242 INJURIES OF BONES. It must not be forgotten that fat-embolism, of which mention was made at some length in the early part of this article, is especially apt to ensue upon fractures of the leg, in which the conditions upon which that pathological process depends are more fully met than in fractures of any other part of the skeleton. A peculiar form of fracture, affecting, almost if not quite exclusively, the lower part of the leg, was described w4th much accuracy by Gosselin,^ nearly thirty years ago. Both bones are broken ; but it is the lesion of the tibia which is important. This bone yields to a force of which torsion is a princi- pal element, according to some observers the only one ; but I think that there is ground for believing that there is first a flexion or cross-breaking strain. However this may be, the tibia sustains, first, a V-shaped fracture, the apex of the V presenting downward, and in some, if not in all the cases, on the antero-internal face of the bone, instead of along its crest. From this apex, or from a part of the V ("^ose to it, there runs downward a fissure, always in a spiral direction, to cross the ankle-joint, from behind forward, and then to run upward and join the main fracture at some other point. I think that the mode of production of this fissure will at once suggest itself in the lateral pressure of the apex of the V against the sides of the corresponding part of the lower fragment. This is the explanation admitted by Tillaux,^ who has given a very clear and practical discussion of the whole subject. These fractures have been designated as V-shaped, wedge-shaped, spiroid, or helicoid; but none of these terms adequately describe them. The V-shaped portion is of importance only as, under torsion, causing the fissure ; it does not act as a wedge ; " spiroid" is at best a mongrel word, and neither it nor "helicoid" is suggestive of the very long and really but slightly curved line in which the bone splits. Tillaux thinks the phrase " oblique fracture of the leg" a good one, with the addition, if another epithet be required, of the word helicoid." I venture to suggest that " Y -fractures of the tibia" w^ould con- vey the idea of the essential features of the lesion. Hulke^ says that the fracture of the fibula, in these cases, always has more or less of the V-shape ; and that this bone sometimes gives way at more than one point. Tillaux gives an instance in which it remained intact. There are obvious reasons why fractures of the kind just described should be attended w^ith danger of serious consequences. Besides the involvement of the ankle-joint, the damage done to the bone itself is extensive, and the medulla can scarcely escape bruising, hemorrhage into its substance, and in- terference with its nutrition. Hence, arthritis, osteo-myelitis, pyaemia, or septicsemia, ma}^ ensue, and cost the patient his life. Yet these risks are often successfully met, as in cases recorded by Gosselin. Two specimens are known to me, one in the Miitter Museum and the other in the Wistar and Horner Museum at the University of Pennsylvania, in which union has taken place in a very perfect manner, the line of the fractures, however, being clearly traceable.'^ Fractures of the leg at its lower part have been sometimes said to be analogous to those at or just above the wrist ; but it seems to me that this idea is apt to lead to error. Supra-malleolar fractures are in some small de- gree similar to those of both bones of the forearm close to the wrist ; but even here the resemblance is but slight and superficial. 1 Grazette des Hopitaux, 1855 ; Mem. de la Societe de Chirurgie, tome v. 1855 ; and Bulletin de la Societe de Chirurgie, tomes vi. et ix. See also Clinical Lectures on Surgery, translated by Stimson, pp. 90 et seq. *2 Op cit., p. 1149. 3 Holmes's System of Surgery, vol. i. p. 1043. ■* For tiirtlier in formation in regard to these fractures, the i-eader is referred to the articles and Works bctoro art of the fibula. The outer malleolus sometimes sufi:ers, as will be sliown in speaking of fractures of the fibula alone. Supra-malleolar fractures may be due to direct violence, or to a wrenching by outward or inward movement of the knee when the foot is fixed, or, as I believe, in some cases to extreme extension or flexion of the ankle, the foot beini;' fixed. I have several times seen, in persons who had fallen from heii^hts, alii2;hting on the feet, fractures which seemed to be explicable in the latter way alone. Fracture of the inner malleolus, with fracture of the fibula at some point generally about three inches above the ankle, is commonly known as Pott's fracture, having been first described w^ith accuracy by the distinguished sur- geon of that name. It had previously been regarded either as a sprain or as a (lislocjition. Although, as I shall presently further show, this lesion varies greatly in difierent cases, there are certain features which always belong to it and dis- tinctly characterize it. There are two ways in which it may be produced. When the foot is strongl}^ everted, so that the sole looks outward, the internal lateral ligament is put upon the stretch, and a cross-breaking strain is brought to bear upon the inner malleolus, which gives way. As soon as this happens, the astragalus and calcaneum are forced up against the end of the fibula, which bends and breaks, generally at a point some three inches above. On the other hand, if the foot is strongly inverted, so that the sole looks inward, the inner malleolus may be, as it were, pushed ofii", while the outer malleolus is drawn inward, and the fibula gives way to stress tending to bend it outward. In either case, the force is brought to bear across the columns of the can- cellous tissue of the inner malleolus, while the point at which the fibula generally gives way is where it is slenderest and least able to resist. By way of illustrating the difierences presented by the lesions in these cases, I may simply quote the descriptions of three specimens in the Patho- logical Cabinet of the Xew York IIos[)ital.^ In one, taken from a man aged thirty, injured l)y the caving in of a bank of earth, the fibula is seen to be fractured ti-ansversely two inches above the joint; the internal malleolus is torn ofi", and the posterior margin of the articular surface of the tibia is broken into three pieces." In another, " the internal malleolus is bi-oken off", and the fibula is fractured obliquely one inch above its lower end." jS'o history of the case is given. In the third, taken from a man aged fifty-three, who made a mis-step and iell upon the pavement, " there was a fracture of the fibula, commencing at the level of the ankle-joint, and running so obliquely upward and backw^ard as to leave a fragment nearly three inches long connected with the astragalus. The internal malleolus was torn oft', and the whole of the posterior third of the articulating surface of the tibia was comminuted and broken off" by a fracture running upward and backward from within the joint, thus leaving several large fragments still attached to the astragalus below." Occasionally the portion detached from the tibia is very small, consisting merely ot the tip of the malleolus ; and the lesion may then be properly ranked among " sprain-fractures." The symptoms of the fractures now described are placed together here by 1 Catalogue, p. 119 ; Nos. 233, 234, and 235. 244 INJURIES OF BONES. Deformity in "Pott's fracture.' way of contrast. Those of the " V-sliaped fracture" are : projection, but not generally very marked, of the up- ^ig- 844. per fragment ; pain, utter loss of power, swelling, ecchymosis ; mo- bility and crepitus only at the seat of the oblique fracture, the bone as a rule not being noticeably separated at the fissures. General tenderness alway s exists along the whole course of the fracture. Effusion occurs rapidly into the ankle-joint. In " Pott's fracture" there is gen- erally very marked deformity, the ankle being bent as in the cut (Fig. 844), and very movable until effusion has taken place in the joint, Ecchymosis occurs gradually. Fractures of the lower portion of the leg, involving both bones, usu- ally unite well, although some cases of non-union in this region are upon record, and sometimes consolidation takes place but slowly. In cases of Pott's fracture, unless the deformity is effectively remedied by treatment, the ankle remains permanently distorted, in a position similar to that of talipes valgus, and for a long time there is serious difficulty in walking. Sometimes, however, even when the bones have united in bad position, there is ultimately a much better result than might have been expected. The treatment of fractures of the leg has long been recognized as a matter of great importance, and to describe all the contrivances for the purpose which have been brought forward would be a formidable task. I shall en- deavor to give an idea of the principles to be carried out, and of the chief methods proposed for so doing, dwelling especially upon those which are of most practical value. As in most other fractures, the main points are the correction of the defor- mity, the restoration of the normal shape of the part, and the maintenance of the limb in this condition until the fragments shall have become firmly united. Sometimes the reduction is accomplished with ease, but sometimes it pre- sents great difiiculties. When the fragments are very loose, the distal por- tion of tbe limb dangling and very movable, the replacement is, as a rule, easier than when, though the displacement is less marked, the two portions of the tibia are interlocked. Very oblique fractures are sometimes attended with great overlapping, but this may be rectified without much trouble ; its recurrence, however, can scarcely be obviated, except by well-adapted means, carefully applied. Angular deformity is in general overcome by gentle manipulation, and ought not to be permanent under proper treatment. The rotation of the lower portion of the leg outward or inward must be carefully corrected, and in so doing the surgeon should make sure that both bones are placed in pro- per line ; otherwise the tibia may be straight, but the fibula bent so as perhaps to give the patient a limp in his gait. It will readily be seen that the reduction should be effected at the earliest possible moment, for two reasons: in the first place, because the swelling which soon ensues increases the difficulty of the procedure, and prevents the sui^geon from j.udging how far he has succeeded in accomplishing his object; and secondly, because the resistance of the muscles is greater the longer the FRACTURES OF THE BONES OF THE LEG. 246 frai>;inent8 have remained in their false position. Muscular action is not the sole cause, often not even the chief cause of the deformity, which is in gen- eral due to the fracturing force, or to the weight of the parts; but it very commonly is an obstacle to its correction. Hence this process is facilitated by relaxing the muscles, whi(;h is done by flexing the knee, and slightly extending the foot. Fractures which cannot be reduced at all with the knee straight will often yield promptly as soon as it is bent. The test of th*e limb being in jiroper line is that the inner edge of the patella, the inner side of the ankle, and the inner side of the great toe, are in the same vertical plane. And the fingers passed along the tibia should detect no angular irregularity in its surface. I have said that the main difliculties in reduction are due to interlocking of the fragments of the tibia, and to muscular contraction. Sometimes the condition of things is more complicated, and may be very obscure : — A woman, aged fifty, was brought into St. Joseph's Hospital, Philadelphia, having been run over by a wagon which had producey elevating the heel, this prominence is, i^enerally, almost if not altog(^ther made to disappear; or perhaps it would be more correct to say that the lower fragment is thus caused to follow the upper, so that they are FRACTURES OF THE BONES OF THE LEG. 249 restored to their normal relation. Care must be taken not to overdo this, so as to produce an angle salient backward, which would give rise to most troublesome lameness. Ormerod' records two cases in which this anterior displacement was not manifested for some time after the receipt of the injury ; under such circumstances it would seem attributable to defective treatment. Section of the tendo Achillis, according to Malgaigne, was first proposed and employed as a remedy for this condition by Laugier. It would seem to have found more favor in England^ than elsewhere ; a case has very recently been reported by Bryant,^ in which the operation was attended with success. Malgaigne proposed, for the correction of this deformity, the use of a steel point on a screw stem, passed through the centre of a bow of metal, which could be fastened to the back splint by means of a strap and buckle ; the bow being placed over the limb a little above the seat of fracture, tbe point was carried down through the skin, and screwed in so as to produce the requisite amount of pressure. An equally efficient and safer plan would be to sub- stitute for tlie point a little plate carrying a pad. By slightly shifting the point of pressure from time to time, all risk of its injuring the skin could be readily avoided. I am not aware that Malgaigne's contrivance has ever been used, except in the very few instances mentioned in his work ; and, indeed, nature does so much, in the way of rounding olf projecting points of bone, that it would seem to me needless to interfere, unless the deformity were more marked than in any case that has ever come under my notice. A curious consequence of fracture of the leg has been recorded by Terrier;* two months after the injury, a small cyst-like tumor show^ed itself on the inner surface of the limb near the fracture, and proved to contain free oil, effused from the broken bone; it was evacuated, and finally disappeaued. Pseudarthrosis is not uncommon after fracture of l:)oth bones of the leg. In Agnew's tables,^ out of 685 cases, 100, or nearly 15 per cent., were in this region. In thirty -one of these the exact seat of fracture is not given : in one it is said to have been at the junction of the upper and middle thirds; in twenty-four at the middle; in six in the middle third; in nine at the junc- tion of the middle and lower thirds; and in twenty -nine in the lower third. Hence it would appear that non-union is met with, in both bones, very nearly as often in the low^er third of th,e leg as in the middle third ; but the fact that in so large a proportion out of the whole number the exact seat of the lesion is not stated, prevents the drawing of absolutely positive inferences upon this point. The treatment of this condition has been sufficiently discussed in a pre- vious part of this article. Union with deformity has been observed in a large number of cases of fracture of both bones of the leg, and is often productive of such total dis- ability as to demand surgical interference. In not a few of these cases it has happened that the callus has yielded after the patients luive be2:un to walk, and in almost all there has been a progressive increase of the bending of the limb. When the shafts of the bones are concerned, the angle is almost always salient anteriorly; I know of only a few exceptions to^^this rule, in which the bones projected backward. Toward the lower part of the leg, the deformity is, for the most part, like that of talipes valgus, the upper tibial * Op. cit., p. 54. * See Med.-Chir. Transactions, vol. xxxiii- 1849, and Guy's Hospital Reports, 1855. 3 Lancet, June 2, 1883. * London Med. Record, Oct. 15, 1878, from Revue Mensuelle de Medecine et de Cliirurgie, No. 7, 1878. * Op. cit., vol. i. pp. 752 et seq. 250 INJURIES OF BONES. fragment projecting inward, and the outer side of the foot being drawn up. In some recorded cases there has been atrophy of the bones also. The procedures resorted to for the relief of this condition have been of various degrees of severity. JN'orris^ quotes Dupuytren^ as authority for the use of combined pressure and extension, and cites a case thus treated with success by M. Desgranges, four months after the receipt of the injury. Forcible refracture has been found effectual. Malgaigne cites cases from Bosch and Oesterlen, and one has been reported by Mussey.^ In 1851, I witnessed the performance of an operation of this kind, by Dr. W. E. Horner, on a leg broken twelve weeks previously ; the result was perfectly successful. Brainard^ made refracture easier by first drilling the bones at the abnormal angle ; ten days afterward the callus yielded readily, and a good result was obtained. Hunt^ resorted to similar means, and with ultimate success, although the patient's life was for a time in great danger. Section of the callus was first performed, according to Malgaigne, by Oes- terlen in 1815; afterwards by Dunn,^ Portal,^ Key, « Barton,^ Miitter,^^and Josse." ^^orris mentions that he knew of similar operations by Warren, of Boston, and Stevens, of ^ew York, and cites one by Rynd, of Dublin. I myself witnessed one such operation by the late Prof. Joseph Pancoast, and believe that he had others, never published. The modern method of subcutaneous osteotomy, which seems admirably adapted to the treatment of deformed union in some situations, cannot be so readily employed in cases afiecting the leg, for obvious reasons, unless the chisel is substituted for the saw. Dr. Fenger, of Chicago, has published^^ accounts of three cases in which he obtained success in this way. Another w^as reported, ^3 and the patient, a man fifty-eight years old, shown to the Leeds and West Riding Medico-Chirurgical Society, bv Mr. Jessop, of Leeds ; the case was one of Pott's fracture, which had firmly united in such a posi- tion as to render the limb useless. A section was made through the fibula, 2 J inches above the ankle, and another thi^ough the base of the inner mal- leolus ; and union was obtained so that the limb became straight and useful. Compound fractures of the leg are always serious injuries, and are of very common occurrence in hospital practice. The damage to the soft parts may be due to the fracturing force, as in railway accidents ; or it may be produced by eftbrts to walk on the part of the patient, by Vv^hich the broken ends are thrust through the skin. Occasionally, the displacement being irreducible, the skin gives way over the projecting fragments, and a fracture at first sim- ple becomes compound subsequently. Sometimes the fracture of one of the bones only is compound, that of the other being simple. Often in these cases the question of amputation presents itself, and must be settled upon principles elsewhere laid down. If the attempt to save the limb be decided upon, I think it right to cleanse the parts thoroughly with carbo- lized water ; reduction should then be accomplished, the wound closed, but with suitable provision for drainage,^^ and dressings applied. I prefer hot ' Contributions to Practical Surgery, p. 113. 2 Injuries and Diseases of Bones, Syd. Soc.'s translation, pp. 63, 66, and 68. 3 Am. Journal of the Med. Sciences, April, 1851. * Chicago Med. Journal, Jan. 1859. 5 Philadelphia Med. Times, Oct. 26, 1872, and Surgery in the Pennsylvania Hospital, p. 151. s Med.-Chir. Transactions, vol. xii. p. 181. 1 Am. Journal of the Med. Sciences, Oct. 1841, from an Italian Journal. s riuy's Hospital Reports, 1839. 9 Med. Examiner, Jan. 8, 1842. '0 Am. Journal of the Med. Sciences, April, 1842. " Quoted by Malgaigne. 12 Medical News, April 15 and 22, 1882. '3 British Med. Journal, April 14, 1883. '1 See an excellent article by Markoe, on Through-drainage in Compound Fractures of the Leg, in the Am. Journal of the Med. Sciences, April, 1880 ; and a paper by Dr. E. Mason, with its discussion by the New York Surgical Society, in the Medical News, Jan. 7 and Jan. 14, 1882. FRACTURES OF THE BONES OF THE LEG. 251 water, hot laudanum, or laudanum and lead-water. The fracture-box answers admirably in these cases, but my own practice is always to suspend it, not only because the patient is thus rendered more comfortable, but because the fragments are thus less likely to become displaced. At a later stage, when, as very generally hap})ens, suppuration ensues, and especially if the discharge be profuse, the bran-dressing devised by the late Dr. J. R. Barton is of great value. It is applied by means of a fracture-box, in which is placed a lining of muslin on which the bran is heaped, making a bed for the limb, which is then covered over with more bran, and the sides of the box brought up. It is not always necessary to secure the foot to the foot-piece, but if is better to do so if suspension is to be used. At this stage patients are apt to have become accustomed to conlinement, and to have learned to lie perfectly still. Bracketed splints of various forms, intended to control the limb while leaving the wound exposed for the purpose of changing the dressings, have been devised. Their value depends entirely upon the accuracy of their adaptation to the size and shape of the limb in each case ; and it seems to me safer for most practitioners to rely upon simpler means. As soon as the wound has healed, or the fragments have been so covered up by granulations as to be no longer exposed to the atmosphere, the lesion assumes the character of a simple fracture, and nmch of the danger is set aside. In the former case, the side splints, moulded to the limb, or the im- movable apparatus, may be resorted to ; but care should always be taken lest by undue or misplaced pressure the soft parts should be irritated, and fresh mischief ensue. Various circumstances may arise in the course of cases of this kind re- quiring special interference. Extreme swelling and tension of the soft parts sometimes come on within a few hours of the injury, and may be greatly relieved by free incisions. Hemorrhage may occur to an extent that demands the use of prompt and thorough means for its control. At a later period, there may be burrowing of pus" along the limb ; and counter-openings, drain- age, and properly applied pressure may be needed. Fractures of the tibia alone are, according to some observers, much less frequent than those of the fibula alone ; but the statements of others are de- cidedly at variance with this, as may be seen by a glance at the table quoted from Gurlt on a preceding page. The widest difference exists between the figures given by Malgaigne, 29 of the tibia to 108 of the fibula, and those of Blasius,"30 of the tibia to 15 of the fibula. When the tibia is broken of itself, it is generally by direct violence, but sometimes by indirect. One instance has been recorded by Caspary,^ in wdiich it was thought that the bone had yielded to muscular contraction, in a strong healthy man of twenty-six; but as he had had a venereal sore six years previously, and had complained of rheumatic pains for some time before the occurrence of the accident, it seems probable that the texture of the bone may have undergone pathological change. The fracture may be but slightly oblique ; it is seldom as markedly so as when both bones give way. "l have met with three recorded instances of incomplete fracture of the tibia. One, quoted by Malgaigne from 0am- paignac, was that of a girl, twelve years old, run over by a cabriolet ; at her death the lesion just stated, with a curvature of the fibula, was ascertained by dissection. Gray^ reported to the Boston Society for Medical Improve- » Berl. klin. Wochenschrift, 28 Jan. 1867. 2 Am. Journal of the Med. Sciences, Oct. 1853. 252 INJURIES OF BONES. ment the case of a boy of six, who " was standing on an iron rail fence, and in trying to jump down was caught by the heel and left hanging in that position ;" the subsequent deformity, without crepitus, and the straightening of the limb by means of splints, seemed to warrant the diagnosis given, which, however, could not be absolutely verified, as the patient recovered.' The third case was observed by Menzel,i of Trieste, in a man aged forty-eight', who was run over. There was some elastic mobility of the bone ; the patient died of pyaemia, and " the left tibia was found partially fractured between the^ inferior and middle thirds ; about seven-eighths of its substance was divided transversely ; the remainder presented not even a trace of fissure." Sometimes, although the main line of fracture is nearly transverse, there are subordinate breakages, making a commiimtion of the bone. James^ ha." recorded a case of longitudinal and transverse fracture of the tibia, witlf extensive extravasation of blood into the tissues of the leg. Epiphj^seal disjunctions have been observed in the tibia: Madame Lacha- pelle's case, in which the lower epiphysis of the femur and the upper of the tibia were detached in the delivery of a child, has been already mentioned, as has one of separation of the lower epiphysis of the tibia, quoted by Holmes from E. W. Smith. Stimson^ has reported to the ^ew York Surgical Society the case of a child, aged eighteen months, run over by a horse-c^r, in whom the upper epiphysis of the tibia was cleanly separated ; the upper end of the shaft was denuded of periosteum, which was adherent to the epiphyseal fragment. A specimen of separation of the upper epiphysis of the tibia, from a crush of the leg which required amputation, is figured by Ashhurst.^ The original is in the Museum of the Episcopal Hospital. Another case, in a boy of seventeen, has been placed on record by Quain f the lower epiphysis was detached, the boy falling with his foot doubled under him. Martin^ reports a case of compound separation of the lower epiphysis of the tibia, which may be mentioned here, although the fibula was also fractured about four inches above. The patient, a German boy, eleven years old, fell from about half the height of a telegraph pole. " The distal end of the shaft of the tibia had been separated from the epiphysis, and was protruding through the integuments. It had been thrust into the hard frozen earth, friction with which had stripped the periosteal covering of the bone from its entire external surface for the space of at least one and three-quarter inches. The peculiar stellate radiations of the extremity of the shaft where it joins the epiphysis were found to be perfect, when the dirt which had been packed into them had been removed." The boy recovered perfectly in two months. Eeference has already been made, in the early part of this article,^ to sprain fractures." Besides the instances there mentioned, a very instructive account is quoted by Hulke^ from Dr. Hutton, with a representation of the specimen, of detachment of the spine and central portion of the head of the tibia, with part of its left articular surface, the fragment remaining adherent to the anterior crucial ligament. The injury was sustained in wrestling. The symptoms of fracture of the tibia are not always very marked. Although the uninjured fibula is not strong enough to sustain the weight of the body, it is sufficiently so to prevent any great separation between the fragments of > London Med. Record, May 27, 1874 ; from Gazz. Med. Ital. Lomb., 28 Marzo. 2 Australian Med. Journal, 1882 ; quoted in Index Medicus for May. 1883. 3 Med. Record, July 15, 1882. 4 Principles and Practice of Surgery, 3d ed. page 269, Figs. 132, 133. Philadelphia, 1882. 6 British Med. .Journal, Aug. 31, 18()7 ; Holmes's System of Surgery, 3d ed., vol i. p. 1039. 6 Boston Med. and Surg. Journal, Sept. 27, 1877. 7 See page 19. s Holmes's System of Surgery, 3d ed., vol. i. p. 1039 ; the original account is in the" Dublin Hospital Gazette for 1846. FRACTURES OF THE BONES OF THE LEG. 253 the tibia, and the deformity is hence limited. Some projection of the edge of one or the other fragment, generally the upper, can be felt on passing the fingers along the bone, and this is apt to be more marked, the nearer the fracture is to either end of the bone. Haj's, however, has reported^ a case of fracture of the internal malleolus, clearly defined, without any displace- ment. The pain is for the most part severe enough to forbid attempts at standing or walking. Crepitus may be felt, and decidedly, although the fragments may be but slightly movable upon one another. Swelling and eccliymosis are apt to ensue, just as in fractures of both bones; and even although the fibula is not broken, it may be bruised, so that this symptom will present itself on the outer side of the leg as well as in the neighborhood of the more serious injury. The diagnosis may be made out clearly enough as regards the fracture ot the tibia, but it is by no means always easy to determirie whether or not the fibula has also given way. On this point it will be better for the surgeon to restrain his curiosity ; if mobility be not at once detected, it sbould not be vigorously or persistently sought for. In any case of doubt, the prudent course is to assume the probability of fracture. When the tibia alone is broken, the tixatmeM is essentially the same as that of fracture of both bones, and need not be again detailed. N^on-union is very rare in these cases, by reason of the support, slight as it would seem to be, afi:brded by the unbroken fibula ; yet Schiiller has reported^ an instance in which this condition was due to the interposition of the tibialis anticus ten- don between the fragments ; the patient, a healthy German woman, aged forty, had been run over by a wagon ; subperiosteal resection Avas performed, and afterward the periosteum was suiured, with the result of obtaining com- plete bony union, with very little shortening, in four months. Sometimes consolidation takes place very rapidly. Schweich^ relates the case of a peasant, aged forty, whose tibia was fractured transversely at about its middle, pro- ducing obvious displacement. A starched bandage was applied, and the re- porter ceased his attendance on the sixth day. The patient walked in his room on the t^velfth day, and returned to his work on the fourteenth. On the twenty-fifth he called on his surgeon, and exhibited a well-formed callus. Fracture of the fibula alone may be produced by direct violence, at any point ; when due to indirect force, it is generally seated within two or three inches of the external malleolus. In the former class of cases the mechanism is sufiaciently obvious ; in the latter it admits of some question, Avhich is, however, not of serious importance. It may simply be said here, that it is probable that sometimes, as when the foot is brought very forcibly into abduction, so that the sole is turned outward, the tarsal bones are pushed against the malleolus so as to bend the fibula toward the tibia, and cause it to break at its w^eakest point. On the other hand, wdien the foot is violently adducted, so as to turn the sole inward, the stress upon the external lateral ligament may be such as to bow the fibula outward, and oause it to yield in the opposite direction, but at the same point — possibly a little lower down. Wagstafte^ has reported two cases in which, by a twisting movement, the lower end of the fibula was split longitudinally, and a fragment detached which became rotated and wedged against the tibia so firmly that its re})lace- ment was found impossible. In one, recovery took place, though Avalking ^ Am. Journal of tlie Med. Sciences, Aug. 1837. 2 Quoted in the London Med. Record, Dec. 15, 1878, from the Gaz. Hebdomadaire, 12 Juillet. ' Am. Journal of the Med. Sciences, Oct. 1848 ; from Caspar's Wochenschrift. * St. Thomas's Hospital Reports, vol. vi. 254 INJURIES OF BONES. was difficult ; in the other, the patient dying in thirteen hours, the con- dition was verified by dissection. When the fibula gives way by extreme abduction, there may be either a rupture of the internal lateral ligament, or a tearing off of the tip of the inner malleolus — sometimes of a larger portion. When the opposite condition obtains, the malleolus may be broken ofl' by the forcible impact of the tarsal bones against it. But these cases have already been discussed under the head of Pott's fracture.^ The symptoms of fracture of the fibu«la are occasionally obscure. Some- times the patient can walk, but there is always some pain, by reason of the fragments irritating the muscles, or by the slight strain brought to bear upon the broken part in the balancing motion of which walking so largely consists. Pain on pressure is alwa^^s present, and swelling and ecchymosis are very apt to-occur. Crepitus is generally very slight, on account of the small size of the bone, and there may be no perceptible deformity. Keen^ has pointed out, as a symptom of fracture in the lower third of this bone, a widening of the ankle, allowing of motion to a more than normal degree of the astragalus between the malleoli. This can be developed by grasping the leg above the ankle, at about the supposed seat of fracture, and then with the other hand taking hold of the astragalus itself. Malgaigne^ speaks of the widening of the inter-malleolar space, but only very casually. Fractures of the fibula are sometimes attended with other serious symptoms, especially when the upper portion of the bone is involved. Duplay^ has reported two such cases, in woi'kmen caught in machinery bands and thrown against a wall. Among many other lesions, " there was found above the ordinary position of the head of the fibula a bony prominence, immovable, continuous with the tendon of the biceps. Below there was a manifest de- pression A few days later, a paralysis of the extensors of the foot and of the peronei muscles was noted, due doubtless to lesion of the external popliteal nerve In one case the diagnosis was verified post mortem; the other man left the hospital after several months, the paralysis remaining, as it still does." M. Perrin mentioned a similar case in a rider whose horse fell with him, and caught his right leg beneath him for a moment. There was arrachement " of the head of the fibula, and very considerable diastasis of the knee-joint, with some etFusion. Complete aneesthesia and paralysis of the anterior and outer part of the leg ensued. The ultimate result is not stated. Callender* mentions two cases of compound fracture of the head of the fibula, in both of which amputation became necessary on account of the injury inflicted on the peroneal nerve. BarwelP has recorded an instance in which fracture of the fibula was followed by the development of malignant disease. In the majority of cases, however, fractures of this bone unite favorably, and the functions of the limb are early and completely restored. As to the treatment of fractures of the fibula, it may often be almost iden- tical with that of other fractures of the bones of the leg. When there is no marked displacement, the limb may be simply kept at rest in a fracture-box, or done up with side splints, or with the Bavarian splint. If there is a strong tendency to either eversion or inversion of the foot, it may be cor- rected by placing a single long splint on the side toward which the foot is 1 A very elaborate memoir on fractures of the fibula was published by Maisonneuve in the Archives G(inerales de Medecine, for 1840, and was republished in his Clinique Chirurgicale, tome i. Paris, 18G3. The reader may consult it with advantage, 2 Pliiladelphia Med. Times, Aug. 15, 1872. » Traite des Fractures, etc., tome i. p. 813. 4 Gaz. Med. de Paris, 17 Avril, 1880. 5 St. Bartholomew's Hospital Reports, 1870. ^ British Med. Journal, Feb. 11, 1882. FRACTUKES OF THE BONES OF THE FOOT. 255 twisted, with a well-adjusted pad or long wedge-shaped compress to push the toot outward or inward as the case may be. Fractures of the Bones of the Foot. Fractures of the tarsal bones are not of very common occurrence. Those of the astragalus and calcaneum are the only ones which need be considered separately, although the other bones may be crushed, as in cases of railroad accident, or of other very great violence applied to the ankle — the fall of a heavy stone upon it, for instance. Such fractures are very apt to be compound, or to be attended with so much damage to the soft parts that amputation is inevitable. Fractures of the astragalus are very possibly more frequent than has been suspected, since they may easily escape recognition, and be regarded simply as severe sprains. Lonsdale^ mentions a case in which the patient jumped from a height, alighting on his feet ; there was no deformity, and the ankle was supposed to be badly sprained. Intlanm:iation of the joint ensued, and the man died on the twelfth day, when, on dissection, the astragalus was found to be split in two or three directions. Here it seems to me that the violence was direct, although exerted through the medium of the os calcis. In a case recorded by Croly,^ the fracture was due to the patient catching his foot in the stirrup as he fell from a horse ; and here the force was jDrobably indirect. Sheppard^ observed, in the dissecting-room, four specimens of frac- ture affecting the outer projecting edge of the groove for the tendon of the Hexor longus pollicis ; in three the detached piece was connected by fibrous tissue with the rest of the bone, and in one osseous union had taken place. These specimens were without history ; it would seem proper to place them in the category of " sprain-fractures." i^eilP has recorded an instance in which the posterior extremity of the bone was broken off, and remained un- united. Displacement of the broken portion sometimes takes place. Bryant says, " I have recently removed from the inner aspect of the ankle of a man the upper half of the astragalus, that had been fractured six months previously, and displaced so as to present its upper articular facet inward." This case had been previously supposed by the surgeon in attendance to be a fracture of the tibia and fibula. Vollmar^ reports an instance of fracture of the head (>f the astragalus, in a stout countryman who fell from a height of eight or nine feet, and presented a bony prominence in the arch of the left foot. In front of the articulating extremity of the tibia and fibula there lay, under the raised integuments, a bony swelling, separated by a deep depression from -the outer malleolus." 'No hollow could be detected. Eeplacement was effected by extension, and in four weeks the patient was able to walk about. MacCormac^ has reported a fracture of the neck of the bone, the posterior portion only being dislocated, so that the trochlear surface ^vas directed in- ward and slightly backward ; the inner malleolus was als*o detached. He refers to a similar case seen by LeGros Clark. Other cases of fracture with dislocation have been recorded by I^'orris'' and John Ashhurst, Jr.^ Goyder^ ' Op. cit., p. 531. 2 British Med. Journal, March 18, 1882. 3 Medical News, Aug. 5, 1882 ; from Lancet, July 1. * Am. Journal of the Med. Sciences, Julj, 1849. 6 Med. Times and Grazette, Jan. 27, 1855 ; from Zeitschrift fiir Chirurgie und Greburtsk., 1854. 5 Trans, of Path. Society of London, voL xxvi. 1875, ' Am. Journal of the Med. Sciences, August, 1837. 8 Ibid., April, 1862. 9 Med. Times and Gazette, Oct. 15, 1882. 256 INJURIES OF BONES. has reported a case of compouod comminuted fracture of the astragalus, the malleoli being unbroken ; recovery took place with a movable joint. In a case seen by Bryant,^ a compound, complicated fracture of the head of the bone was produced by a fell from a height of some ten or twelve feet, the patient alighting on his feet. The head of the bone was removed, and the body of it restored to its normal position. Recovery ensued " with some use of the limb." The sym.jptoms of fracture of the astragalus are only obscure when there has been great violence, and swelling occurs rapidly. If there is luxation of either portion, the deformity will call attention to it, when crepitus will probably be readily detected. When the bone retains its place, there will be tenderness on pressure across it, and crepitus may be perceptible. Walk- ing, or standing on the injured foot, will be impossible. Swelling and ecchy- mosis will almost certainly come on ; but a patient in my wards at the Episcopal Hospital, in 1882, presented neither of these symptoms, although the line of fracture could easily be felt, and crepitus was distinct. The treatment in uncomplicated cases consists simply in keeping the foot at rest and preventing or allaying inflammation. When there is luxation, it may be a question whether the fragment should be removed or left to itself, if reduction is found to be impossible. In i^'orris's case one fragment was excised, and the other was allowed to remain ; it became carious and loose, and was removed, but the adjoining bones also became carious, and at length amputation of the leg was performed, with a fatal result. In deciding the question of operation, the patient's age, habits, and constitution must be taken into account, the prospects of a young and sound person, who has never been debilitated by excesses or hardships, being much better than those of an old, or dissipated, or broken-down subject. When the fracture is merely compound, the surgeon should be guided by general principles. So great a probability of permanent stiffening of the ankle exists in all these cases, that a very guarded prognosis should be given. Fracture op the os calcis was formerly supposed to be always the result of muscular action ; but it is now known to have occurred in a number of instances by crushing. I believe that the two causes are apt to be combined, the tension of the muscles of the calf acting strongly upon the posterior portion of the bone, and exerting a leverage which must aid in overcoming the resistance of its tissue to force applied from without. On examination of a vertical, antero- posterior section of a well-developed calcaneum, it will be seen that the arrangement of the cancellous structure is principally in radiating lines from the upper articular surfaces ; and that although this is admirably adapted to meet the stress ordinarily sustained, it makes the bone, crushing being once begun, very liable to be rent apart. The accident which has most frequently given rise to this injury is a fall from a height, the patient alighting on the heel. Lawrence^ saw a case in which the patient had jumped'from a stage-coach, and fractured the posterior part of the bone ; the fragment was drawn upward by the muscles of the calf, but, upon pulling it into place, crepitus could be readily elicited. The case did well, although the patient halted somewhat in walking. CostancG^ met with a case in which a woman, aged fifty, had her heel crushed under an overturned coach, and the fractured portion of the calca- ! Lancet, June 2, 1883. 2 Lancet, May 29, 1830. * Am. Journal of the Med. Sciences, Nov. 1829 ; from Midland Med. and Surg. Reporter, May, 1829. FRACTURES OF THE BONES OF THE FOOT. 257 neura was drawn up " as high as five inches." It could not be replaced, and the patient, after extensive inflammation and sloughing of the soft pa4'ts, recovered with the fragment firmly adherent in its false position, and its place filled by soft " cellular substance." South^ says that in the Museum of St. Bartholomew's Hospital there is a specimen of horizontal fracture of the tuberosity of the calcaneum, ^'extending to its hinder upper joint-surface, where it is continued upwards at nearly a right angle ; the fractured piece does not appear to have been actually pulled out of place." He knew nothing of its history. He relates a fatal case of compound fracture of this bone, under his own care, and quotes another seen by Lisfranc, in which union was first fibrous, and afterwards bony.^ Sometimes both calcanea are simultaneously broken. Of this Malgaigne says that he himself saw an instance, and that one was reported by Voille- mier.^ Fifield^ records the case of a robust German, who fell about eighteen feet, alighting on his heels ; in the right foot a compound comminuted fracture of the inner side of the calcaneum was at once detected, but in the left there was simply great swelling. About a month afterward, the swelling having subsided, a plaster bandage was applied, and in less than an hour the patient died from pulmonary embolism. The left os calcis was then found to be completely smashed. Fractures of the os calcis by muscular action have been reported by Coote,* in a woman aged fifty-five, and by Anningson,^ in a woman aged forty-two. Stimson^ presented to the ^ew York Surgical Society a specimen supposed to be of this character. The accident had occurred eight years previously, and the history of it was somewhat obscure. It appeared that the patient, a man then aged forty-five, had been knocked down by a passing wagon. " The fragment was the portion to which the tendo Achillis was attached, at least partially. It was more than an inch in length, and about three-fourths of an inch in breadth. On its outer side the periosteum was complete ; on the inner side there was a growth of bone which presented the appearance of having been the result of reparative process. The fragment had united with the bone at its upper border, but was about half an inch anterior to its origi- nal position." It seems to me that in some of these instances (the last mentioned, for ex- ample), the lesion might be properly ranked among "sprain-fractures." Although it might seem very natural to expect that both the astragalus and the calcaneum would often suffer together, such is very rarely th.e case. I have, however, seen two specimens of this kind, one derived from a case of railroad injury, and the other said to have been caused by a fall on the heel. Of course in the crushes due to falls from great heights, to the passage of wheels, to entanglement in machinery, or to the fall of a heavy body upon the part, there can be no limit set to the damage likely to be done. In the Museum of the Pennsylvania HospitaP there is a specimen in which " the inner malleolus is broken off', and there is a transverse but fissured fracture of the fibula two inches above the malleolus. A small piece has been broken oft' from the postero-inferior part of the astragalus, and an irregular trans- 1 Translation of Chelius's Surgery, vol. 1. p. 640. * See Archives Grenerales de Medecine, Janvier, 1828. * Malgaigne gives no reference for this case, and I have not been able to find it. 4 Medical News, Feb. 3, 1883. 5 Lancet, April 28, 1866. 6 British Med. Journal, .Tan. 26, 1878. I find also in the Index Medicus for July, 3 883, the following reference : Saussol, Un cas de fracture du calcaneum par arrachement ; Graz, Hebd. des Sciences Med. de Montpellier-. 7 Annals of Anatomy and Surgery, July, 1883 ; also Medical News, Feb. 3, 1883. 8 Catalogue, p. 45 ; No. 1189. VOL. IV. — 17 258 INJURIES OF BONES. verse fracture of the os calcis has occurred half an inch below its articulation with the astragalus." The patient had fallen from a second-story window ; he refused amputation, and died of pyaemia, after erysipelas, sloughing, abscess, and secondary hemorrhage, for which the anterior tibial artery was tied.. Fracture of the lesser process, or sustentaculum tali, has been studied and described by Abel.^ It is said to be due to falls on the sole of the foot, or to forced inversion of the foot, so that the sole looks inward. The me- chanism of such an injury is obvious. The symptoms of fracture of the os calcis, as may appear from what has already been said, are not always such as to lead to its easy recognition. Of course there is pain, inability to bear weight on the heel, and tenderness on pressure, while sometimes the posterior fragment is drawn upward by the muscles of the calf acting through the tendo Achillis. But Malgaigne says that he mistook the lesion, in the first case seen by him, for fracture of the fibula, and that the same error was fallen into by Voillemier as well as by Bonnet ; and it is very possible that surgeons of less experience have been deceived in like manner. Abel says that when the sustentaculum tali is detached, any attempt to stand or walk everts the foot, giving the ankle the valgus position ; crepitus and abnormal mobility^ although present, may be masked by the sw^elling ; but the astragalus and tibia are displaced somewhat backward, lessening the distance between the posterior border of the inner malleolus and the tendo Achillis. The course of these cases can hardly be definitely laid down. Consolida- tion would appear to take place only very slowly, and it is apt to be a long time before the foot becomes useful again. I think that sometimes, in the cases of caries or necrosis of the os calcis, which are met with in children, there may have been in reality an unrecognized fracture, the nutrition of the bone being irretrievably damaged. The prognosis must always be doubtful. As to the treatment^ it must consist in obviating displacement as far as pos-. sible, by keeping the foot in a proper position, attention being at first paid, of course, to keeping down inflammatory action. The best dressing for these cases is a splint along the front of the leg, extending as far as the roots of the toes, and having an obtuse angle corresponding to the instep ; it may be kept in place by an ordinary roller, and afterward by a plaster or silicate bandage. The old plan of putting a slipper on the foot, and attaching it by a band to a fillet around the lower part of the thigh, is open to the grave objection that the pressure of the heel of the slipper would itself tend to push the posterior fragment out of place. Fractures of the other tarsal bones can hardly occur except from crush- ing force, and present no features which need be dwelt upon. I have never seen such a case, except when the w^hole ankle was smashed, and when ampu- tation was the only resource. Fractures of the metatarsal bones result only from crushing, as by heavy weights falling upon the foot, and are nearly always compound. If amputa- tion is not demanded, the only course open to the surgeon is to allay inflam- mation, and to keep the foot at rest until union shall have occurred. Any displacement of the fragments must be remedied as far as possible by careful manipulation; the result is apt to be favorable. Malgaigne says : "I recently had to treat a carter, who was thrown down under his vehicle, and had the 1 British Med. Journal, Nov. 9, 1878 ; from Arch, fiir klin. Chirurgie. CONTUSIONS OF BONES. 259 three middle metatarsal bones broken by the wheel passing over them. The anterior fragments were very greatly depressed; there was a lacerated wound on the back of the foot, and the inflammation was most intense. It was therefore impossible to remedy the displacement, and, indeed, the saving of the foot could hardly be hoped for. The patient recovered, and could plant his foot very firmly on the ground, but the great projection of the upper fragments at the back of the foot obliged him to wear a peculiarly-shaped shoe." Hammond^ reports a case of compound comminuted fracture of the right ankle as well as of the first and second metatarsal bones of the left foot, iif which the patient made a good recovery without amputation. Boyd, however, has recorded^ the case of a woman, aged fifty-nine, with fracture of the four outer metatarsal bones, followed by thrombosis of the femoral artery, pulmonary embolism, and death. Such cases are not very uncommon among the broken-down subjects of hospital treatment. Fractures of the phalanges of the toes are very rare, except from great direct violence. Yet I have several times seen them produced by accidents to persons bathing at the seashore, without serious injury to the soft parts, the pain, crepitation, and abnormal mobility placing the character of the lesion beyond doubt. In these cases the treatment is the same as for like injuries to the phalanges of the fingers, although the small size of the parts renders the aplication^of splints at the same time more difiicult and less need- ful. A little bit of pasteboard may be laid along the back of the toe, and bound on with a strip of adhesive plaster. I have never seen permanent lameness follow a hurt of this kind. Compound fractures of the toes, as a rule, require amputation ; but there is room for the exercise of judgment in deciding this question, as nature will sometimes do more in the way of repair than might at first be thought likely or even possible. The risk of tetanus from such injuries ought never to be wholly overlooked. Other Injuries of Bones. Besides fractures, the bones are liable to other forms of injury concerning which the surgeon should not be ignorant. Contusions of bones are not very uncommon ; and although the soft parts are also bruised, and the soreness in them masks that of the bone, yet there is often perceptible for a long time a deep-seated tenderness which ^ives ev 1 dence that the bone has suftered. Such injuries generally aftect the super- ficial bones, and especially the tibia, which is very apt to be hurt in the rough sports of boyhood. As a rule nature repairs the damage inflicted in this way; but occasionally the results are more serious, and inflammation may ensue ; the periosteum may swell, and necrosis of the underlying bony substance, or perhaps osteitis, may follow. In rare instances, and probably only where there is a constitutional vice, the nutrition of the entire bone becomes in- volved, and its inflammation or its death may take place. Or, if the dis- order be more localized, an abscess may form in the cancellous substance, and give rise to very troublesome symptoms. The treatment of contusions of bone consists in the enforcement of rest, and the use of hot-water dressings, and perhaps leeches ; but it is seldom that 1 Trans, of the New Hampshire Medical Society, 1882, p. 105. 2 Trans, of the Pathological Society of London, vol. xxxiii. 1882. 260 INJURIES OF BONES. the surgeon is called upon in such cases until the more serious secondary symptoms have declared themselves, the mode of managing which will be elsewhere detailed Incised wounds of bone sometimes occur. They are most frequent as the result of accidents m saw-mills, hut are occasionally met with in carpenters or wood-cutters. I once saw an old man who had fallen with his knee on the upturned edge of a scythe, which had cut clean through the patella, and laid the joint open entirely across. Gross^ mentions the case of a man, aged thirty- nine, who had had his olecranon severed by a cut with a butcher-knife; the joint was of course laid open, and there was free bleeding. Union took place with anchylosis. In 1876, 1 had in my ward in the Episcopal Hospital, a man aged twenty-five, who had had a very similar injury inflicted ui:)on him with a "drawing-knife;" the closure of the wound was impossible, and I excised the entire joint, with a fairly good result, although the motion of the parts was very limited. Of course injuries of this kind must always be compound, and their gravity will vary according to the seat and extent of the damage inflicted on the bone, as well as the degree to which the soft parts are involved. If a limb be cat entirely through, the question will necessarily arise whether union can take place or not. Some marvellous stories are told of cases in which severed fingers have been readjusted, and with perfect success ;2 but my own experi- ments in this way have uniformly failed. ^ The treapnejit must be adapted to the circumstances of each case. Some- times it will consist simply in arresting hemorrhage, closing the wound, and putting the parts at entire rest by means of splints and bandages ; just as in compound fractures. Sometimes amputation will be clearly indicated ; and sometimes, as in my case above mentioned, excision may be the proper course. Punctured wounds of bone have been met with, especially in Indian war- fare. These have already been considered at sufficient length in the article on Bayonet and Arrow Wounds.^ I once myself, in making an autopsy, sustained a punctured w^ound of the second phalanx of the middle finger ; the point of a scalpel penetrated the bone,_ and it was seven months before the w^ound healed, the bone itself remaining s woollen and tender. ^ Gunshot wounds of bone have already been fully discussed m the article on injuries of that class.'' 1 Op cit., vol. i. p. 831. . 2 For one of the most extraordinary, in which the forearm is said to have been cut through ali but a strip of skin, and to have healed again perfectly, see the quotation of General Hunter's case. (Med. and Surgical History of the War of the Rebellion. Part Second, Surgical Vol. v. 918, note.) ° ' 3 See VoL II. pp. 105 et seg. < See Vol. II. pp. 125, 147 et seq. INJURIES OF THE BACK, INCLUDING THOSE OF THE SPINAL COLUMN, SPINAL MEMBRANES, AND SPINAL CORD. BY JOHN A. LIDELL, A.M., M.D., liATE SURGEON TO BELLEVUE HOSPITAL, NEW YORK ; ALSO LATE SURGEON U. S. VOLUNTEERS IN CHARGE OF STANTON U. S. ARMY GENERAL HOSPITAL ; INSPECTOR OF THE MEDICAL AND HOSPITAL DEPARTMENT OF THE ARMY OF THE POTOMAC, ETC. The region whose injuries are to be considered in this article, embraces the posterior part of the neck, chest, abdomen, and pelvis, or, in other words, the posterior part of the whole trunk excepting the head. The organs con- tained in this region are, (1) the spinal cord, with the spinal meninges and the roots of the spinal nerves ; (2) the vertebral column, from atlas to tip of coccyx inclusive ; and (3) the muscles both great and small which are attached to the vertebrae, together with the integuments that cover them. The welfare of these organs is a subject of extremely great importance, inasmuch as their integrity, considering them as a unit, is essential to the very existence of man as an animal. I cannot emphasize this point in any better way than by calling attention to the fact that the' vertebral column is the first portion of the skeleton to appear in man, and the centre around which all other parts of the skeleton are produced ; that the spinal cord is the first formed portion of the nervous system, and the centre to which all other parts of the nervous system are appended; and that the chorda dorsalis of the embryo " forms the basis around which the vertebral column is deve- loped." At first, the vertebral column is a simple cartilaginous tube which surrounds and protects the primitive trace of the nervous system in the em- bryo ; but, as it advances in growth and organization, it becomes divided into 33 distinct pieces constituting the vertebrje ; of which 24 are called true and 9 false. At a still later period, the false vertebrpe coalesce, the upper 5 of them to form the sacrum, and the lower 4 to constitute the coccyx, the process of coalescence being completed at maturity or the termination of growth. The true vertebrae, however, do not coalesce ; but, placed one above the other, they constitute a flexible tubular column, composed of ring-shaped bones alternating with lenticular disks of firm yet elastic intervertebral substance, and bound together by broad, thin planes or bands of ligamentous tissue, many of which are also elastic. The vertebral tube is lined by the spinal dura mater, or theca vertebralis, which is continuous with the cerebral dura mater ahove it, and contains much cerebro-spinal fluid in which the spinal cord, attended by large plexuses of veins, hangs suspended from the base of the brain by its attachments to the pons Varolii, as it were, in a well. The cerebro-spinal or sub-arachnoidean fluid also keeps up a constant and gentle ( 261 ) 262 INJURIES OF THE BACK. Fig. 851. pressure upon the entire surface of the spinal cord as well as upon that of the hrain, and jdelds with the greatest facility to the various movements of the spinal cord and spinal column, giving at the same time to the delicate structures of the cord and hrain the advantages of the mechanical principles so usefully applied by Dr. Arnott in the hydrostatic bed. Thus we find that the spinal cord is protected iu a truly wonderful manner from the ill eftects of blows, and shocks, and pressure, by an elastic, fluid medium which every- where surrounds and gentlj^ compresses it. The traumatic lesions of the back naturally arrange themselves in three groups, as follows : — I. Injuries of the integuments and muscles, or soft parts generally. II. Injuries of the vertebral column. III. Injuries of the spinal membranes, spinal cord, and spinal nerves. For the purposes of study and description, this classification of the trau- matic lesions to which the dorsum of the trunk is exposed presents some advantages which are quite obvious, and, therefore, I shall follow it as far as may be found se r viceable. It sh ould be borne in mind, liowever, that the examples which claim the surgeon's attention in practice usually illustrate at least two of these forms of injury; and that, not unfrequently, all three are simultaneously exhibited in the same patient. The symptoms and treatment of these lesions must there- fore be described from general or com- mon, as well as from specific points of view. From most writers on surgery, inju- ries of the back have not received that degree of attention which their importance j ustly demands. This neg- glect may have arisen on the one hand from undervaluing the functions of the spinal cord itself, and holding it to be merely an appendage of the brain, or^ on the other hand, from considering the injuries which involve the vertebral column and spinal cord, in general, to be hopeless lesions for which the sur- geon's art can do no good. ^N^everthe- less, I am fully persuaded that a con- siderable share of even the least pro- mising cases are susceptible of per- manent relief by judicious treatment from the surgeon ; and I am supported in this view by the extremely large proportion of recoveries which has resulted from the attempts to reduce dislocations^ and fractures of the vertebrae that have been recorded. For instance, thirty-four cases are mentioned in Dr. Ashhurst's tables,^ in which reduction was attempted by various appropriate procedures, and recovery Posterior view of the vertebral column, ribs, etc., the integuments and muscles having been laid open and deflected from them. (Sibson's Medical Anatomy, PI. XII.) Injuries of the Spine, pp. 71-121. Philadelphia, 1867. INCISED AND PUNCTURED FLESH-WOUNDS OF TlfE BACK. 263 ensued in all but four. In many, the successful issue of the efforts at reduc- tion was indicated by an audible sound or a snap." In several the paralysis was instantly relieved. I. INJURIES OF THE SOFT PARTS. Incised and Punctured Flesh-wounds of the Back. Wounds are inflicted with cutting and puncturing instruments in the back part of the neck, chest, abdomen, and pelvis, by accidents, by criminal de- sign, and in war, with so much frequency as to require at least some mention of them in this place. For instance, " punctured and incised flesh-wounds of the back were exemplified by fifty-six instances [thiring our late civil war]^ of which twenty-one were cases of bayonet-stabs, thirteen of sabre-cuts, and twenty-two of punctures and incisions by sundry weapons. None of these cases are recorded as terminating fatally, though in six the result has not been ascertained ; forty-five were sent to duty, and five were discharged. Several of these cases were examples of severe though not dangerous sword- wounds."^ Of the thirteen examples of sabre-cuts, twelve were received in action. The bayonet-stabs, however, appear to have been inflicted almost entirely by sentries, or by provost-guards, or in brawls, or through accidents. But one example is specified as a wound received in action, and this wound may not have been inflicted by the enemy. Sabre- wounds of the back are seldom mentioned in the literature of surgery. No instance is related by either Gathrie or Hennen. Bilguer, however, gives an instance that occurred in the Seven Years War (1756-63) : A cavalry soldier, J. R., while retreating and leaning over his horse's neck, received two cuts in the lumbar region.^ He appears" to have recovered. But Morgagni records an autopsy in a case of sabre-thrust in the back.^ Incised wounds which sever to a considerable extent the fasciculi of the trapezius, latissimus dorsi, or rhomboid muscles, are apt to gape widely open. In treating such wounds, it is necessary, after stanching the bleeding and removino; the coagula and all other foreign bodies, to introduce at the outset sutures of carbolized silk, which are antiseptic, or of silver or iron wire, which are also antiseptic ijer se, in sufficient number and at sufiiciently short intervals, and at a sufficient depth, to bring the divideil parts into complete apposition, where they should be allowed to remain until the union is com- plete. Under this plan of treatment, with quietude, the results of flesh- wounds of the back (incised) are almost always very favorable. But if no sutures be introduced, and the gaping wound be allowed to fill up and heal by granulation, some considerable time may be required before recovery takes place. Incised or Punctured Flesh-wounds of the Back of the Neck. — If these penetrate deeply, they may open the vertebral or the occipital artery, and thus cause a hemorrhage which, if not restrained, Avill speedily prove fatal, on the one hand ; or, unless promptly treated in a radical manner, will give rise to a traumatic aneurism of an almost equally fatal character, on the > Med. and Surg. History of the War of the Rebellion, Second Surgical Vol. p. 429. 2 Chirurg. Wahrnehmungen, S. 493. Berlin, 1763. » De Sed. et Causis Morb., Ep. liii. p. 270. 1765. 264 INJURIES OF THE BACK. other. Hennen, indeed, remarks that " simple incised wounds on the back of the /leck, although sometimes penetrating to a great depth, and even un- covering the vertebral arteries, are not beyond the reach of simple bandage, and retention by adhesive strips and sutures ; feebleness of the extremities, particularly the lower, is a more frequent source of complaint, in these cases, than hemorrhage."^ ^Nevertheless, there are many cases on record in which stabs in the nape of the neck opened one of the vertebral arteries, and thus gave rise to most disastrous consequences. Dr. Kocher, of Berne, relates an excellent example of this sort, in Langenbeck's Archives f and he remarks that it is the twenty-first recorded case of traumatic aneurism of the verte- bral artery. In twelve of these twenty-one cases, the wounds were stabs. In ten cases the result was fatal before any pulsating swelling appeared. In eleven cases where life was prolonged until there was pulsating swell- ing, but two recoveries occurred.^ Thus it appears that flesh-wounds in the nape of the neck which involve either of the vertebral arteries are ex- ceedingly dangerous to life, that the ratio of mortality for this lesion has, hitherto, exceeded 90 per cent., inasmuch as nineteen out of twenty-one recorded cases have proved fatal, and that the surgical treatment of this form of injury is a subject of very great importance to practitioners as well as to patients. It may be useful to state in this connection the chief causes of this striking want of success. In eleven cases, the carotid artery was tied, through error in diagnosis, and this operation probably rendered the evil greater, by increasing the blood-pressure in the wounded vertebral artery ; indeed, in two of the cases thus operated on, the patient died of violent hemorrhage from the seat of injury ; and in three other cases belonging to the same category, death occurred from bursting of the aneurism. In five instances, the ligation of the carotid was followed" by paralysis that proved fatal. Liicke, in a case where the aneurismal swelling increased rapidly after ligating the carotid, injected into the sac chloride of iron, and also applied plugs saturated with the perchloride ; the patient, however, died with symp- toms of paralysis. Maisonneuve, in a case of gunshot wound, tied both the vertebral and the inferior thyroid arteries, and extracted the missile. The bleed- ing was arrested, but death ensued from the infiltration of pus into the spinal canal, and consequent inflammation. One patient died of septicemia follow- ing suppuration of the connective tissue of the neck. In several cases there was hemorrhage that resulted in death.* But, as stated above, an error in diagnosis, a mistaking of the wounded artery for a branch of the carotid with consequent ligation of that vessel, was by far the most frequent cause of failure in treating these cases ; and, inasmuch as such errors in diagnosis are avoidable when the likelihood of their occurrence is borne in mind by sur- geons, there is good reason to hope that much better results will hereafter be achieved in treating flesh-wounds in the nape of the neck which involve either of the vertebral arteries. ^ But flesh-wounds of the posterior cervical region may lay open other arte- ries of importance as well as the vertebral, for instance, the jwofunda cervicis, a branch of the subclavian, the arieria princeps cervicis, a branch of the occi- pital which inosculates freely with the profunda cervicis, and even the occi- pital artery itself In Dr. Kocher's case it was, at first, uncertain whether the \'ertebral or the deep cervical was injured ; but the occurrence of hemor- rhage on removing the dressing, and the result obtained by introducing a finger into the wound as far as the transverse processes of the vertebrae, * Principles of Military Surgery, p. 285, Am. ed. « Archiv fiir klin. Chirurg., Bd. xiii. S. 867. * New Sydenham Soc. Bien. Retrospect, 1871-72, pp. 202, 203. * Ibid., p. 204. INCISED AND PUNCTURED FLESH-WOUNDS OF THE BACK. 265 whereby the blood was perceived to issue from a point between two trans- verse processes, apparently the fifth and sixth, soon made the diagnosis clear. In Mobus's case, which is mentioned by Dr. Kocher as the only instance of traumatic aneurism of the vertebral artery, besides his own, which eventuated in recovery, there was a pulsating tumor below the occipital bone on the right side. It might have arisen from a wound of the occipital just as well as from a wound of the vertebral artery ; but the pulsation was not arrested by com- pressing the occipital artery, and the tumefaction was not lessened by com- pressing the carotid, wherefore the vertebral was inferred to be the seat of the lesion.* Flesh-wounds in the posterior cervical region that also lay open one of the occipital arteries, have proved almost as deadly as similar wounds that lay open the vertebral arteries, mentioned above. The princii)al reason for these untoward results has been that surgeons, owing to difficulties real or fancied that they have met with in trying to tie the wounded occipital artery in the wound itself, have resorted to untrustworthy expedients, instead of persevering as they should have done until success had crowned their etibrts to ligature the bleeding vessel on each side of the aperture in its walls. From the em- ployment of temporizing measures, it has resulted that the hemorrhage, although restrained for a brief period, has burst forth afresh from day to day or from time to time, until, finally, the patient has perished miserably from ansemic exhaustion, or, in other words, has slowly bled to death, and that, too, beneath the surgeon's very eyes. The following example well illustrates this subject. A young man, aged 22,^ received in an affray a stab-wound in the neck, two inches in length by one inch in depth, behind the left ear, and about two inches distant from the auditory meatus. Half an hour afterward the medical man found him pale and faint from loss of blood. The hemorrhage still continued in feeble jets ; but pressure ap- plied at the bottom of the wound with a finger readily suppressed it. On failing to grasp the wounded artery with forceps, it was resolved to treat the hemorrhage by com- pression. Thereupon the wound itself was stuffed with lint, and the lips thereof Avere drawn together over it, and secured in apposition with interrupted sutures. This pro- ceeding controlled the hemorrhage for five days, when slight bleeding recurred. On the sixth day there was more hemorrhage. On removing the dressing the bleeding was very profuse, and could not be entirely suppressed by pressure with a finger in the (\^ound. The left common carotid artery was then tied, and the bleeding ceased. Three days afterward, however, a slight hemorrhage appeared in the original wound, and in twelve days more hemorrhage again occurred from the same wound^ on opening which, the blood was found to issue from the occipital artery, at a point behind the mastoid process. Manual compression was now resorted to, but two days subsequently the patient died, having survived the wound twenty-three days, and the deligation of the common carotid artery seventeen days. An autopsy, made ten hours after death, showed that the knife had penetrated between the mastoid process of the left temporal bone and the transverse process of the atlas, and had opened the occipital artery in the occipital groove. The occlusion of the carotid was perfect. The brain was not diseased. Death appears to have resulted from anaemic convulsions and anaemic exhaustion, that were caused by the regurgitant hemorrhages from the wounded artery. Deligation of i;he common carotid in this case failed to control the hemor- rhage, because it did not control the circulation of blood in the wounded part of the occipital artery ; and it did not control the circulation because of the great freedom with which the terminal branches of the two occipital arteries inosculate with each other across the median line, and with branches of the temporal and posterior auricular arteries in the scalp, and likewise by meana 1 Ibid-, p. 204. 2 American Medical Times, May 18, 1861, p. 320. 266 INJURIES OF THE BACK. of the arteria priiiceps cervicis with the profunda cervicis in the deep part of the neck. In consequence of the great freedom of this arterial intercom- munication, the closure of the common carotid was not attended with such a stoppage of the blood-flow in the wounded part of the occipital artery as is requisite for the formation of blood-clots which can permanently^ close the aperture in the arterial tunics, and thus effectually restrain the hemorrhage. Wherefore it happened, that, as soon as the blood-pressure rose again after the operation of tying the common carotid was performed, the occluding clots were driven out of the aperture in the arterial tunics, and the bleeding started afresh from the distal as well as from the proximal portion of the w^ounded artery. Thus it is shown that the only procedure which might have saved this patient would have consisted in tying the injured artery in the wound itself with two ligatures, one of them being applied on each side of the aper- ture in its walls, so as to prevent the regurgitant as well as the direct hemor- rhage ; and had this operation been promptly performed by the physician who first saw the patient, there is good reason to believe that he would have promptly recovered. In treating flesh-wounds of the posterior cervical region which open any iDloodvessel of importance, the first and the most important indication consists in suppressing the hemorrhage, without delay, by applying two ligatures to the injured vessel in the wound itself, placing one of them on each side of the bleeding aperture in its walls. To fulfil this indication it will be necessary to bring the bleeding orifice or ends of the vessel distinctly into view ; and, to this end, whenever the wound is not large enough to allow the bleeding point or points to be seen and secured with ligatures, the surgeon, having first introduced a finger of his left hand into the w^ound, and placed the tip of it on the spot whence the blood issues from the vessel, feo as to control the hemorrhage for the time being, should enlarge the wound with a bistoury, held in his right hand, until the source of bleeding is fairly brought into view, bearing in mind, of course, the anatomical structure of the parts in- volved, and carefully avoiding all nerves and other organs of importance. Then he must ligature the distal as well as the proximal end of the wounded artery, in order to repress the regurgitant as well as the direct hemorrhage ; and, in cases where the artery is not already completely divided, it is well to finish the operation by' completing the division of the arterial tube with a bistoury, applied midway betw^een the two ligatures, so that the ends of the vessel may be allow^ed to retract and contract. However great the obstacles in such cases may be, the surgeon must persevere until he has overcome them, and has suppressed the hemorrhage in this radical manner; otherwise he will pretty certainly be annoyed and mortified by seeing his patient slowly bleed to death, in spite of all that he has done, as happened in the case just related. The application of a distal as well as a proximal ligature to the vertebral artery, when wounded, is quite as necessary as it is in the case of the occipital, or the profunda cervicis ; for the two vertebrals unite together to form the basilar artery, and, therefore, the blood is capable of regurgitating in either of them with great force. But a large part of the course of each vertebral artery is occupied by its passage through the foramina in the transverse processes of the upper six cervical vertebrae, together with the spaces intervening between the transverse processes of these six cervical vertebrge. E'ow, the vertebral artery is not unfrequently wounded in this part of its course, and here, because of its anatomical relations, ligatures cannot be applied. What, then, is to be done in such cases in order to stanch the hemorrhage ? Happily this problem has been solved by Dr. Kocher, w^ho has presented us with a success- ful example, already several times referred to above. His plan of treatment I shall now proceed to describe : — INCISED AND PUNCTURED FLESH-WOUNDS OF THE BACK. 267 The patient was a man, aged 48. He had a stab-wound in the nape of liis neck, the hemorrhage from whicli had been restrained to a considerable extent by plugs soaked in styptic solutions, etc. On removing the dressings, there was seen at the level of the fifth and sixth cervical vertebra?, about an inch to the left of the spine, a roundisii wound about two-thirds of an inch in diameter. On removing tiie coagulum which lay in the wound, some dark blood escaped; and, on withdrawing the finger used for exploration, a rather violent hemorrhage of bright red blood followed. The wound was then laid open to the extent of about three inches, and a large quantity of coagu- lum was removed by the finger. Thus a cavity was found, having the size of a small apple, and at the bottom the posterior surfaces of the left articulating processes were felt, and, more distinctly, the transverse processes of the vertebrae. A transverse incision was now made, an inch and a half in the anterior, and half an inch in the posterior direction ; and the blood was then seen to issue from a point between the transverse processes of two vertebriis, apparently tiie fifth and fcixth cervical. The blood escaped from the distal as well as from the proximal portion of the artery ; and the hemorrhage was arrested by pressing against the transverse processes, either from above or from, below. No ligatures could be applied to the wounded artery. A plug of charpie of the size of a pea, soaked in a solution of the perchloride of iron, was therefore introduced between the transverse processes, and left there. It stopped the bleeding. The external wound was closed with sutures, and dressed antiseptically. The head was kept fixed by a stiff collar. On the fourth day after the operation, the plug in the deep part of the wound was removed, partly by means of a stream of water, partly by forceps ; no bleeding followed. The patient was discharged cured, a little more than five weeks after the operation.^ Ill similar cases, the wounded vertebral artery might be successfully plug- ged by pressing into its lumen one or more cones, made out of fresh animal tendons (readily procurable at almost any butcher's stall), having the diameter of a pea, and having been smeared over with a strong solution of ferric per- chloride, instead of a wad of charpie. The animal-tissue plugs could be allowed to remain in situ, where ultimately they would undergo absorption and be replaced by new connective tissue. Both ends of the wounded verte- bral artery must, in general, be plugged. When the muscular and connective tissues of the neck are extensively infil- trated with blood, as soon as the wounded artery has been securely ligatured or pluo'o-ed, and the coagula have been removed, the wound itself should be thoroif^hly cleansed with a two-per-cent. solution of carbolic acid. Exter- nally, the wound having been closed by interrupted sutures should be dressed antiseptically, and should have left in'^it an adequate drainage tube, reaching to the bottom. Thus, septicaemia, which is very apt to appear and prove fatal in such cases, may be avoided. Hennen calls attention to the fact that in wounds of the back, " sinuses are also very apt to form along the spine, and they often j^rove very troublesome; I would never trust [he justly observes] to pressure In t"hese cases, but would make a free though cautious incision. These incisions are sometimes ren- dered very necessary by the lodgment of balls, pieces of cloth, etc."^ These sinuses and abscesses along the spine and in the muscles of the back having been freely opened, their contents discharged, and all foreign bodies removed, they should be thoroughly washed out by injecting a two-per-cent. solution of carbolic acid, and should be treated by securing complete drainage with velvet-eyed tubes of rubber, deeply inserted, as well as by applying antiseptic dressings externally. To sum up the treatment of flesh-wounds which also lay open important arteries in the posterior cervical region : — « New Sydenham Soc. Bien. Retrospect, 1871-2, pp. 202, 203. 2 Op. cit., p. 350. 268 INJURIES OF THE BACK. (1) The diagnosis as to what vessel is injured must be made by exploring; the wound Itself with a finger, ascertaining by the tactile sense the point whence the blood issues, and determining by the same means its anatomical relations. (2) The bleeding vessel must be brought into view by enlarging the wound without delay ; and it must then be tied at the place of injury with two ligatures, one of them being applied on each side of the aperture in its walls or to each end of the artery if it be severed. The artery should be divided midway between the two ligatures, for the purpose of allowing its ends to retract and contract, in all cases where it has not been severed by the orie-inal wound. ^ ^ • (3) When one of the vertebral arteries is wounded in that part of ita course which lies in the canal formed by the foramina in the transverse pro- cesses of the SIX upper cervical vertebrae, the hemorrhage must be restrained by plugging the injured artery in the manner described above, because in this situation ligatures cannot be applied. (.4) These wounds should be thoroughly cleansed with antiseptic lotions. Iheir hps should then be drawn together, and held in apposition, by means ot interrupted sutures. Should the occurrence of deep-seated suppuration be probable, adequate drainage tubes should be inserted. Antiseptic dress- ings should be employed externally. (5) Inasmuch as there is great flexibility in the neck, fixing the head by means of a stiff collar, so as to secure quietude in the cervical muscles will considerably expedite the recovery, and diminish the liability to secondary hemorrhage; and it should therefore always be employed in these cases. ^ I have considered the flesh-wounds in the posterior cervical region which mvolve^ also the vertebral, the occipital, the deep cervical, or other arteries at considerable length, because of the enormously high rate of mortality which has attended the reported examples of these lesions, amounting to tully 90 per cent.; and I believe that the principles of treatment enunciated above, when generally applied in practice, will greatly lessen this awful ratio, and correspondingly increase the chances of recovery from these exceedingly troublesome forms of inj liry. Incised or Punctured Flesh-wounds of the Back, received between the Shoulder-blades.— These wounds not unfrequently penetrate the thoracic cavity. The following example, taken from my note-book, affords a good illustration of this point : — A government teamster, middle-aged and robust, was stabbed in the back, at Wash- ington, August 15, 1861, in a brawl. He received a cut about three inches in length, extending up and down, between the base of the left scapula and the spinous processes of the dorsal vertebrae, but rather nearer to the scapula than to the spinous processes. The muscles were divided down to the ribs, and the left pleural cavity was freely opened, so that air in large quantity was drawn into and expelled from that cavity by each respiratory movement. He was at once taken to the E Street Infirmary. When admitted, he was much prostrated from shock, and had considerable dyspnoea. As soon as the bleeding was completely stopped, which required a little time, the lips of the wound were brought into apposition and retained by three points of interrupted suture, and by strips of adhesive plaster. August 20 — Most of the wound has united by the " first intention," and he has con- valesced thus far without even one unfavorable symptom. There has been no pain in the side nor any other sign of pleurisy. Subsequently he did well in every respect, and soon left the hospital entirely cured. INCISED AND PUNCTURED FLESH-WOUNDS OF THE BACK. 269 It was observed in this case that the wound gaped considerably ; and, therefore, each of the three points of interrupted suture was passed through the rhomboid muscle, as well as through the exterior plane of muscles and the skin. Thus the edges of the wound were securely held in close appo- sition, and a speedy recovery was obtained. Incised wounds of the back not unfrequently perforate the theca verte- bralis, and lay open the spinal canal. The occurrence of this lesion is attended with the escape of cerebro-spinal fluid ; and, in cases where the spinal cord and spinal nerves had not been injured, the escape of this fluid through the wound would alone indicate the nature of the lesion. Professor Agnew has pointed out " the exposed condition of the contents of the spinal canal' in the posterior region of the neck," and states that " it is due to the horizontal direction of the spinous processes, by which vulnerable spaces are left between." Professor Agnew also says : " The popular notion that posterior cervical wounds are followed by sexual impotence must be founded on cases of injury to the cord or its membranes. ^ The testimony of Leo-ouest, who had abundant opportunities for observation on this point during the conflicts of the French with the Turks, gives no countenance to this opinion."^ But incised wounds in the posterior region of the chest also not unfre- quently penetrate the spinal canal, and cause paraplegia by injuring the spinal cord, notwithstanding that the spinous processes of the dorsal vertebrae do not ex- Fig. 852. tend in a horizontal direction. The follow- ing example occurred during the late civil war : — Private George S., Co. B, loth New York Engineers, was admitted to Armory Square Hos- pital, Washington, April 22, 1863, having been stabbed with a knife in the back at Falmouth, Va., on the 20th, that is, two days before. He was completely paraplegic ; the urine had to be drawn off by a catheter ; and nothing but cro- ton oil, in three drop doses, succeeded in moving ..u^ 1 /• ' J • • 4. A Z The fourth, fifth, and a part of the Sixth dorsal his bowels, three days after admission ; two days ^^^^^^^^^ ^^^^ ^^^^ ^^^.^.^ ^ after that, involuntary defecation and micturition ^^^^^ ^^-^^^ broken off after traversing set in. Sphacelus of all the projecting points on the spinal canal and spinal cord. (Spec. 1160, the lower part of his body soon followed, and a. m. m.) proceeded rapidly until it nearly exposed the spines of the sacrum. On May 10, chills came on, and recurred daily. Death ensued on May 26, from exhaustion. The autopsy showed that the knife had penetrated the fifth dorsal vertebra. The fourth, fifth, and a part of tlie sixth dorsal vertebrae were removed and sawn through longitudinally to exhibit the knife-blade, which appears to have been broken off, and to have remained fixed in the body of the fifth dorsal verte- bra ever since the injury was inflicted. The specimen is preserved in the Army Medi- cal Museum ; and it is represented by the accompanying wood-cut. (Fig. 852.)^ Another instance of incised wound of the back, involving the vertebral column, was likewise recorded during the late civil war: — Private Wm. D. Cook, company D, 6th Tennessee Cavalry, aged 25, was admitted to Overton Hospital, Memphis, Tenn., November 25, 1864, with an incised wound of the spine inflicted on the 10th, that is, fifteen days before, with a knife. Simple dressings were applied. The patient was returned to duty on December 15.' 1 Principles and Practice of Surgery, vol. i. p. 321. • Medical and Surgical History of the War of the Rebellion, First Surgical Volume, p. 425. » Ibid., p. 45. 270 INJURIES OF THE BACK. In this case it does not appear that the spinal cord or spinal nerves sus- tained any injury. No other examples belonging to this category were re- ported during the late civil war. Dr. Meryon^ presents a very instructive case of incised wound in the back, penetrating the vertebral column and injuring the spinal cord, in which com- plete recovery took place. A boy, aged 15, received a wound from a cutting instrument in the back, which penetrated between the tenth and eleventh dorsal vertebra, and, probably divided the right half of the spinal marrow. There was complete paralysis ol' motion, and incom- plete loss of sensibility in the right thigh and leg. The patient made a good recovery, and at the end of two months was able to walk four or five miles. • A prominent symp- tom in this case, which has often been observed in similar cases, was the escape of a quantity of cerebro-spinal fluid from the wound during the first twelve days after the injury. Dr. Schwandner reports a somewhat similar instance, in which a punctured wound of the back injured the spinal cord between the second and third dorsal vertebrae. Paralysis of the right foot and leg, shortness of breathing, together with involuntary defecation and micturition, were present. The foot remained partially paralyzed ; but, in other respects, the recovery was complete.^ Under the head of punctured wounds of the back, the followina" examples are also embraced : — ^ Hennen reports that, "in a sergeant of the Enniskillen Dragoons, wounded at Waterloo, a piece of the shaft of a Polish lance stuck fast between the spinous processes of the last two dorsal vertebrge, completely paralyzing him until it was removed. In arrow-wounds of the back the missile sometimes penetrates the verte- bral column, as happened in a case the specimen from which is represented by the accompanying wood-cut (Fig. 853). This speci- Fig. 853. nien was obtained from the body of a white man killed by Indians (by an arrow-wound of the heart, etc.) in 1869, at an outpost near Fort Concho, Texas, and was sent to the Army Medical Museum. It con- sists of the fourth and fifth, together with portions of the third and sixth, dorsal vertebrse. An arrow-head is shown impacted in the right transverse process of the fourth dorsal vertebra and posterior extremity of the rib. The spinal canal was not opened by the missile.'* "The force with which arrows are pro- jected by the Indians is so great that it has been esti- Showing an arrow-head, im- mated that the initial velocity of the missile nearly pacted in the right transverse equals that of a musket ball. At a short distance an process of the fourth dorsal ver- ^^.^^^ ^- 1| perforate the krgcr boucs without commi- M. M.) ° nuting them, or causing a slight fissure onty."^ tebra.— (Spec. 5673, Sect. One example of an incised flesh-wound of the sacral region has come under my own observation. The patient was a lad, aged about 18, who was cut by the lower angle of an axe that accidentally fell from his right shoulder, upon which he was carrying it as he walked, and struck again&l^ the sacrum, a little to the right of the median line. The wound was "about two and a J Researches on the Various Forms of Paralysis, p. 69. London, 1864. Quoted from L'Union Medicale, 18f)0, p. 552. • 2 New Sydenham Soc. Year-Book, 1859, p. 429. 3 Qp_ ^^^^ p_ 359^ ^ Circular No. 3, S. Gr. 0., August 17, 1871, p. 153. « Ibid. p. 160. CONTUSIONS AND CONTUSED WOUNDS OF THE BACK. 271 half inches in length, extending somewhat obliquely from above downward, and penetrated to the bone, which was also slightly cut by the edge of the axe. There was considerable hemorrhage, but no ligatures were required. The bleeding having been stanched, and the coagulum entirely removed, the edges of the wound were brought into apposition, and fixed without difficulty by strips of adhesive plaster. The wound united throughout by the first intention, but the patient complained for a long time of having pain and soreness in the sacrum beneath the cicatrix. These symptoms, however, ultimately disappeared without the occurrence of suppuration or the dis- charge of any pieces of bone. Contusions and Contused Wounds of the Back. The skin on the dorsal region of the human subject is so thick and strong that it w^ill stand a great deal of hard usage without breaking. There is, however, a considerable liability to the occurrence of contusions and con- tused wounds in the posterior cervical, dorsal, lumbar, and sacral regions, from railway accidents, from falls, from blows with blunt instruments, and from the impact of falling bodies or of the missiles of war. The following examples are in point : — Contusion of the Sacral Region from a Railway Accident, — Private John Hol- den, Co. C, 29th Infantry, aged 23 ; was injured at Keswick, Va., September 28, 1868. He was admitted to the post hospital at Camp Schofield, Lynchburg, on the next day, and stated that, while riding on the top of a box car, and seeing the next car in front rolling over an embankment, he jumped off, but, being unable to escape, was struck on the back by the car as it rolled over. He complained of intense pain over the sacrum, extending between the anterior superior spinous process and the right tuber ischii. The parts over the sacrum were exceedingly tender under pressure, the slightest motion or touch causing him to scream with pain. No crepitus could be elicited. He could flex the leg on the thigh without pain, but was unable to flex the thigh on the pelvis. The injured part was much ecchymosed ; and he had a dull, mov- ing, continuous pain, extending across the whole front of the pelvis. Anodynes, with a nourishing diet, were administered. The patient made a good recovery, and was returned to duty on November 26.^ Contusions of the Dorso-Lumhar Region from Blows with the Butt-end of a Musket Private Thomas Carroll, Battery L, 1st Artillery, aged 23, presented himself at surgeon's call October 5, 1867, at Fort Porter, N. Y., stating that, some time during the previous night, he had been struck in the back with the butt-end of a musket in the hands of a sentinel. The blow liad knocked him down, whereupon he had been struck twice in the splenic region with the same weapon. On examination, a slight wound, such as might have been made by the percussion hammer of a musket, was found about an inch and a half to the left of the articulation of the twelfth rib with the twelfth dorsal vertebra. About two inches lower, at the same distance from the second lumbar verte- bra, another wound of the same character was found. The man was treated in the post hospital at Fort Porter, until Oct. 21, when he was returned to duty entirely cured.^ Contusion of the Back caused by a Fall August Burtz, artificer of Co. H, 2d Infantry, aged 38, was admitted to the hospital at Taylor Barracks, Ky., November 7, 1868, having fallen from a ladder to the floor, a distance of fourteen feet. He com- plained of pain in the bowels, and inability to pass water, and suffered considerably from shock. A stimulant and an anodyne were administered. On the 8th he was improved. On the 10th he was taken with intermittent fever, which yielded to quinine and iron. He speedily recovered, and was returned to duty on the loth.^ » Circular No. 3, S. G. 0., August 17, 1871, p. 106. a Ibid., p. 106. * Ibid., p. 106. 272 INJURIES OF THE BACK. These examples well illustrate the usual course of ordinary contusions of the back, when they are treated with quietude, nourishing food, and ano- dynes, as required. But, these excellent results are not always so easily, nor so speedily obtained, by even the best-devised plans of treatment; as the follow- ing case, in which a severe bruise of the sacral region was followed by perios- titis and sub-periosteal abscess, will serve to show : — Private Thomas Morgan, Co. A, 42d Infantry, aged 34, was admitted to the hospital at Fort Niagara, N.'Y., October 2, 1867, the wheel of a loaded cart having passed over his pelvis on tlie previous day. There was swelling, together with extensive ecchymosis, of the integuments over the upper part of the sacrum, and he complained much of pain. He also was not able to walk. A stimulating lotion was applied to the contused part, and anodynes were administered. A tumor, which formed in the injured part, was several times evacuated by incisions. The patient likewise suffered from chills and fever. By November, his general health had improved under expectant treatment ; but the wound of operation was still open. On December 6, he was per- mitted to do light duty. On the 27th he was returned to hospital ; the wound was swollen, inflamed, and freely discharged dark purulent matter. The swelling having subsided by January 13, 1868, and the condition of the wound remaining unchanged, an incision three inches long was made down to the diseased structure, which was found to be a hard cartilaginous growth containing osseous deposits, between which and the periosteum the purulent matter had be^n lodged, and had been escaping there- from by means of an opening. On dissecting out this morbid growth, and touching the walls of the residual cavity with nitrate of silver, the wound was closed with adhe- sive strips, and a compress was applied. But little suppuration followed; and, on the 28th, the wound being nearly healed, the patient was returned to duty.^ Not unfrequently, however, the degree of injury -is much more considerable than it was in either of the above-mentioned cases, and the process of repara- tion then consumes much time, on the one hand, or a fatal result ensues from sloughing of the injured part, from long protracted suppuration, or from septicaemia, on the other. One of these conditions is very apt to obtain in cases where the injury is inflicted by the missiles of war. A striking example of violent contusion of the soft parts in the dorso-lumbar region came under my observation at Stanton Military Hospital, during the late civil war. The patient, who was a soldier, tall, broad-shouldered, and very strongly built, aged about 30, was injured by the explosion of a shell while lying on the ground face down- wards, probably in line of battle. He thought that the butt-end of a shell had struck his back. On examination, there was found centrally situated in the dorso-lumbar region, a circular portion of the skin fully six inches in diameter, that was very much discolored by ecchymosis, although wholly unbroken, was raised up considerably above the surrounding surface, and exhibited fluctuation distinctly when the fingers were applied to it, because a copious extravasation of blood into the subcutaneous connec- tive tissue had taken place. So there was in reality present an immense haematoma, having a flattened shape, and a diameter of at least six inches, the product of an exceedingly powerful blow on the middle of the back, which did not break the skin. The treatment consisted of quietude, a nourishing diet, the administration of anodynes, and the application of camphorated oil to the injured part. But, notwithstanding the care taken to prevent it, the integuments sloughed off" throughout the whole of the circular space above mentioned, and the extravasated blood was completely discharged thereby, leaving, however, a healthy granulating surface fully six inches in diameter. Simple dressings with unguentum resina? were applied, the supporting plan of internal treat- ment was continued, and the sore rapidly cicatrized. When his recovery was far advanced, the patient was transferred to a northern hospital, and thus passed out of my sight. » Ibid., p. 108. LACERATED FLESH-WOUNDS OF THE BACK. 273 Concerning the occurrence of contusions of the hack in the Crimean War, Staif-snrgeon T. P. Matthews writes : " Very many wounds of this region were inflicted by shell, and the position uniformly adopted as safest while awaiting a shell explosion, viz., lying on the face, accounts for this. The contusions were often large and serious, and, when not immediately fatal, enormous masses of tissue often sloughed out, and the patient died exhausted and worn out by profuse suppuration, or, if recovery took place, the wound healed by the granulating process.''^ Hennen reports the following case of contusion of the back from a spent cannon-ball, which proved fatal : — A t^allant artillery officer received a contusion from a spent round-shot, at the battle of Vi'ttoria, which struck him exactly between the scapulae, barely leaving a discolora- tion of the skin, and a slight stiffness of the parts. To this he was advised to apply cloths wet in a saturnine solution, which he gradually increased in strength. He derived, however, very little benefit from this mode of treatment ; the stiffness still continued, the discoloration increased, and he was advised by some casual visitor to apply a blister to the part. In an evil hour this advice was acceded to ; and in a very few days the whole back, down to the lumbar region, was covered with a dusky erysi- pelatous inflammation. Sloughing abscesses speedily formed in the injured part, which were attended with a horribly offensive discharge; and, in a few weeks, death closed the scene.'^ Hennen also justly remarks concerning this case : " To apply strong satur- nine solutions, or leeches, to a part under these circumstances, is extremely injurious, because they tend to depress stiii more the powers of life; to over- stimulate by blisters is equally destructive of the vitality of the parts, and more hurtful to the general constitution."^ As to the treatment of contusions of the back when caused by the explosion of shells or the impact of spent cannon-balls, there are three points to be most carefully attended to in managing these cases : First, the lotions applied as discutients should not be purely sedative, nor powerfully exciting, but of a mildly stimulating nature. Secondly, when effusions of blood (hsematomata), or formations of purulent matter (abscesses), are clearly diagnosed, and require removal, they should be evacuated through small valvular apertures, and the admission of air should be avoided, as far as possible. Thirdly, the dressings should be antiseptic in their nature ; for instance, a two-per-cent. solution of carbolic acid in water already containing ten per cent, of alcohol, or a four- per-cent. solution of carbolic acid in camphorated oil, should constitute an important element of the dressings. Furthermore, a nourishing diet should generally be allowed in these cases, and, not unfrequently, alcoholic stimu- lants also. Lacerated Flesh-wounds of the Back. Hippocrates, in the twenty-third section of his work on wounds, treats briefly of wounds of the back, and directs attention almost exclusively to those inflicted by the lash, that is, to certain forms of lacerated wound occurring in this region. For the cure of these injuries he recommends the application, at first, of cataplasms, consisting of boiled onions or of squills ; and, subse- quently, of an ointment made of goat's fat or fresh lard, together with oil, resin, and salt of copper — a preparation upon the whole not unlike the cera- tum resinjB of the modern pharmacopoeia (a most useful dressing for slowly I Med. and Surg. History of the British Army in the Crimea, vo\. ii- p. 336. « Op. cit., ppo 92, 93. ^ Ibid., p. 93. VOL. IV. — 18 '274 INJURIES OF THE BACK. healing and indolent sores), to which a small percentage of cupric sulphate or acetate has also been added. But some of the most impressive instances of lacerated flesh-wounds of the back, on record, have resulted from explosions of shells. The next two examples are reported in the Medical and Surgical History of the War of the Rebellion, and they will serve to illustrate this topic in an excellent manner : — A soldier, aged 19, was wounded July 13, 1864, in the entrenched lines before Petersburg, by a large shell-fragment, which tore away the dorsal integuments over a space measuring at least six by eight inches, and severely lacerated the subjacent mus- cles, but without injuring the ribs or the vertebral column. There was no bleeding, and the shock was comparatively slight. The lesion is well shown by the accompany- ing wood-cut (Fig. 854). The patient, after partaking of restoratives, and having the raw surface of his wound covered up by a water dressing, was taken to the Depot Field Hospital, at City Point. While here, only such tissues sloughed as were utterly disor- ganized by the projectile, and the large surface that was exposed soon granulated kindly, so that, after a month, the patient was in a condition to be transferred northward ; and, on August 15, he entered the Whitehall Hospital, at Bristol, Pa. The cicatrization progressed rapidly. On September 12, he was furloughed, and on October 4, he Fig. 854. Showing a shell-wound of the back, 6 by 8 inches in extent. Kecovery ensued. was readmitted, being fairly convalescent. On January 23, 1865, he was sent for modified duty in the Veteran Reserve Corps. On June 24, he was mustered out of the service. No application for a pension has been made by this man or his heirs.^ Inasmuch as the men were often ordered to lie on the ground, face down- ward, while under artillery-fire, huge lacerations of the back were not infre- quently observed by our military surgeons during the late civil war. Com- monly, however, these wounds rapidly healed, as happened in the case just related. But, sometimes, the process of reparation was very slow after such lacerations. Other conditions being equal, flesh-wounds in the flanks and buttocks were found to be more serious than those in the upper dorsal region. In cases where large masses of muscular tissue were torn away, the cica- trization was sometimes protracted for years, as happened in the following instance : — A soldier, aged 20, was wounded at the battle of Chancellorsville, May 3, 1863, by the explosion of a shell. The integuments over the gluteal and lumbar regions were 1 Medical and Surgical History, etc., Second Surgical Volume, p. 429. LACERATED FLESH-WOUNDS OF THE BACK. 275 torn off, and, on the right side, a large portion of the gluteal muscles was also removed. This huge wound is well illustrated by the accompanying wood-cut (Fig. 855). The shock appears to have been considerable. On May 8, reaction having taken place, the patient was sent to Armory Square Hospital, at Washington. He suffered but little Fig. 855. Fig. 856. Showing an immense shell-wound of the lumhar and gluteal regions ; tetanus ; recovery. pain, and had a good appetite. He was ordered the best of diet, with porter; lint wet with a disinfectant lotion to the wound ; and an anodyne internally at night. The patient did well until the forenoon of the 15th, when he complained of inability to separate his jaws, and of stiffness in the muscles of the neck. The trismus was attended next day by opisthotonos and other tetanic symptoms, caused perhaps by spinal meningitis. Large doses of morphia were administered at short intervals, and with a good effect. On the 22d, a large dejection from the bowels occurred. From this date the patient steadily improved. On July 10, he was furloughed. On November 24, he re- turned to the hospital. On December 5, an examina- tion showed that the wound had cicatrized, except- ing a patch having the size of the palm of a iiand, and that this portion was kindly granulating. The right buttock was wasted and flattened. His gait was feeble and uncertain. His general health appear- ed to be good. On December 15, he was discharged from the service and pensioned. A drawing in colors of the huge wound in this case, as well as of that in the preceding case, was made by Hospital Steward Stauch soon after the reception of the injury. Both drawings are preserved in the Army Medical Mu- seum. An excellent chromo-lithograpli, made from the drawing in the last case, is presented in the sec- ond volume of the Surgical History of the War. Tlie accompanying wood-cut (Fig. 855) is a copy (re- duced) of the chromo-lithograph. On November 30, 1870, tlie pension-examiner reported as fol- lows in the case : " A shell- wound over sacrum of large extent ; is not so well as formerly ; the sore now shows no disposition to heal, and, in all proba- bility, will remain an open ulcer. His weight is 130 pounds ; the pulse 70 ; the respiration normal ; dis- ability total." In 1871, the late Dr. Otis, the much-esteemed editor of the Medical and Surgical History of the War, addressed a note of inquiry to this soldier, regarding Showing tne appearance of the cicatrcx nine years after the wound represented ia Fig. 855 was inflicted. In the centre of the cicatrix an indolent ulcer of irregular ?hape remains. 276 INJURIES OF THE BACK. the condition of his wound. His attorney courteously responded to this letter, and transmitted a photograph and diagram of the cicatrix, which then bounded a raw sur- face of irregular shape, three inches wide by two inches in height. The photograph is reproduced in the accompanying wood-cut (Fig. 856). For a long time the granula- tions on this raw surface had been indolent, and the cicatrization had made no progress ; there were no sinuses nor fistulous tracks to indicate the existence of diseased bone, or of any other internal cause of irritation. The invalid's general health was satisfactory. Dr. Otis advised that M. Reverdin's plan of skin-grafting, on which Messrs. Bryant and Pollock had latterly reported so favorably, should be resorted to ; but, at the time of writing, he had not been informed whether this advice had been followed.^ G. Fischer^ cites the case of a French soldier, who, while kneeling, was struck by a rolling cannon ball, which carried away a portion of the buttocks having the size of a dinner-plate. In another instance, a piece as large as a man's hand was torn off. In both cases luxuriant granulations arose, and complete recoveries were expected. Concerning the treatment of this class of injuries, not much remains to be said. The chief risks pertaining to them arise from a liability to the occur- rence of tetanus, of spinal meningitis, of septicaemia, of pysemia, or of ex- haustion from profuseness and protractedness of the suppuration. The plans of treatment should, therefore, be framed with a view to avoid the occurrence of these complications as far as possible. To this end, the dress- ings applied to the wounds should always be antiseptic in their nature, a nourishing diet, with tonics and stimulants, should generally be allowed, and constitutional irritation, as well as pain, should be promptly allayed by a judicious administration of opium or morphia. The action of opiates in these cases, to allay nervous irritation, may sometimes be advantageously supplemented by exhibiting the bromides or chloral hydrate. The cicatriza- tion of the wounds, especially when the sores are large, and have become chronic J should be aided by introducing skin-grafts, as recommended for this class of' injuries by Dr. Otis. In civil life, immense lacerated wounds of the back are sometimes inflicted with the implements of labor, accidentally or designedly. For example : — *' Dominick Jeffri, an Italian laborer, was struck in the back with a pickaxe in the hands of John Cannon, a fellow workman, and fatally injured yesterday. The men, who were recently arrived emigrants, were employed in making an excavation for gas pipes on Atlantic Street, Brooklyn, when Jeffri stepped backward in a stooping position just as Cannon's pick was descending. The full force of the blow drove the sharp- pointed, heavy pick through the back, near the spine, for the depth of five or six inches, causing the blood to flow from a terribly lacerated wound.^ The treatment of this form of injury should be conducted on the principles which have already been laid down. Gunshot (small-arm) Flesh-wounds of the Back. In the Second Surgical Volume of the Medical and Surgical History of the late Civil War, at page 428, there is presented a tabular statement embracing 12,681 cases of gunshot flesh-wound of the back. The number of deaths was exactly 800, which gives a ratio of mortality of a trifle over 6 per cent. The proximate causes of death are specified in 380 of these cases. Eighty- three of them were complicated by other wounds. Of the remaining 297 » Ibid., p. 430. 2 Deutsche Zeitschrift fur Chir., 1872, Bd. I. S. 198. (Otis.) 3 N. Y. Herald, June 8, 1882. GUNSHOT FLESH-WOUNDS OF THE BACK. 277 patients, 27 are reported as having succumbed to tetanus,^ 33 to secondary hemorrhage, and 28 to gangrene. ^ The fatal termination was ascribed to surgical or traumatic fever in 17 cases, to pyaemia or septiccernia in 67 cases, to pneumonia or hepatitis (probably instances of embolism) in 17 cases, to erysipelas in 8 cases, to typhoid fever in 31 cases, to diarrhoea and dysentery in 39 cases, and to peritonitis in 7 cases. In one instance the administration of chloroform, it was thought, caused the fatal result. Two patients died from diphtheria, two from smallpox, and 18 from various intercurrent dis- orders due to ''hospitalism,'' and not directly connected with the traumatic lesions. Dr. Otis makes the following observations, which may be of special interest to statisticians: "Analysis of this large series of gunshot flesh- wounds indicates that the mortality of these non-penetrating wounds has been over-estimated by some European writers of acknowledged authority in matters pertaining to surgical statistics. Making every allowance for errors, and admitting that the aggregate may have been swelled by the admission to liospital of trivial cases of wounds "^of the integuments, the percentage of mortality remains much lower for this group of injuries than has been here- tofore represented."^ The foregoing exhibit of the causes of death which were noted in 1^,681 cases of shot flesh-wounds of the back, shows that these lesions were but seldom mortal, unless septicsemia, pyaemia, gangrene, or tetanus (that is, traumatic spinal meningitis) supervened, or arterial hemorrhages occurred, which, doubtless, were not infrequently maltreated, and so proved fatal, as I have shown, on a previous page, was the case in numerous instances of incised and punctured wounds of the posterior cervical region. ^ Nevertheless, sep- ticaemia, pyaemia, gangrene, tetanus, and maltreated arterial bleedings, were encountered with such frequency in this class of injuries as to make the em- ployment of special precautions against their occurrence a necessary feature in every plan of treatment. The destructive eftects of "hospitalism," and of exposure to infectious disorders, such as typhoid lever, smallpox, and diph- theria, were likewise observed with such frequency as to require the adoption of preventive measures. But flesh-wounds of the back, inflicted by small-arm missiles, usually — that is, in a large majority of instances — gave no particular trouble, and soon terminated in recovery. The following example will serve to illustrate this point : — Private John Cosgrove, Company F, Eighth U. S. Infantry, aged 23, was wounded March 17, 1869, by a conoidal ball, which entered the right side of his back near the fifth lumbar vertebra, passed forward and outward, and emerged immediately oyer the anterior superior spinous process of the iUum. He was admitted to the post hospital at Columbia, S. C, on the 18th. Simple dressings were applied, and in April he was returned to duty.^ However, the observations collected by surgeons in several different wars have shown that there are certain forms belonging to this group of injuries, which are particularly liable to prove troublesome in respect to^ manage- ment, and to be followed by imperfect recovery or physical disability. For instance, Hennen found that " extensive injuries, or the permanent lodgment of balls, gave rise to either death or incurable paralysis."^ Stromeyer ob- served that, while shot flesh-wounds of the back did not in general exhibit ' I have no doubt that most of these 27 fatal cases of so-called tetanus were, in reality, examples of traumatic spinal meningitis, in which inflammatory irritation of the motor filaments produced tetanic spasms in the corresponding peripheral muscles. 2 Op. cit., p. 432. 3 Circular No. 3, War Department, S. G. 0., August 17, 1871. 4 Op. cit., p. 350. 278 INJURIES OF THE BACK. a special tendency to suppuration, it frequent]}^ occurred in long transverse seton-wounds of this region that, their orifices having promptly healed and remained closed, their tracks, months afterward, filled up internally with puru- lent matter so as to form fluctuating tumors, which had to be lanced, inasmuch as the thick skin of the back was but slowly pierced by ulceration. He likewise remarked: "Many surgeons err in trying to relieve such ailments by several small incisions, or even punctures, parallel to the spine; these afibrd no relief, and it is absolutely necessary, in such cases, to make incisions several inches in length, at right angles to the spine.''^ It should also be stated, that, if the surgeon does not lay open the track of the ball, in such cases, dame is^'ature herself will not unfrequently do it by ulceration or sloughing. During the late civil war, 1 saw several examples of long, seton-like, transverse flesh- wounds of the back, in which the bridge of injured muscle and inte2:ument had been completely carried away by ulceration and sloughing, and the seton-like wound itself had been converted into an immense open sore whose long diameter extended transversely, that is, was perpendicular to the vertebral column. The cicatrices resulting from such wounds, as a rule, seriously impaired the functions of the injured muscles. Again, I also saw during the late civil war, several instances of long seton-like flesh-wounds of the dorsal region, which extended between the scapulge in a longitudinal direction, that is, were parallel to the vertebral column. These wounds had been received by men deployed as skirmishers, while advancing by crawling on their bellies over the ground. In some of them, the missile, having passed through the trapezius, tore for itself a way across the fibres of the rhomboid muscles, dividing them to great extent from above downward, and escaped from the integuments over the latissimus dorsi. In such cases, a considera- ble degree of disability always remained, owing to the contraction and agglu- tination of the injured muscles which ensued. Furthermore, Dr. Otis remarks concerning this group of injuries: "There were some curious instances of long, circuitous, ball-tracks ; and, among the fatal cases were noted several in which the projectiles had lodged under the scapula. Dur- ing the late civil war, I several times had occasion to observe that the results were exceedingly unsatisfactory, in all cases of shot flesh-wound of the back, where the missiles lodged beneath the scapula. These patients often com- plained of having great pain in the injured region, and begged to have the missiles extracted by operations to which they were always ready to submit; the fistulous tracks made by the missiles remained open, discharging purulent matter, while the injured muscles became matted together in consequence of the inflammation and suppuration, and the movements of the injured shoulder always remained much restricted. In one of these cases, after the lapse of many months, the missile which had penetrated above the superior angle of the scapula, and lodged beneath that bone on the inner side of the serratus magnus anticus, sank downward by the force of gravity until it rested on the costal origin of the latissimus dorsi from the last three ribs. It was extracted by making an incision through the integuments and the latissimus dorsi. Thereupon, the patient's sufterings, which had been very great, immediately ceased, and a fistulous channel, which had remained open and discharging, soon became permanently closed ; but I do not think that the man ever regained very good use of the injured shoulder. Dr. Beck^ remarks, in substance, that when the fleshy covering of the back is injured, much depends on the depth to which the laceration of the muscles extends, the length of the shot channel, the amount of concussion (as ' Quoted by Otis, op. cit., p. 429. a Op. cit., p. 430. 8 Chirurgie der Schussverletzungen, 1872, S. 448. (Quoted by Otis, op. cit., p. 430.) GUNSHOT FLESH-WOUNDS OF THE BACK. 279 from large shot or shell fragments), and the degi-ee of implication of the ribs or spine. §hot wounds limited to the areolar tissue and muscles mamly, are of no special interest, unless attended by exceedingly large loss of substance, or by a very long, seton-like ball-track. Cases in which bloodvessels of the laro-er order, and the main branches of nerves, arc contused or lacerated, are^more serious. The functions of the dorsal muscles are, in some cases, much impaired by shot lacerations. :Many invalids of this class are unable to move freely, and complain of difficulty in breathing, stooping,^ turning the head, etc. ; complications due, unquestioiTably, to cicatrices resulting from lacerated shot wounds that have either been attended by sloughing, or have required incisions to relieve deep suppuration. These observations of Dr. B. Beck confirm those of other surgeons, which have been presented above. Flesh wounds of the back from small-arm missiles, especially when much inflamed, may be attended by paraplegia, as happened in the following case, which Staff-surgeon T. P. Matthew declares " may be accepted as typical of many wounds of this region : — " " Maurice Garvey, aged 19, was wounded, on 8th June, by what he supposed to be a spent ball, which struck him on his back about opposite the seventh dorsal vertebra. On admission to his regimental hospital, there was immense swelling of the back, and complete loss of motion of both lower extremities, but not of sensation. The swelling in great measure subsided in a few days, under the use of fomentations, when two wounds were discovered, giving the idea of entrance and exit of a ball, but no injury of the bones of the spinal column could be detected. The wound healed under simple dress- ings, but the paralysis continued, and he was transferred to the Castle Hospital, on 24th October. Here, under the impression that the persistent paralysis might be due to chronic inflammation of the theca vertebralis, he was twice put under the influence of calomel, with diuretics, and upon each occasion with, it was thought, marked bene- fit. Subsequently strychnine was given, in suflicient quantity to produce convulsive spasms of the affected limbs. This did not seem productive of any good, and, after per- sistence in its use for three weeks, it was omitted. He very slowly improved, however^ and on 26th January, was invalided to England, having got comparatively fat, and able to stand upon the affected limbs, and even walk a few paces with the help of crutches."^ Was the motor paralysis, which presented itself in this case, due to ex- tension of the inflammatory process which arose in the injured tissues of the back, and caused immense swelling inwardly until it reached the theca verte- bralis, etc., or was it due to concussion of the spinal cord? This question no one can authoritatively decide, although the fact that mercurials and diuretics proved markedly beneficial on two occasions, decidedly favors the idea that there was a secondary spinal meningitis. 2>ea^?ne?y^.— Flesh-wounds of the back made by small-arm missiles should be carefully explored at the outset, and all foreign bodies, including spent balls, frao;ments of clothing and of equipments, and all coagula, should be promptl/ extracted. If there be arterial hemorrhage— whether primary, intermediary, or secondary— it must be suppressed by exposing to view the wounded vessel at the place of injury, and ligaturing it on each side of the aperture in its walls. The occurrence of septicaemia, pyemia, and gangrene, must be obviated as far as possible by applying antiseptic lotions, such as a ten- per-cent. solution of alcohol in water, to which two per cent, of carbolic acid has been added, with a view to increase its efficacy. Drainage tubes should be inserted in all wounds where the purulent matter exhibits a tendency to stagnate, or does not readily flow away. Pain and constitutional irritation should be subdued by administering opiates and sedatives. A nourishing » Med. and Surg. History of the British Army in the Crimea, vol. ii. p. 337. 280 INJURIES OF THE BACK. diet should generally be allowed ; and, not unfrequently, wine, bitter ale, porter, or alcoholic liquors should also be prescribed. But the most impor- tant of all the points concerned in treating this group of injuries, consist in promptly removing all foreign bodies, in dressing the wounds antiseptically, and in draining them thoroughly by passing appropriate velvet-eyed India- rubber tubes of suitable size into them deeply, or completely through them, which is still better. When arterial bleeding occurs in this group of injuries, to such an extent as to constitute surgical hemorrhage, the wounds should not be stuffed with plugs soaked in ferric persulphate or perchloride solutions, neither should these liquids be injected into them, for both proceedings are worse than useless in such cases ; on the contrary, the bleeding vessel should be promptly exposed to view at the place of injury, by enlarging the wound itself or by direct incisions, and then it should be tied with two ligatures, one of them being applied on each side of the aperture in its tunics ; and, finally, it should be completely divided midway between the ligatures, so that both ends may retract, and thus considerably lessen the liability to return of the hemorrhage. Instructions on this point of treatment are by no means idle or unnecessary, for during the late civil war (as has already been stated) no less than thirty-three fatal cases of secondary hemorrhage from flesh- wounds of the back, inflicted by small-arm missiles, were reported by our military surgeons.^ It is advisable, however, to add that parenchymatous hemorrhages from flesh-wounds of the back, when due to occlusion by coagulated blood (throm- bosis) of the veins proceeding from the injured part, or to any other cause, must sometimes be treated by covering the raw or granulating surface from which the blood is exuding, with compresses of lint thoroughly wetted w^ith a solution of persulphate or perchloride of iron ; but arterial hemorrhages must not be treated in this manner. Sprains, Twists, and "Wrenches of the Back. The several bones which compose the vertebral column, that is, the true vertebrse themselves, together with the sacrum and coccyx, are united to each other, and to the bones that lie in contact with them, by ninety-nine joints or articulations. All of these joints are more or less susceptible of motion. In some of them, however, the degree of mobility is but slight, as for instance, in the sacro- coccygeal articulation ; in others, it is very considerable, as for example in the occipito-atloid and atlo-axoid articulations. The several bones which constitute the vertebral column are likewise strongly bound together by ligaments, a considerable proportion of which are elastic. A brief enumeration of these ligaments may aid us materially to comprehend the eflects of sprains, wrenches, and jars of the vertebral column : (1) The lenticular disks of intervertebral substance^ interposed between the bodies of all the vertebrae from the axis to the sacrum, perform not only the oflice of liga- ments, but they also have elastic properties, which enable them to act in a manner not very unlike that of India-rubber bufters, when placed between the cars of a railway train, in obviating the injurious eflects of jars and shocks upon the vertebral column itself, and upon the organs contained in the spinal canal. (2) Tiie anterior and posterior common ligaments likewise bind together the bodies of the vertebrae. (3) The ligamenta subflava gird together the arches of each pair of vertebrae, from the axis to the sacrum. These liga- ments are also elastic ; and by means of their elasticity, they counteract the ' Med. and Surg. History, etc., Second Surgical Vol., p. 432, SPRAINS, TWISTS, AND WRENCHES OF THE BACK. 281 efforts of the flexor muscles of the trunk, so tliat in maintaining an uprio-ht position ot the vertebral column, they lessen considerably the expenditurJ'of muscular force by their automatic work. (4) The capsular lujaiacKt^ and synovial membranes hold together the articular processes of tlie vertebra\ (5) The inter-spinous and supra-spinoas ligaments fasten together the spinous processes in the dorsal and lumbar regions. (6) The intcr-transversc ligaments connect the transverse processes of the lower vertebrje with each other. Furthermore, the ligamenta sitbflava are in direct relation, by both surfaces with the meningo-rachidian veins; and, internally, they are separated froin the dura mater of the spinal cord by these veins and some loose connective and adipose tissue. A laceration of these ligaments would probably be attended by a rupture of these veins. Again, the posterior common ligament IS in relation by its anterior surface, not only with the intervertebral sub- stances and the bodies of the vertebrae, but also with the vena^ basam vertebra- rum. It IS in relation by its posterior surface with the dura mater of the spi- nal cord, some loose connective tissue and numerous small veins alone beincr interposed. A laceration of the posterior common lij^ament would probably be attended by a rupture of these veins, wdth a rupture of the vense basum vertebrarum, and a considerable injury of the spinal dura mater. Indeed the anatomical relations of the ligamenta subflava and the posterior common ligament are such that traumatic spinal meningitis, as well as hemorrhage from the contiguous veins, might readily result from a traumatic lesion in- volving either of them. Violent strains and forcible flexures, and strong twists or wrenches of the back, produce injuries of the joints and ligaments of the vertebral column, and of the adjacent parts, both soft and hard, which are strictly analogous to the , lesions that result from the same kinds of hurt when they affect the joints of the extremities. The lesions which are met with in the back in consequence of these forms of injury, vary from a slight laceration of some fibres of the vertebral ligaments, and of the contiguous connective tissue, and lesser bloodvessels, on the one hand, all the way up to a very extensive tear- ing through or detachment of the vertebral ligaments, with a correspondino-lv extensive rupturing of the contiguous muscles, tendons, connective tissue, and bloodvessels, on the other. Indeed, the lesions which result from severe sprains and twists, or wrenches of the vertebral column, differ only in decree from those which attend dislocations of the vertebrae. But, according to the observations of Mr. Hilton, "the most frequent lesion in injury to the spine a partial severance of the vertebra from the intervertebral substance Ihis view receives support from the fact that the junction of a more to a less elastic^ body is the weakest spot, and, therefore, receives the full eflfect of a srrain. _ The or phenomena which attend these accidents are pain in the injured parts, and mabihty to move them, with tumefaction and tenderness under pressure ui the same region ; and, not unfreqnentlv, subcutaneous ecchymosis appears m the swelling. These symptoms, however, all vary in degree and extent aceordmg to the amount of the injury that has been sns- ;i, i"g ™ay or may not be attended by eccliymosis ; and some- times the latter does not make its appearance for several days. The tenderness under pressure is usually not restricted to the spinous processes of one or two nLa^"" jertebr* (which circumstance, if it were present, would excite a sus- picion that vertebral tracture existed), but is equally noticeable over several contiguous spinous processes. At the same time, on tracing the tips of these spinous processes, they are found to be in a normally strai|ht line, and on a ' On Rest and Pain, Am. ed., pp. 47, 48. n Ibid., p. 48, foot-note. 282 INJURIES OF THE BACK. proper level. So much at present concerning the immediate effects of these accidents. Among the remote effects of the lesions of the back, especially when they have been neglected or improperly treated, are permanent lameness of the back from chronic inflammation of the injured joints, and curvature of the spinal column from vertebral caries. Mr. Hilton thinks that severances of the vertebrae from the intervertebral substances, when inadequately treated, are particularly liable to give rise to vertebral caries.^ Among the possible consequences of sprains or wrenches of the vertebral column, spinal meningitis must likewise be mentioned. The following state- ment concerning a case, hi which a wrench of the back was received while on board of a street railway car, has recently been printed, on apparently good authority, in a prominent morning paper in isTew York : — " As one turns into Sixteenth Street off Union Square, on the west side, one notices the tan-bark laid thickly in front of a handsome house in the middle of the block. Here lies G. G., the popular soubrette of the Theatre Comique. She stopped a car a few weeks ago, and the conductor started it before she had fairly got on, giving her such a wrench and start that she felt at the time a severe pain in her back. From that day to this she has been unable to move, lying dangerously ill with spinal meningitis."^ Sprains, Twists, and Wrenches in the Cervical Region. — I^o other cases of spinal injury or disease are so immediately dangerous to life as those in which the upper part of the cervical region is the seat of injurj^, but especially the first and second cervical vertebrae, or the space between them ; for, when spinal paralysis results from injury or disease of this part of the cervical region, the nerves which cause the respiratory muscles to act are likewise paralyzed, and then complete stoppage of the respiratory movements, or death, instantly ensues. Mr. Hilton has reported a number of cases which give so much information of very great value to both surgeons and patients concerning this group of injuries, especially about their symptoms, conse- quences, and treatment, that my work were but illy done should I omit to mention them. Concerning a case where death from pressure upon the spinal marrow was impending, which ultimately ended in recovery, he says : — " In 1850, I was requested by Dr. Addison to see, w^ith him, a young woman, suffer- ing from injury in the upper part of the spine, the result of an accident. I found her almost pulseless, with great distress in breathing, loss of voice, inability to swallow, and nearly complete paralysis of the arms and legs. She had had, from the early part of her illness, severe pains spread over the back of her head and neck, increased on pressing the head downward upon the spine. Her symptoms had gmdually arrived at this stage of danger, without benefit of medical treatment. 1 might here say, that the difficulty of breathing and deglutition had so greatly increased of late, that it was thought necessary, or to her advantage, to lift her up more and more in the bed ; but the change of posture seemed only to add to her distress in breathing and swallowing. These were the difficulties for which my assistance was requested. She was then propped up in bed by pillows at her back, with her head inclined somewhat forward, or dropping upon the chest. As the impediment to swallowing was almost an insur- mountable difficulty, I was desired to examine the throat, but I could not discover anything wrong in it. It was our opinion that her life was in imminent, or perhaps, instant danger. She was paralyzed, and could not swallow ; her voice was excessively feeble, and her pulse not very perceptible ; she scarcely breathed at all, and was not quite conscious. It was evident that something must be done without delay. Believ- ing that her symptoms resulted from the odontoid process of the second vertebra press- ing upon the spinal marrow, close to the medulla oblongata, I advised that she should be made to lie down immediately. On saying to her, 'You must lie down in bed,' she 1 Ibid., p. 48. 2 N. Y. Sun, June 4, 1882. SPRAINS, TWISTS, AND WRENCHES OF THE BACK. 283 replied, in the smallest possible voice, ' Then I shall certainly be killed ; I can't get my breath.* Seeing there was no time for contention, I told her our opinion was, tiiat, if not placed longitudinally in bed, she would in all probability die in a very few minutes. Being paralyzed, or nearly so, she could ofFer no resistance to my purpose; and 1 shall never forget the weight of the responsibility, when I took hold of her, desired the pillows to be removed from her back, and, supporting her head and shoul- ders in my arms, slowly placed her upon her back, nearly flat upon the bed, with her head upon a thin pillow, some additional support to tlie hollow of her neck, and two sand-bags, one on each side of her head, to prevent any lateral or rolling motion. Here was a patient in the greatest possible danger, and 1 do not hesitate to express tlie opinion, that, if the head had fallen forward, say half an incli, she would liave died in an instant. Her sense of suffocation was soon relieved by the horizontal position, and she remained lying down during six months uninterruptedly, at tlie end of which time all the serious symptoms had disappeared. She was then allowed to move about the ward, with caution ; and, a few^ months afterward, left the hospital, well, with the exception of a stiff neck, most probably depending on anchylosis, or bony union, be- tween the atlas and the axis. In this case, nothing but complete rest was employed as a remedy ; rest was the only element of success in the treatment, and I think it is a very striking example of its power to prolong life, by enabling Nature to repair her injuries undisturbed."^ In this case, the sprain or wrench of the joints between the atlas and the axis was followed by chronic inflammation of these joints, of a destructive character, which, happily, terminated in a cure by anchylosis, under the benign influence of prolonged rest. The severe pain over the back of the head and neck, which helped to mask the vertebi^al lesion, for some time, was due to irritation of the occipitalis major and minor nerves, and, perhaps, of other branches of the anterior and posteiior cervical plexuses of nerves' also. ' Mr. Hilton continues in a most instructive vein : — " I will now direct your attention to another case of diseased cervical vertebrae (also caused by a hurt), which terminated in sudden death. It is that of a little child, five years and five months old, seen by me in 1841. She was a small, delicate, unhealthy girl. She had been accustomed to ride a good deal in the country, with her mother, in an open carriage, and was thought, in that way, to have caught a cold in the back of the neck, which became gradually stiff and swollen, accompanied by pains in the head and neck. These pains were believed to be rheumatic, and the treatment em- ployed had reference only to that impression, which was supposed to be supported by some pain experienced in the limbs, with cramps and stiffness in walking. She fre- (luently suffered from fever and loss of appetite, and had been under medical treatment during many weeks, the symptoms slowly increasing in severity. The mother told me afterward that she had thought her an obstinate child, and that she sometimes threat- ened to punish or to shake her well because she would not take her food. I have no doubt, if she had done so, she would have killed the child. Upon careful examination, I thouo-ht I made out the case to be one of disease between the first and second cervical vertebrfe, or thereabouts. I say thereabouts, because the parts were too much swollen, and too pain- ful, to admit of a more accurate local investigation. There was pain at the back part of the head, in the course of the great occipital nerve ; pain behind the ear, in the course of the great auricular, and of the small occipital ; pain in the higher part of the neck, on rotation of the vertebrae upon each other ; and pain in the same vertebrje, probably the first, second, and third, by pressing the bones upon each other. She had some diffi- culty in deglutition, and the voice had lately changed its character, and become more feeble, indicating that the pneumogastric nerves, and possibly the spinal accessorv, were involved in the mischief. Thus, having, in common with the sum-eon in attend- ance, recognized the real nature of the case, directions were given that the child should be placed upon her back, with her head resting upon a thin pillow, and some additional » Op. cit., pp. 60, 61 284 INJURIES OF THE BACK. support to the nape of the neck, each side of the head to be supported by sand-bags, so as to prevent any lateral or rotary movement in the neck. It was plain that, if the life of the child was to be prolonged or saved, it could only be accomplished by a long-con- tinued rest to the spine ; and, for the purpose of securing easy rest to the little patient, a water-bed was sent from London, and the child was safely placed upon it, with the sand-bags extending from the shoulders to beyond the head. In about a fortnight the nurse specially appointed to attend the child, finding that her rest at night was now so calm and quiet, that she was so free from pain and fever, that her appetite and power of swallowing were so much improved, as well as her temper, and thinking she was alto- gether so much better, and willing, no doubt, to mark her own penetration, as well as to please the mother by telling her in the morning what had been done by her little charge — this meddlesome and officious woman, instead of giving the child her breakfast, as usual, without disturbing her head or neck in the least degree, desired the child to sit up to breakfast. The child did so ; the head fell forward, and she was dead. The post-mortem examination proved that disease existed in the articulations between the first and second cervical vertebrae, that the bones were loose, and that, when the head with the atlas fell forward, pressure had been made upon the spinal marrow, close to and below the medulla oblongata, at the point of decussation, so that the child was killed almost instantly, as in pithing animals. This was a case in which both the sur- geon and nature were completely thwarted. The local disease was considered at the time to be dependent upon a constitutional or a scrofulous cause ; but I have since under- stood that it was the result of a blow given to the little girl by her brother, who struck her with something he had picked up in the room. It was not constitutional ; there was no visceral disease of any kind."^ In this case, then, there was a destructive inflammation of the joints between the atlas and the axis, arising from a blow upon, or a wrench of, these joints, and the real character of the lesion was, for a long time, over- looked ; but, in all probability, it would have been cured, as the preceding case was cured, by proper and long-continued rest, had nature and the sur- geon not been thwarted by the misadventure. Moreover, the morbid con- dition of the atlo-axoid articulations, which was revealed by the autopsy, in this case, sheds a flood of light upon the pathogenesis of the preceding case, and frees it from all obscurity or doubt. Thus, the history of this case is the complement of that of the preceding case, and fully elucidates it. Mr. Hilton also relates the case of a lady, aged about 30, who had a disease of the spine affecting the occipitalis major and minor nerves, the third cervical nerves, and the nerves forming the left axillary plexus, that was caused by a blow on the left side of the head with a bolster, or cushion, which forcibly displaced it laterally, and thus strained or wrenched the joints of the first, second, and third cervical vertebrae. She fell upon the carpet, and was unconscious for some little time. She had, as reported to herself, a sort of struggling fit. On recovery, she was put to bed ; and, in a day or two, nothing remained of the accident, excepting some tenderness in the upper part of the neck ; but, soon afterward, the symptoms about to be described came on. When Mr. Hilton first saw her, some nine or ten months after the injury, " she had pains on the left side, at the back of the head, and at the posterior part of the external ear ; pain over the clavicle and shoulder (all on the left side) ; pain, with loss of power, in the left arm ; pain deep in the neck, on pressing the head directly downward upon the spine, and on rotating the head ; some fulness and tenderness on pressure about the first, second, and third cervical vertebrae, especially on the left side. She could not take walking exer. cise in consequence of the increasing severity of all the symptoms. She had almost sleepless nights, and her appetite was very poor. It was obvious that there existed some disease or injury of the spine affecting the occipital nerves, the third cervical nerves, and the nerves forming the left axillary plexus. As far as I [Mr. Hilton] could interpret the case, rest appeared to be the proper remedy. The patient maintained, almost uninterruptedly, the recumbent position, during nearly three months, two sand- ' Ibid., pp. 61, 62. SPRAINS, TWISTS, AND WRENCHES OF THE BACK. 285 bags being placed one on each side of tlie head. The only medicine employed was one- sixteenth of a grain of bichloride mercury twice a day, during about two months. At the expiration of three months the patient had lost all pain and tenderness, and had regained the use of the arm, neither did pressure nor rotation of tiie liead induce pain. The ful- ness in the neck had also disappeared."^ To conclude tlie case, this lady left town, and, afterward, reported herself quite well, being perfectly cured. The wrench of the vertebral column, in this example, appears to have been attended with cerebral concussion, caused by the same blow on the head which produced the sprain of the neck, and there was loss of consciousness for some little time. She was placed in bed, but she was not kept there long enough for the injured joints connecting the first, second, and third cervical vertebrae together to become sound again. The consequence was, that, as soon as she got up and began to go around, the inflammation in the sprained joints mcreased, the contiguous sensory nerves became irritated thereby, and pains appeared m the parts to which they were distributed, that were mistakenly considered to be rheumatic pains ; and so the poor lady went on for nine months, constantly under treatment for rheumatism and hysteria, but gettino- worse the whole time. Eest, that is, enforced quietude of the injured articu- lations, was the sole means of importance, which finally secured her recovery ; and the same means, had it been applied to her case at the outset, for only a few weeks, would have saved her from a year of intense suiFering. " The next case is that of a surgeon," writes Mr. Hilton, " who was in the yacht of another gentleman. Running along from one part of the ship to another, he struck his head against the top of a door, and was thrown backward with great force. Very shortly after- Fig. 857. ward he had pain in the distribution of the occi- pital nerves at the back part of the head and the back of the neck. [See Fig. 857, «, b.] Six weeks from that time (he still continued in the yacht), having experienced some increase of pain, and heard and felt a grating sensation in his neck, he was somewhat alarmed, and came to me, suffering from pains indicating disease of the second or third cervical vertebra. He was ulti- mately cured by lying down — that is, by rest. On the 8th of February last he came to me per- fectly well, and says he was quite cured by rest. Time will not permit me to dwell on the details of this surgeon's case."' In order to illustrate the varieties in strains of the neck, together with the symptoms and treatment of recent cases, the following examples must be briefly presented : — A young carpenter, while stepping backward. Showing, a, the portion of the scalp supplied tripped on a heap of planks, and fell upon his occipitalis major nerve; &, the portion back. His shoulders were received on the planks • ^"pp^^^^^ ^''^ occipitalis minor nerve ; c, the but, his head and neck projecting beyond them, j'^;;^;j;^PP"^^ by the auriculo-temporal nerve. the neck was abruptly bent backward with much force. Swelling at the back of the neck, from occiput to scapula, so ^reat to be visible at a distance, appeared soon after tlie accident. He was unabTe to keep his head erect ; and before attempting to do so, placed a hand on each side to steady it He was placed m bed. At the end of a montii, having been provided with an artificial support, he was made an out patient.^ • Ibid., pp. 54, 55. t ^^^^^ ^ 55 5g 8 Holmes's System of Surgery, 2d ed., vol. ii. p. 359. ' ' ' * 286 INJURIES OF THE BACK. Again, a shoemaker, aged 32, while stooping, tripped and rolled over, with his head under him. His neck received thereby a twist that caused much pain. He lay motion- less, flat on his back, for ten minutes, being without the power to move both arms and legs, and having a sense of numbness and of pricking throughout the body. In trying to stand, his legs gave way under him, as if he were intoxicated. Sensation, also, was impaired but not lost. Within twelve hours, however, both motor power and sensation were restored ; and the paralysis did not return. He complained of acute pain in the neck, which was aggravated by the slightest movement of the head ; and he, therefore, kept the head perfectly still. He lay in bed, on his back, with his neck sunk on to a low soft pillow, and propped up by sand-bags. On examination, the chief tenderness was found at the fourth cervical vertebra ; and there a deeply seated swelling was per- ceived. For treatment, absolute rest of the neck was enforced, and tincture of iodine ap- plied. In a month he was allowed to leave his bed, with his head supported by a plastic shield extending from the shoulders to the occiput. He could then perform the nodding, but not the rotatory, movements of the neck. In nine weeks, all the cervical movements seemed quite restored ; but, for precaution's sake, he was kept in hospital three weeks longer. He returned to his trade, and called several times afterward to show that he was well.^ Finally, a little, ricketty girl, of 3 years, having a large head, was admitted to hos- pital, late one evening, with paralysis of the upper and lower extremities. She had fallen out of bed, that morning, head-foremost, and was insensible for a few minutes. During the day, it was remarked that she did not get upon her feet, nor move her legs ; and that she did not use her hands. When examined, motor power was found to be lost in both upper and lower extremities. She showed no signs of pain when the skin was pricked anywhere below the upper part of the chest. Reflex movements were excited in the lower extremities when the skin of the abdomen, and it alone, was pricked ; and then the child gave a slight cry of pain ; respiration natural ; bladder and rectum not aflected. She uttered cries whenever the neck was moved, or the back of it was pressed on by the fingers ; and, after it, seemed pleased to keep the head at per- fect rest on a pillow. For three days no change in the symptoms was observed ; on the fourth day there were visible signs of improvement ; on the fifth, it was discovered that she could freely move both upper and lower extremities, and that motion of the head had ceased to give pain. There was no further trouble, and she remained quite well.^ The main point in the treament of recent, as well as in that of old cases, in which the articulations of the cervical vertebrae have been sprained or wrenched, is to maintain them in a state of complete immobility and relaxa- tion until the cure is complete. To this end, the patient must be made to lie continuously in bed, on the back, with only a thin pillow under the head, and barely enough support under the nape of neck to keep it from sinking. Besides, to keep the head straight, and to prevent its rolling from side to side, sand-bags, that are sufficiently long and heavy to fulfil the indica- tions, must be so placed upon the patient's pillow, one on either side of the neck and head, as to give both of the parts a complete lateral support. In- deed, I do not know of any other mechanical expedient, of a simple nature, which answers this purpose as well as sand-bags, made of bed-ticking, of a length sufficient to extend beyond the head, and about three-fourths filled with dry sand. One of them is to be placed with care on each side, close to the neck and head, and is to be accurately moulded thereto, so as to keep the head entirely straight, and to render all lateral or rotatory movements of the parts impossible. Sprains, Twists, and Wrenches in the Dorsal Region.-— The dorsal por- tion of the vertebral column, when compared with the cervical and lumbar portions, is characterized by a relatively much greater rigidity and want of ' Ibid., p. 359. 2 Ibid., pp. 359, 360. SPRAINS, TWISTS, AND WRENCHES OF THE BACK. 2S7 flexibility or capacity for movement n[»oii each otlier of the several bones that compose it, at the articulations ])y which they are linked too;ether. The injuries caused by sprains and twists, or wrenches, in this region are, there- fore, somewhat analogous to those produced by enormously powerful blows, and their deleterious effects are apt to be restricted to the articulations w^hich connect two contiguous vertebrse, instead of being dispersed or dif- fused so as to affect the articulations of many adjoining ])ones, as is usually the case with similar injuries in the more flexible parts of the vertebral col- umn, the cervical and lumbar regions. There is a traumatic, as well as a rheumatic, " crick" in the back, which is not unfrequently caused by lifting, or attempting to lift, a heavy weight while in a stooping position, and is located in the dorsal region. The victim, while exerting his strength to the uttermost in this position, suddenly feels " something give way" in his back, and is soon seized by cramping pains in the affected part, which are aggravated by all attempts to produce motion therein ; so that he carefully abstains from making such attempts himself, fi.nd is only too glad if the injured part be allowed, by the exigencies of life, to remain in a state of absolute quietude. In such cases, the muscular fibres belonging to the strained part are sometimes lacerated to a considerable ex- tent, and the effusions of blood and of inflammatory products into the injured muscular and connective tissue may cause tumefactions, possibly with sub- cutaneous ecchymoses also, which can readily be felt and seen externally. For such cases, the best plan of treatment consists in the enforcement of abso- lute quietude as long as the soreness continues, with the external use of a mildly stimulating liniment, and the internal administration of opiates, whenever necessary to allay the pains. ^ Sprains and wrenches of the dorsal part of the vertebral column are some- times caused by alighting on the dorsal region in falls, or when thrown from the saddle while on horseback. They are also produced, occasionally, in military life, by the trampling of horses upon the backs of men w^ho have suddenly been dismounted, or have been thrown down to earth by other means, in battles or in sham-fights. The vertebral ligaments and joints may likewise be sprained or wrenched by the impact of powerful blows on the dorsal region, no matter what the nistrument may be that inflicts them. In respect to treatment, no additional directions are required. The natural curvature of the dorsal part of the vertebral column, the convexity of which looks backward, undoubtedly exerts considerable in- fluence in the way of lessening the injurious eflects upon the vertebral ligaments and articulations, of violent blows on the dorsal region. This cir- cumstance probably explains why it is that heavy blows on tSis part of the back are so seldom attended w^ith strains or wrenches of the vertebral column, that prove troublesome to manage, or even require a surgeon's care. The principal eftect of strong blows, etc., "when received on the convexity of the vertebral arch in the dorsal region, is to compress the intervertebral substances, and the articulations in general, which enter into the formation of the arch; and, therefore, they usually do comparatively little harm to the spme. But a much more powerful blow— one, for instance, that falls but little short of dislocating or fracturing a dorsal vertebra, and so comes very near to breaking down the dorsal arch — may readily detach the correspond- ing intervertebral substance, to greater or less extent, from the bone, and thus cause an inflammation which may prove destructive to the injured bone and cartilage, especially if the lesion chance to pass unrecognized, or happen to be inadequately treated. It is not improbable that caries of the dorsal vertebrae sometimes begins in this way. 288 INJURIES OF THE BACK. The mechanical effects of falls, however, are widely different from those of blows on the dorsal portion of the vertebral column, especially when the victim's back happens to alight upon some solid body of comparatively small dimensions, whose upper surface is considerably raised above the surrounding ground — for instance the stump of a tree, or a block of wood, etc.; for, in such a case, when the further descent of the back is stopped by striking against the solid body, the downward movements of the head, neck, and upper extremities on the one hand, and those of the abdomen, pelvis, and lower extremities on the other, are not arrested at the same instant of time as that of the dorsal region ; and', therefore, the weight and impetus of these parts simultaneously press downward, with great energy, upon both the upper and lower ends of the arch formed by the dorsal vertelbrse, and on the concave side thereof, in such a manner that the intervertebral substances and bodies of the dorsal vertebrae are in the line of extension, and the spinous processes of these vertebra in that of compression. It is obvious that a comparatively slight fall upon the dorsal region, occurring in this waj^ may badly stretch or strain the anterior and posterior common ligaments of the spine, and may also separate to a considerable extent the intervertebral substances from the bones. It is highly probable that caries of the dorsal vertebrse, in consequence of falls upon the back, not unfrequently originates in this manner ; and that comparatively trifling accidents of this sort may, under favoring circum- stances, suffice to produce this result. Sprains, Twists, and Wrenches in the Lumbar Region. — The vertebral column is sprained and twisted, or wrenched, in the lumbar region, more fre- quently than in any other part thereof Such lesions of the lumbo-vertebral articulations are sometimes produced in attempting to lift great weights while in a stooping position ; and by the impact of blows and falls upon the lum- bar reo-ion itself, quite analogous to those in the dorsal region which have just been cfiscussed. More often, however, they are caused by accidents in which the vulnerating force is indirectly applied to the lumbar region ; for instance, by alighting on the buttocks in falling from a height, or by the falling of a heavy weight upon the head or upper part of the body, while it is in an erect posture, the lower extremities being firmly planted on the ground. Many years ago, a good example of the first-mentioned kind of accident came under my observation : — A young farmer, aged about 20, accidentally slid down from a steep hay-mow, and then falling about fourteen feet, struck the ground upon his buttocks. He received thereby a violent jar in the lumbo-sacral region. His head and shoulders sank back- Avard to the earth, where he lay for some time, unable to arise, barely able to move his legs a little (they also felt benumbed), and suffering terribly from pains in both lumbar regions. At first, he thought his "back was broke." However, after he had lain wet wilh cold sweat for some httle time, he began to feel less faint, or a little stronger, and found himself able to move his lower extremities rather better. The pains, too, gradually abated, and then turning himself partly over, he tried to make his way to the house by crawling on his belly ; but these efforts increased the lumbar pains so much that he was compelled to desist. After lying quite still, a little longer, he found that the paral}^sis of his lower extremities was considerably lessened, and that possibly he might arise. After many efforts he succeeded in doing so, his legs, meanwhile, having given way under him several times like those of a drunken man. He walked with the feeble and uncertain steps of an intoxicated person, from the weakness of his lower limbs ; but after much effort, he succeeded in getting to the house, a distance of about two hundred yards, without any assistance. He was immediately placed in bed. There was con- siderable swelling across the loins, and much tenderness was discovered by pressing upon the lumbar spinous processes. Tenderness was also discovered in and around the bodies of the last three lumbar vertebrae, on pressing upon them through the front wall SPRAINS, TWISTS, AND WRENCHES OF THE BACK. •280 of* the abdomen. There was no displacement of the bodies or spinous processes of tiie vertebra^. For several days, the loins were fomented with a strong decoction of chamo- mile flowers and wormwood. His favorite posture in bed was that of lying upon the side (it did not seem to matter w^hich side), with his body semi-flexed, and knees drawn up. For many days he was reluctant to make any change whatever in his posture, because of the excruciating pains in the lumbar region, which every little twist or flexure of the injured articulations of the spine, and every contraction of the lumbar muscles, gave rise to. As continuous confinement to bed was enforced, tiie first im- portant evidence that he was recovering was noted when he began to move himself about in bed, of his own accord. On discontinuing the fomentations, a large belladonna plaster was applied to the loins. He was confined to bed just lour weeks, and the com- plete rest of the injured parts, thus secured, was the chief means relied upon to promote his recovery. He wore belladonna plasters, and complained of feeling lame and weak in the lumbar region for a long time afterward ; but, in the end, he perfectly recovered. In this case, the articulations of the lumbar vertebrse were wrenched in a peculiar manner. The young man's buttocks, in falling from a height of fully fourteen feet, struck the ground with great force. At that instant, the lower part of the spinal column was suddenly compelled to support the weight and impetus, or momentum, of all parts of the body situated above the loins, the first effect of which was to compress the intervertebral substances, to be followed, however, in an instant afterward, by a violent bending of the spinal column backward, at the peculiar curvature formed by the lumbar vertebrae on top of the sacral curvature. The greatest part of the strain, therefore, fell upon the articulations of the last three lumbar vertebrpe ; and, at the same time, the intervertebral substance and the bodies of these vertebrae were in the line of extension. In this way, the anterior and posterior common ligaments of the spine, and the intervertebral substances, in the lumbar region, together with the psoas muscles, were all severely stretched ; and this circunistance accounts for the fact that much tenderness under pressure was discerned on examining the lumbar vertebrae through the front wall of the abdomen. The nature of the lesion also explains why it was that the attempt to crawl on the belly caused so much increase of the pains in the injured part ; for, on elevating the shoulders in order to execute the movements which constitute crawling, the injured vertebral ligaments and muscles were again put on the stretch. A good illustration of the last-mentioned kind of accident, in which the vulnerating force is indirectly applied to the lumbar region, was lately under my care : — E. B. C, aged about 60, while walking in the second-story hall of an old house, January 21, 1882, entirely oblivious of danger, was suddenly struck on top of the head by a mass of plastering, estimated to weigh over two hundred pounds, that, having become loosened, had fallen down from the ceiling, which itself was rather lofty, being about sixteen feet high. The blow on the head, of course, was exceedingly violent ; it gave him a scalp-wound two and one-half inches long over the right parietal bone, with severe concussion and contusion of the brain. His body was also bent forward, and doubled up, by the force of the blow on the head and the weight or momentum of the falling mass of plastering, so that he was instantly crushed down to the floor, where he lay stunned for some little time. The forcible bending forward and doubling up of his body took place at the loins ; and thus the lumbar muscles and the articulations of the first, second, and third lumbar vertebrae were badly strained. Obviously, the structures of the fore- part of his spinal column suffered powerful compression at the place of forcible flexure, while those at the back-part thereof were subjected to violent elongation and over- stretching. The cerebral lesion masked to a great extent the subjective symptoms of the lumbar lesions, for a considerable time ; but, objectively, there soon arose a swell- ing across the injured loins which attained the thickness of a man's hand, was very tender under pressure, and lasted a long time. Tiie quietude and other remedial mea- VOL. IV. — 19 290 INJURIES OF THE BACK. sures that the cerebral contusion demanded, were sufficient to relieve the lumbar lesions also, so that no special medication was ordered for the lumbar region until April 12, when a large belladonna plaster was prescribed, giving much relief. His recovery, how- ever, was not complete (as to the loins) until the 1st of June. Usually, considerable swelling across the loins soon follows such injuries of the lumbar region as have just been described. Subcutaneous ecchymosis may or may not attend the tumefaction. Sometimes the ecchymosis does not appear until several days after the accident. On tracing the spinous processes with the fingers, their positions are found to be the same as in the normal state. On examining the bodies of the lumbar vertebrse through the anterior wall of the abdomen, no displacement is detected. Tenderness under pres- sure, in such cases, is usually observed over a considerable space. Oftentimes the patient, with evident difficulty, and much exhibition of pain and weak- ness in the loins, will endeavor to place his vertebral column in an erect position ; if his eflbrts be successful, and no deformity be presented, it may confidently be assumed that there is no fracture. The posture which patients having lumbar sprains generally assume in bed, is, as described above, that of lying on one side, with the trunk semi-flexed, and the knees drawn up ; and, for many days, they are usually reluctant to make any change of posi- tion, from dread of the pains and sjDasms in the injured muscles, which all attempts at movement are liable to excite. When such patients begin to move themselves about in bed, of their own accord, they furnish the best possible evidence of progress toward recovery. The treatment^ as shown above, does not differ essentially from that of sprained joints in general. The most important point is to enforce absolute quietude of the injured parts for a sufficient length of time. Commonly, it requires from four to six weeks' confinement to bed for recovery to take place. If the bowels be at all confined, a mercurial purge may be adminis- tered with advantage. If there be febrile movement of a sthenic character, saline drinks may be given with benefit, and the diet should be low while it continues. Should the lumbar pains or the muscular spasms prove trouble- some, they may be quieted by exhibiting opium in the form of Dover's powder. The diet must be nourishing in asthenic cases, and in all others likewise after the acute stage has been passed. Fomentations with decoction of poppies, applied to the injured loins, also appear to do good. But those which consist of a strong decoction of chamomile and wormwood (mentioned above), are perhaps still better. At a later period, camphorated oil, or camphorated soap-liniment, should be used instead of fomentations. The patient, when about to leave his bed, should be furnished with a riding-belt stiffened with additional whalebone. (Shaw.) At the same time, a large belladonna plaster can generally be applied with benefit. Inflammation of the Vertebral Articulations arising from Sprains, Twists, or Wrenches. — From such injuries, an inflammation of the over- stretched or lacerated ligaments, tendons, muscles, and connective tissue, more or less severe according to the nature of the case, soon ensues. This appearance of inflammatory reaction in the damaged tissues is a necessary consequence of the original lesions. Its occurrence should, therefore, be anticipated, and its treatment should likewise be provided for by the sur- geon from the very outset of the case. Moreover, this traumatic inflamma- tion may, in general, be completely controlled by patiently applying the principles and methods of treatment just enunciated. But when the presence of traumatic inflammation in the vertebral joints happens, from any cause, to be unrecognized, or, if recognized, \o be made light of, and when, therefore, SPRAINS, TWISTS, AND WRENCHES OF THE BACK. 291 Fig. 858. the disorder receives no treatment whatever, or at best is very inadequately treated, then the inflammatory process is quite liable to become chronic and suppurative in character, and, in the end, to destroy the vertebral articula- tions involved, just in the same way as the joints of the extremities are de- troyed by disease under similar circumstances. It is this chronic or consecu- tive disorder of the vertebral articulations, that not unfrequently results from sprains and twists, or wrenches, of the vertebral column, which we have now to consider. It is, perhaps, more often met with in cases where the symptoms of injury originally are not severe, than in cases where they are strongly marked ; for, in the latter instance, the severity of the symptoms themselves will be apt to secure that thoroughness and sufficiently long continuance of treatment which is indispensable for recovery. However this may be, it nevertheless is certain that this disorder not unfrequently appears in cases where the symptoms of vertebral injury have been originally by no means severe ; and sometimes, too, in cases where the symptoms of vertebral injury have been comparatively slight at the outset, so that the disastrous conse- quences have unexpected!}^ ensued. When the articulations of the spine that have been damaged by sprains, etc., are occupied by chronic inflammation, they are liable to exhibit at first gradually increasing tumefaction and indura- tion ; then indolent suppuration, like that which takes place in other joints that are similarly aflected, and, finally, ulceration of the cartilages and caries of the vertebrae. Among the earliest symptoms in these cases, not unfrequently, are pains, located not in the spine itself, but in the parts supplied by the terminal branches of the sensory nerves which issue from the vertebral column at the seat of the lesion, and give rise to the pains, because their filaments are irritated by the inflamma- tory process going on in the intervertebral foramina through which they pass. Several examples have already been presented where disease of this sort, situated between the first and second cervical vertebrae, was attended by pains located on the back part of the head, behind the ears, etc., because the occipitalis major and minor nerves with the auricularis magnus were irritated in this manner within the spinal column (see Fig. 857). In such cases, the pains due to the spinal disease are apt to be mistaken tor rheumatic pains, and to be maltreated accordingly. In like man- ner, pains at the pit of the stomach may be caused by diseases ot the dorsal vertebrae, which irritate the sixth and seventh dorsal nerves (see Fig 858). Mr. Hilton presents two examples which well illustrate this point. Both patients, however, made good recove- ries, by adopting rest as the chief remedial agent, and without applying anythmg to the dorsal region.* Mr. Hilton also points out that these pains are almost always symmetrical, that is, alike on both sides ot the median plane, when they arise from disorders in the lower cervical, dorsal, or lumbar vertebrae, whilst they often are uni- Side view of the chest and abdomen, showingr the course of the sixth and seventh dorsal nerves. (Hilton.) Op. eit., pp. 48-50. 292 INJURIES OF THE BACK. lateral, or one-sided, when caused by disorders betweeii the occiput and the atlas, or between the atlas and the a^is. The most probable explanation of this peculiarity is, that a spinal disorder occurring between the occiput and the atlas, or between the atlas and the axis, may be confined to only one of the joints between these bones, whilst a disorder of the lower cervical, dorsal, or lumbar vertebrae, generally involves the bodies of the vertebrae or the in- tervertebral substances, entirely or completely.^ I have, however, lately seen a case wherein pains of this sort, that were caused by chronic inflammation following a wrench of the lumbar vertebrae, appeared on one side only. The following case, which is related by Mr. Hilton, illustrates the symp- toms of this lesion, when it involves the eighth and ninth dorsal vertebrae, in a most useful manner : — It is that of a moderately robust little girl, aged 4^ years, who, while enjoying good health, fell down out of bed upon her back, a distance of about two feet. But nothing appears to have been thought of it at the time, though she at once began to lose flesh, and her face become anxious. About three months afterwards, she began to complain of symmetrical pains in her belly, was easily fatigued also, and stooped a little in walk- ing. Her fall upon the back having been forgotten, she was treated for the abdominal affection by several surgeons, but rapidly grew worse instead of better. She became much reduced in flesh and strength, and unable to walk about, from spasmodic pinching pain in the abdomen, which " doubled her up." In a -short time, however, having been kept quiet in bed, she recovered her flesh and strength, so as to be enabled to walk about a little without pain. But, quickly, all the untoward symptoms again super- vened ; the abdomen became large and tumid, the bowels irregular, with pain in the belly, as if a, cord were drawn tightly around the abdomen and tied. Another surgeon was now consulted, who declared the mesenteric glands affected. The urine was phos- phatic and ammoniacal. She was allowed to go about as usual. In a short time the alteration and unsteadiness of gait became more marked, and, the other symptoms con- tinuing, she was taken to London for advice. Disease of the eighth and ninth dorsal vertebrae was detected, with slight projection backward, or angular curvature. Her tall upon the back h?ld recently been remembered. Uninterrupted rest in the recumbent posture was ordered, with no medicine, and the child completely recovered in four or five months.^ It is apparent that in this ease the real cause was, for a long time, entirely overlooked ; that the abdominal symptoms were treated as depending on Bome error in the abdominal viscera, when they w^hoUy depended on the spine ; and that the spinal condition itself was meanwhile altogether ignored. "Nevertheless, almost all the symptoms which attend chronic inflammations of the veYtebral joints, in consequence of neglected sprains and wrenches, were present in this case. For example, there were pains in the belly, which w^ere due to irritation of the sensory filaments of the ninth pair of dorsal nerves. There were also cramps or muscular spasms in the belly, which were caused by irritation of the motor filaments of the same pair of nerves, during their passage through the intervertebral foramina. Besides, there was paraplegia (incomplete), which probably resulted from compression of the spinal cord. The urine, too, became phosphatic and ammoniacal, and the bowels tympanitic, in consequence of accompanying myelitis. More- over, the appearance of angular curvature of the spine, at the seat of mjury, served to show exactly what joint was sprained, and the nature of the dis- order which invaded the bodies of the contiguous Vertebrae in consequence of the articular lesions. By adding to this account of the symptoms, a state- ment that tenderness under pressure and some swelling of the soft parts were found over the eighth and ninth dorsal vertebrae, which without doubt was 1 Ibid., pp. 51, 52. « Ibid., pp. 52, 53. SPRAINS, TWISTS, AND WRENCHES OF THE BACK. 293 the case, a complete picture of the symptoms pertaining to the disorder in question is presented. So much, then, for the symptoms which are liable to result from traumatic spinal arthritis, when it becomes chronic and advances unchecked for some considerable time ; or until caries of the bodies of the contiguous vertebrae ensues. Caries of the vertebrae, however, Avill not be specially discussed in this article, as it will be fully dealt with elsewhere. Inflammation of the verte- bral joints is here considered only in so far as it is a consequence of sprains and twists or w^renches of these jomts, and in so far as it becomes necessary for surgeons to thoroughly understand the symptoms, final results, and treat- ment of these hurts, in order to recognize their importance, and take care of them in such a manner as to save patients from the great evils which, Avhen neglected, they are liable to cause. To this end I have presented the fore- going examples and observations that illustrate these forms of injury, and the principles which should guide their treatment. It is necessary, still, to point out briefly some direful consequences of these lesions which have not yet been mentioned, and which are as follows: (1) The consecutive inflamma- tion may extend to and destroy the spinal nerves that are contiguous to the injured articulations, and thus cause permanent paralysis of the parts w^hich they supply. (2) The consecutive inflammation may spread from the joints of the spine to the theca vertebralis, and thus induce spinal meningitis. What then is chiefly to be apprehended is, that the product of this meningeal inflammation, on being eft used into the spinal arachnoid cavity, may c"om- press the spinal cord so as to arrest its functions, and thereby cause paraplegia, or even death. (3) The consecutive inflammation may spread still further toward the centre, and attack the spinal cord itself, thereby causing spinal myelitis, and, in this manner, paralysis witi! a fatal result. Happily, how- ever, there is not the same risk that an inflammation which involves the bones of the vertebral column will spread inward, and successively attack the spinal meninges and the spinal cord, as there is, in cases where the cranial bones are inflamed, that the inflammatory process will spread inward and suc- cessively attack the cerebral meninges and the cerebral substance ; for, in the head, the dura mater, being flrmly adherent to the cranium, performs the office of an internal periosteum, whilst, in the spine, not only does each verte- bra possess a distinct periosteum, but the theca vertebralis, or spinal dura mater, is also comparatively free, being attached by a very loose connective tissue only to the walls of the spinal canal. Whilst the cranium, the cerebral meninges, and the brain itself, are formed in close connection with each other, the vertebral column, the spinal meninges, and spinal cord are formed in loose array ; and, therefore, an inflammation cannot extend itself from one structure to another, through contiguity, in the latter organs, with anything like the same facility that it can in the former. After long and wide experience, Mr. Hilton concludes : " I have generally found that almost all these diseases of the spine are the result of slight acci- dents overlooked."^ It has been shown in the preceding pages, that slight falls upon the back, especially on the dorsal region thereof, and where the intervertebral substances and bodies of the vertebrae are situated in the line of extension, and the laminae, spinous processes, etc., in that of compression, may be attended by detachment (more or less extensive) of the intervertebral substances from the vertebral bodies, and that these lesions, if overlooked or maltreated, can lead to all the evil results that have been mentioned above. The importance of continuous rest in bed, as a remedial measure, in such cases, cannot be over-estimated, and must not be forgotten. 1 Ibid., p. 52. 294 INJURIES OF THE BACK. HEMATURIA FROM CONTUSIONS AND SpRAiNS OF THE Back. — Traumatic lesions of the kidneys, with bloody urine, occur so frequently in cases where severe contusions and strains, or wrenches, are sustained in the lumbar regions, that a pretty full account of them is necessary in this place. The source of the hemorrhage, in these cases, it is seldom difficult to deter- mine ; for, when blood is found intermingled with the urine, after such injuries of the loins, it may generally be inferred with safety that one (at least) of the kidneys is also injured. When, however, slender, cylindrical, pale pieces of fibrin, or dark-colored coagula having a similar shape, are seen in the urine, the surgeon may be sure that the blood has come from the kidney, for these clots have been moulded in the ureter and then have been washed down therefrom by the urine. Moreover, when blood is passed inti- mately blended with the urine, but without coagula, in cases of lumbar injury, it has likewise, in all probability, a renal origin. It will be remembered that the kidneys are two dense and rather brittle glands which lie close to the sides of the spinal column from the first to the third lumbar vertebrae inclusive, and outside of the peritoneum; that they are surrounded, and held in place with considerable firmness, by connective tissue containing much fat ; that the right kidney lies rather lower than the left ; and that each of them projects downward below the last rib, and, behind, is covered by the quadratus lumborum muscle. Hence, all violent flexures of the upper 1 umbo- vertebral articulations from sprains or wrenches are liable to be attended by corresponding bends and breaks of the kidneys ; hence, also, the impact of powerful blows on the lumbar muscles may readily be transmitted through these muscles to the kidneys themselves, with enough force to contuse or even tear those organs. Finally, the renal lesion in these cases, whether consisting merely of contusion, or of slight rupture, or of extensive laceration of the renal substance, is usually attended by hsematuria. But, when the kidneys contain calculi, and when they are congested, as, for example, in the first stage of Bright's disease, or when their texture has become weakened, as, for instance, in chronic parenchymatous nephritis, com- paratively slight injuries of the lumbar region may be attended by heematuria. The clinical features or characteristics of the above-mentioned forms of renal injury can best be presented by the narration of some examples. In military life, the blow on the lumbar region which causes the mischief, may result from the explosion of a shell, as happened in the following instances, two in number, which w^ere reported during the late civil war : — J. H. P., Co. K, 142d Pennsylvania Vols., aged 20, was struck on the left lumbar region, July 2, 1863, at Gettysburg, by a large fragment of shell, which caused a grave contusion with ecchymosis, but without abrasion of the skin. There was shock, and much pain and tenderness at the injured part, and the urine was scanty and bloody. The pain extended along the course of the ureter, and there was retraction of the tes- ticle with smarting at the orifice of the urethra. There was much difficulty in micturi- tion, and occasionally tubular clots of blood were passed, after wdfich the urine flowed in a stream, with great relief. The patient was also suffering from diarrhoea. He was treated with hot fomentations applied to the injured part, and with chalk mixture and spirit of nitric ether, until the 11th, when he had rallied sufficiently to be transferred to the Satterlee Hospital, at Philadelphia. There he was treated wnth infusion of buchu, together with counter-irritation applied to the loins ; and, as soon as the irrita- bility of his bowels permitted, he was placed on nourishing diet, with ferruginous medi- cines, and bitter tonics. The haematuria disappeared after the third week from the reception of the injury. The patient gradually convalesced, and, on December 31, 1863, was transferred to the Invalid Corps.^ » Med. and Surg. History of the War of the Rebellion, Second Surgical Vol., pp. 20, 21. SPRAINS, TWISTS, AND WRENCHES OF THE BACK. 21)5 This example aftbrds a good clinical illustration of the traumatic lesion of the kidneys, by which powerful blows on, or violent contusions of, the lumbar regions, are not unfrequently accompanied. The renal symptoms were very clear. They w^ere shock, pain in the bruised and torn kidney, which extended downw^ard along the course of the corresponding ureter, with retraction of the testicle on the same side, and smarting at the urethral orifice. The urine was bloody, and, at times, contained also coagula which had been moulded in the ureter. At such times the act of urination was very difiicult, and the difficulty lasted until the coagula had passed through the urethral canal. Their voidance was always followed by copious urina- tion, and by a sense of great relief. The hsematuria continued for three weeks, but the patient gradually recovered. From the nature of the vulnerating force, from the presence of shock, from the intensity and persistency of pain in the injured kidney and its ex- cretory duct, etc., from the long continuance of hsematuria, and from the severity of the renal symptoms in general, it is but just to infer that the renal lesion in this case w^as extensive, and probably consisted of laceration as well as contusior^ of the renal parenchyma. jSTotwdthstanding, the patient slowly regained his health. This pohit is of much practical importance; for, aside from other considerations, the happy result helps to show that rupture of the kidney is an accident from which recovery is more common than it is from a similar lesion of any other important viscus. The next case belongs to the same category as the last : — Lieutenant H. T. Burrows, Co. C, 7th Maryland Vols., was struck May 5, 1864, by a fragment of shell, on the left lumbar region. He was treated during one week at the second division hospital of the Fifth Corps, in the field. Severe pain and difficult micturition, with haematuria, led to the belief that laceration of the left kidney had resulted. On the 1 2th, this officer was sent to Washington, and there was treated in quarters. He recovered ; and, on June 8, he was placed on court-martial duty.^ Besides the examples just related, there were also observed, during the late civil w^ar, a number of cases of recovery in wdiich there was reason to sus- pect the existence of laceration of the kidney, or, at least, of severe contusion of its substance. Unfortunately, they are not reported with fulness or pre- cision of detail."^ Taking these cases, however, for what they are worth, they will serve to increase considerably the aggregate of instances in which trau- matic lesions of the kidneys, attended with h?ematuria, and caused by lumbar contusions, have eventuated in cure; and, for this reason, I have thought it worth while to mention them. Mr. Shaw refers to the case of a woman who had been bruised in the loins, from the falling in of the roof of her dwelling ; and who, it was claimed, had sustained a renal lesion thereby.® Albuminuria also was present. When great strains or wrenches of the vertebral articulations in the lumbar region are caused by alighting upon the feet in falling, the kidney may be extensively ruptured at the same time, as happened in the following instance reported by Dr. Anders : — A well-built lad, aged 15, fell from the second floor ot a house to the ground, with- out becoming insensible. He said that he struck the ground first with his feet, and then with his right hip. No external mark of injury, excepting a slight purplish spot over the right trochanter. No fracture of any kind, and no symptom of concussion of ihft brain or spinal cord. He could not walk very well, but was able to move his I Ibid., p. 21. « Ibid., p. 20. * Holmes's System of Surgery, 2d edition, vol. ii. p 363, foot-note 296 INJURIES OF THE BACK. extremities freely when lying in bed. Pulse 60, and small ; sensibility not decreased. He freely passed bloody urine. He complained of severe pain in the abdomen, espe- cially in the left renal region, but nothing abnormal could be detected by inspection or palpation. The microscope showed the urine to contain a large number of red blood- corpuscles. Well-marked symptoms of internal hemorrhage appeared and increased ; and, at 11 A. M. next day, he died in consequence of inward bleeding. During the night the urine was very little bloody. In the morning it was quite clear. Autopsy A darli-blue tumor of the size of a child's head, extending from the iliac fossa to above the tenth rib, and covering the three superior lumbar vertebrae, was found in the abdominal cavity. It consisted of coagulated blood, wherein the left kidney, which had been torn into two distinct halves, was found imbedded. The rupture was trans- verse, extending from the anterior superior part of the organ to the posterior inferior, througli the capsule and the parenchyma. The pieces of the kidney were about two inches distant from each other, and entirely separated from their adhesions. The left ureter was torn across, and was attached, to the length of two inches, to the lower frag- ment ; the corresponding renal vein and artery were in the same condition. The right kidney was perfectly sound. The peritoneum was not ruptured. No fluid was con- tained in the abdominal cavity, and no blood in the bladder.^ In this case, the left kidney, together with the accompanying ureter, renal vein, and renal artery were torn completely across, while all the other organs were unaffected ; and the force which caused this immense laceration had been indirectly applied. The rationale of the h?ematuria was probably as follows : The blood being still liquid, for some hours after the accident, flowed down through the severed ureter into the bladder, and this sanguinolent flow continued until the ureter itself became plugged by tlie formation of coagulum. Then the urine which was secreted by the right kidney remained clear, that is, un- stained with blood, and in that condition was discharged in the morning before the patient died. But, the lacerations of the kidneys which result from falling upon the feet, buttocks, or back, etc., are, for the most part, also attended with lacerations of other important viscera, as was observed in the following instance recorded by Professor Fayrer : — The patient, a Hindoo, aged 25, fell from a tamarind tree, and fractured both arms. He was brought to the hospital, and appropriately treated ; but the wounds did not do well, and he died in consequence of tetanus, sixteen days after the event. There was no indication of internal mischief beyond a complaint of pain in the epigastrium on the day after the accident, when uniformly bloody urine, without any clots, was passed. Next day, the urine was also bloody, but there was nothing more till death. Autopsy. — At the upper end of the left kidney was a rupture running into the hilus, where the areolar tissue was infiltrated with blood. A great part of this kidney was softened. There was some coagulated blood over the kidney and left side of the pelvis, but no peritonitis. Two ounces of blood clots lay in the great omentum. The spleen had two ruptures in its posterior edge, the upper one being very deep. The liver had a super- ficial rent on the posterior margin of its right lobe, and two others on the under surface. The liver was also studded with light-gray pyaemic patches, which Professor Fayrer attributed to emboli from the ruptured spleen. The heart and great vessels were found to contain coagula.^ In the example just presented, hsematuria appeared on the second day, and constituted a prominent symptom. It was also the form of hsematuria that characterizes renal injury, when no coagala are voided in the urine. It lasted, however, oidy two days, although it was caused by a rupture at the upper ' Med. News and Abstract, January, 1880, pp. 41, 42 ; also Brit. Med. Journal, Oct. 18, 1879. 2 Med. Times and Gazette, May 18, 1867 ; also, New Sydenham Society's Biennial Retrospect, 18G7-8, p. 187. SPRAINS, TWISTS, AND WRENCHES OF THE BACK. 297 end of the left kidney, which extended into the hihis. The patient died six- teen days after the injury, of tetanus ; and, at the autopsy, a great part of tlie torn kidney w/ds found to be softened. Sometimes, the liquid voided by urination, in these cases of renal injury consists of almost pure blood, as was specially noted in the followii^j- in- stance : — * Private Henry Greene, Co.^ H, 9th Cavalry, entered hospital at 6 P. M., December 15, 1870, at Fort Quitman, Texas, having been run over by a wagon at 8 A. M., while on his way to Fort Quitman from Eagle Springs. It was thought that both wheels of one side had passed over his right hip and tliorax. The patient was sufferinc>-, when admitted, from shock and extreme depression. His extremities were cold, "and he was almost pulseless at the wrist. But he was perfectly conscious ; the beatin^r of his heart was feeble but regular, and 104 per minute ; respiration 44. Death from shock and internal hemorrhage ensued at 7.30 A. M. of the following day, " the patient hav- ing passed, through tlie night, a quantity of nearly pure blood from the bladder " Autopsy, ten hours after death — " A large effusion of blood into the abdominal cavity was found, and a longitudinal rupture of the right kidney, througliout nearly its entire extent. The bladder was normal and empty." The liver also was ruptured throucrh almost the whole of its antero-posterior diameter, following the junction of tlie riHit with the left and quadrate lobes, to within an inch of its anterior margin. The sternum was fractured at the junction of its upper and middle third. The eighth rib (rio-ht), too, was fractured two inches in front of its an«-le.i ° Dr. Roddick reported the following case in which pure blood was passed, and ex- hibited the specimen. A healthy woman, aged 60, had fallen down a long flio-ht of stairs, and was picked up insensible. There was no wound, but on recovennor" con- sciousness she complained of great pain in the riglit loin ; vomiting began, and, m spite of all treatment, continued to the end. The bowels became tympanitic and refused to act. Pure blood was passed from the bladder during the first twenty-four hours ; sub- sequently, the urine was mixed with blood, and on the fourth day it was nearly clear. Rupture of the kidney was diagnosed, and ileus was suspected on account of the obstruc- tion of the bowels and their great distension, though no tumor could be felt. Rectal injections were employed without any benefit. At the autopsy a large clot of blood was found surrounding the right kidney, which presented a laceration on the border extending into the pelvis of the organ. The kidneys were firm and slightly o-ranular! The bowels were distended but not obstructed ; it was thought that perhaps the laro-e blood clot might have pressed upon the ascending colon and produced the obstruction.^ Prognosis— ll^m^tmAd from contusions and sprains, or wrenches, of the lumbar region is, in most instances, not a very dangerous symptom ; for usually It disappears in the course of a few days, without leaving any trace of organic disease of the renal tissue behind. Concerning hcTmaturia from this cause, Le Gros Clark says that among the many cases he has witnessed, he has never had reason to suspect that nephritis or organic disease followed in any On the same point Mr. Shaw remarks: " When such an important gland as the kidney has been crushed and broken, to such an extent that hemorrhage goes on from a rent in it for several days, it might be thought probable that the damage w^ould be followed by ulterior bad results, especially that inflam- ination— nephritis— would ensue. But extensive observation negatives this view ; general experience shows that when patients recover from the imme- diate effects of haematuria brought on by sprain of the spine, thev are not more prone than others to renal complaints."* In regard to h^ematuria from sprain of the back, Mr. Bryant observes : " It is not generally a very serious 1 Circular No. 3, S G. O., August 15, 1871. 8 Medical News, November, 18, 1882. 8 British Medical Journal, October 3, 1868. ♦ Loc. cit., pp. 362, 363. 298 INJURIES OF THE BACK. symptom, unless the kidney is ruptured ; as a rule, it disappears gradually, and no evidence remains that organic renal disease is ever the consequence.' ^ Concerning the symptoms smd prognosis when rupture of the kidney is pre- sent, Mr. Bryant also says : " When not very severe, and uncomplicated with other injuries, such cases usually do well. It [that is, rupture of the kidney] is generally known by an attack of heematuria and local pain following a blow on the lumbar region. The hsematuria may be but slight and passing, or not show itself until the second day. It may cease also after the lapse of two or three days, when it is probable that only a contusion of the kidney has taken place ; for, in more severe injuries, the bleeding may last fifteen days or even more. At times clots will be passed, assmning the shape of the ure- ter, and I have before me the notes of some half dozen cases in which these symptoms were present, and from which recovery took place. These clots, however, at times give rise to retention of urine by blocking up the urethra. Retraction of the testicle is an occasional symptom, and so is pain in the course of the ureter. This paragraph sums up so clearly and so tersely the symptoms, etc., of rupture of the kidney from contusions and strains, or wrenches, of the lumbar region, as they severally presented themselves in the examples related above, that I have quoted it in full. It should, however, he noted that in one of these examples (it was recorded by Professor Fayrer), although the hematuria did not appear until the second dav, and lasted only two days, the autopsy revealed a rupture at the upper end of the left kidney which extended into the hilus, instead of a renal con- tusion ; but it is probable that such a limitation of the haematuria is rather exceptional than otherwise, in cases where the rupture is so extensive. In the last two of the illustrative cases presented above, the urinary dis- charge was observed to consist of pure or nearly pure blood. isTevertheless, the loss of blood from hsematuria, when caused by contusions and sprains of the back, is rarely so great as, j^er se, to endanger life. Mr. Shaw, however, relates one case where there was good reason for alarm : — The patient was a young man. Although the sprain was not very severe, the renal hemorrhage was uninterrupted, and unusually profuse, during the first four days ; it nearly ceased for two days ; then it returned, and continued for two days, with its former profusion ; it now ceased for one day ; it appeared, however, on the next day, the tenth, in great quantity ; but then it ceased permanently. The patient, meanwhile, had become blanched and excessively weak.^ In this case, the large quantity of blood that was discharged from the r^n- nary oro;ans, together with the rapid appearance of the signs of acute anae- mia, clearly indicated the danger. So, likewise, in all those rather infrequent cases of h^ematuria where the prognosis is not favorable, the general symp- toms Avill sufficiently indicate the peril. The proofs of strong shock and great depression may present themselves. If the liver or spleen be also rup- tured extensively, there will, too, be unmistakable signs of mternal hemor- rhage. Besides, the torn viscus may exhibit considerable tenderness under pressure. . ^ ^ -, . -, ^ a Wounds of the cortical or secretory portion of the kidney are represented to be less dangerous than wounds of the tubular or excretory portion of the gland. (Agnew.) It is probable that this proposition is also applicable to the lesions of the kidney which are caused by contusions and sprains of the back. Treatinent. — Hsematuria, when very profuse, should be combated by admin- istering the fluid extract of ergot, in half-drachm doses, three or four times a I Practice of Surgery, p. 205, Am. ed. 1879. « Ibid., p. 432. 8 Loc. cit., p. 362. SPRAINS, TWISTS, AND WRENCHES OF THE BACK. 299 day, together with gallic acid, in ten-grain doses, at the same intervals. In some sthenic cases, however, it may be advisable to give, instead of these remedies, the acetate of lead, in styptic doses of two grains, every hour or two, until relief is obtained. But, generally, the emj^loyment of ergot and gallic acid should be preferred. Pain in the injured kidney and ureter, etc., is to be combated with opium or morphia ; but, at the same time, these narcotics must be exhibited with caution. Rest in bed should be enjoined, together with a milk diet. When coagula form in the bladder, and cannot be spontaneously passed by the urethra, causing retention of urine, they should be broken down by injecting w^arm w^ater through a large-sized catheter. The medico-legal relations of hjematuria from contusions and sprains of the back still remain to be considered. Mr. Shaw relates the case of a gentleman who claimed in a law court compensation from a railway company, for Bright's disease resulting from injuries received in a railway collision. The injuries consisted of a bruise over the right ilium and side of the loins. On the following day he observed blood mixed with his urine ; and, for four days, he continued to pass blood. At this time his urine was found to con- tain albumen, and it continued to be albuminous from the date of the acci- dent to that of the trial, a period of eleven months. The medical witnesses for the plaintiff held that the albuminuria, that is, the parenchymatous nephritis, had been caused by the injury of the right kidney that was inflicted in the collision. The medical witnesses for the defence (Mr. Shaw was one of them) " expressed a strong opinion that the plaintiff' was suffering from the disease when he met with the accident, and that the injury could not have brought it on."^ But, to say " that the injury could not have brought the disease on,'' in this case, is tantamount to asserting that a traumatic lesion of the kidney, which manifests itself by heematuria appearing on the day fol- lowing the accident and continuing for four days, cannot give rise to a struc- tural disease of the kidney of an inflammatory character. Such an assertion cannot reasonably be maintained ; for Professor Fayrer, in the case of the Hindoo, related above, who had h?ematuria beginning on the day follqw- ing the accident, and lasting only two days, and who died in consequence of ^ tetanus sixteen days after the injury, found at the autopsy that there w^as a rupture of the left kidney extending into the hilus, and that a great part of this kidney was softened, that is, had become the seat of a structural disease, and had undergone a structural change, such as is not unfrequently produced by the inflammatory process ; or, in other words, that the rupture of the kidney had been attended by traumatic nephritis. There is, therefore, no reason for doubting that, in at least occasional instances, the injury of the kid- ney w^hich causes h«ematuria, gives rise also to Bright's disease. In the case just mentioned, the jury, notw^ithstanding the medical testimony adduced by the defence, awarded heavy damages to the sufferer," and it may well be that the verdict was a righteous one. A legitimate inference from the foregoing, which has value for medico- legal uses, IS, that although some surgeons of large experience have never seen a case in which heematuria from contusions and sprains of the back was fol- lowed by nephritis or by organic disease of the kidney, nevertheless, such cases do sometimes occur ; and that, whenever they do occur, their existence ought to be recognized. It is also pretty certain that Bright's disease does not often arise from renal traumatism ; but, precisely how often, future expe- iience alone can determine. I Loc. cit., p. 363. 300 INJURIES OF THE BACK. Hemorrhage into the Vertebral Canal from Sprains, Violent Flex- ures, AND Twists, or Wrenches, of the Back. — This accident has no sur- o-ical importance, unless paraplegia more or less complete ensues. In the cases where it occurs, the chief proximate cause of disability and danger to life is the compression of the spinal cord, or of the spinal nerves before they issue from the intervertebral foramina, which the extravasated blood occasions. As in the cranium, so also in the vertebral column, the extravasated blood which compresses the nerve-tissue may be eftused iDetween the dura mater and the bone, that is, externally to the dura mater, on the one hand ; or in- ternally to that membrane, that is, betw^een it and the nerve-structures, on the other. We are, therefore, liable to meet with both extra-dural and intra- dural hemorrhages, of a perilous character, in the vertebral canal as well as in the cranial cavity. It has already been stated, in this article, that the ligamenta subflava are in direct relation with the meningo-rachidian veins, and that laceration or violent stretching of those ligaments w^ould pretty certainly be attended^ by rupture of these veins; also, that the posterior common ligament is in relation, by its anterior surface, with the vence basiim vertebrarum, and by its posterior surface, with the dura mater of the spinal cord, from which it is separated only by the plexus venosi spinales interni or longitudinal spinal sinuses, with some loose connective tissue containing fat, and that laceration of this liga- ment would be likely to be attended by rupture of these venous plexuses or sinuses, and, possibly, by rupture likewise of the dura mater of the spinal cord. Moreover, the laceration or violent stretching of these ligaments is liable to be attended by rupture of the arteries which, on entering the vertebral canal, come into relation with these ligaments as well as with the interverte- bral disks, namely, the rami spinales. The arteries which may be ruptured are numerous, the veins are not provided with any valves which could pre- vent re2:urgitant hemorrhage, and the dura mater is attached but very loosely to the inner surface of the vertebral canal. Thus, it appears, that when the vertebral ligaments are much torn by sprains, violent flexures, and twists,^ or wrenches of the vertebral column, there are many bloodvessels from which hemorrhage may occur if these vessels also be torn open, and that ample means are afforded by looseness of the connective tissue for the extravasated blood to accumulate, in great masses, between the dura mater of the spinal cord and the bone, as well as within the hollow cylinder or sheath which is formed by the dura mater itself. When, in such cases, the hemorrhage soon ceases, and the quantity of the extravasation is not large, it is probable that recovery will ensue ; for the effused blood will be more or less completely absorbed, and thus the spinal cord will be more or less completely freed from compression. But, when the hemorrhage continues unchecked, the paraplegia arising therefrom will increase, and it will gradually spread upward until the superior extremities, too, become paralyzed ; and finally, the functions of the phrenic nerves wall likewise be suspended, the diaphragm w^ill no longer contract, the respiratory movements wall entirely cease, and then death will of course immediately result, as happened in the following example which occurred in the practice of Dr. John J. Crane, of New York, and in w^hich I assisted at the autopsy:— Mr. S., an actor, aged about 50, sustained a violent injury in the root of his neck, shoulders, and back, from being thrown thereon while wresthng, on a Sunday after- noon. Being unable to arise without assistance, he was picked up and laid upon a bench by tliose around. Afterward he was put into a coach ; and, being held in a semi-recumbent position, he was carried to his home. Dr. Crane saw him, for the first time, about nine o'clock P. M. He was then unable to move his lower extremities, and exhibited all the symptoms of paralysis from spinal injury, so far as they were cou- SPRAINS, TWISTS, AND WRENCHES OF THE BACK. 301 cerned. His urine, however, was passed voluntarily, the bladder and abdominal muscles being unaffected. The upper extremities, also, were not paralyzed. On the following morning (Monday) it was found that the paralysis had reached a higher point, that there was retention of urine, and that catheterization was necessary. Afterward, the paraplegia continued steadily to advance, travelling up the trunk, involving the upper extremities, involving likewise all the res[)iratory muscles excepting the diaphragm, and, finally, attacking the origin of the phrenic nerves, when he imme- diately ceased to breathe. He died on Wednesday night, somewhat more than three days after the accident. His bowels were moved only once, and then by enema, on Tuesday morning. He complained of pain only in the lower part of the neck, and exhibited signs of severe suffering whenever his head was moved. There was tender- ness under pressure, and considerable swelling in the lower and back part of the cervical region. But no displacement or irregularity of the spinous processes, nor of any other parts of the vertebrae, could be detected. His mind was clear to the end. The autopsy revealed a very extensive effusion of blood within the theca vertebralis, which distended that membrane and compressed the spinal cord throughout almost the whole of its extent, namely, from the cauda equina up to the superior cervical region. The spinal cord itself was not wounded. The theca vertebralis was ruptured to the extent of about one-third of its circumference, in the lower part of the cervical region. The ligaments connecting the fifth, sixth, and seventh cervical vertebrae exhibited much laceration. A fissured fracture also passed longitudinally through the fifth, sixth, and seventh cervical vertebrae. There was not much displacement of bone, certainly not enough to press on the spinal cord in any way, and not enough to be cognizable by external examination. The blood found within the theca vertebralis was, for the most part, extravasated from the^ vessels of the cord — that is, from the arterise spinales, anterior and posterior ; but, no doubt, some blood from without had entered the cavity of the theca vertebralis through the ruptured aperture in that membrane, it was, however, evident that the paraplegia had slowly crept upward in this man's body, just as the effused blood accumulated in the thecal cavity, commencing in the lower end thereof ; and, that death had resulted from compression of the spinal cord, arising from this cause. In the very instructive case which has just been related, there was a longi- tudinal fissuring of the last three cervical vertebrae, as well as such a lacera- tion of the ligamentous tissue and neighboring bloodvessels as is often found in cases of sprains, from contusions and violent flexures of the vertebral column. Still, the case practically belongs to the same category as sprains and wrenches of the vertebral column, because several vertebral articulations did, in fact, sustain the lesions which characterize this form of injury, and examination during life did not and could not reveal any lesion of the verte- bral column, excepting the sprains of the vertebral joints. Moreover, if in this case there had been no intra-thecal hemorrhage, and no compression of the spinal cord, or had the effusion of blood been moderate, and had it been fol- lowed by absorption, the patient's recovery might easily have ensued ; and had his recovery so ensued, the fissures in the last three cervical vertebrse Avould never have been discovered, and the injury would have been considered as merely a sprain or wrench of the back. But, at all events, this example illustrates in an excellent manner the clinical historj^ that is, the symptoms which are likely to present themselves, in f^ital cases of compression of the spinal cord from the extravasation of blood within the spinal dura mater, where life is prolonged for three or four days. To illustrate compression of the spinal cord from hemorrhages which occur externally to the spinal dura mater, Mr. Shaw relates at much length the case of a woman, aged 60, admitted to the Middlesex Hospital under his care, in March, 1841, having been injured in the back by falling down a flight of steps shortly before : — 302 INJURIES OF THE BACK. No irregularity in the line of the spine could be perceived ; and, although she sat up for examination, there was no particular part of the back which seemed to be particu- larly weak. Both upper extremities and the right lower extremity were deprived of voluntary motion ; but sensation was nearly perfect, for she spoke only of a little numb- ness in them. Reflex movements could not be excited in the paralyzed upper extremi- ties, while they were particularly lively in the paralyzed lower extremity. The breathing was not disturbed. There was at first retention of urine ; and, for a few days, incon- tinence ; but soon afterward she regained the natural control over urination. The bowels acted regularly. During the first ten days no perceptible change took place ; but in the following fortnight a slow and gradual increase of power over the paralyzed limbs was observed ; after that, however, all progress seemed to cease. She was re- tained in the hospital for three months; but her subsequent history is not known. " That in this case," says Mr. Shaw, " the blood which escaped had been poured into the loose space intervening between the osseous walls of the canal and the theca spinalis seems most probable ; and, also, that the source of the blood was the venous sinuses which line the interior of the canal in the form of plexuses." He further says: As the paralysis was partial, three alone out of the four extremities being affected, and motor power being the only property lost, it may be inferred that, if blood extrava- sated external to the theca were the compressing agent, it had been collected in the canal in unequal quantities at different parts. Such an hypothesis would explain how one of the lower extremities escaped being deprived of its motor power."^ But, inasmuch as there was no autopsy in this case, the conclusion that intra-vertebral hemorrhage had occurred externally to the theca yertebralis must be held to be unproved, and as at least to that extent uncertain. Dr. Deville, in 1843, in examining the body of a man who had died in consequence of falling from a great height on to the pavement, found, on laying upon the spinal canal, a most extensive extravasation of blood, com- pletely filling up this canal in its whole length, and extending upward, even beyond the point where the spinal cord had been cut across, when the brain was taken out. 'No trace of injury whatever was detected in the cranial con- tents. This man, when admitted to hospital, was collapsed and perfectly insensible. There was no paralysis, nor muscular spasm. In this state he lay for some hours, and then died. Except the intra-vertebral hemorrhage, no cause of death could be found.^ Mr. Le G-ros Clark mentions a remarkable case of the same kind, which was narrated to him, but which he did not see: — A man was violently struck on the back by a chain-cable ; there were no immediate symptoms of spinal injury^, but a paraplegic condition soon supervened, extending rapidly upward and destroying life by asphyxia. The theca was found distended with fluid blood, derived from a ruptured spinal artery. He likewise mentions another case : A man was injured in a coUision in the tunnel, four or five miles from Brighton. He walked this distance with some difficulty into the town ; and, within twenty-four hours, became entirely paraplegic. He slowly recovered, so that, at the end of two years, he was able to walk as well as before the injury. One spot on the back was always tender ; and, at times, still continued so.^ The close resemblance which the symptoms that presented themselves in this case, bore to those that were observed in the preceding case, indicates that the pathological lesion was the same in both instances, namely, extrava- sation of blood within the spinal dura mater from ruptured spinal arteries, whereby the spinal cord was compressed. ^ The symptoms which result most frequently from this lesion are those of 1 Loc. oil., pp. 364-366. 2 Mem. de la Soc. de Chirurg. de Paris, t. iii. p. 180; also Holmes's System of Surgery, 2d ed., .vol. 11. p. 300. » British Medical Journal, October 3, 1868. DISLOCATIONS OF THE VERTEBRA. 303 paraplegia, coming on some little time after a violent contusion or sprain of the back, the paralysis appearing first in the legs, and extending upward with more or less rapidity, according to the nature of the case. At all events, these are the phenomena which were observed in both of the instances men- tioned by Le Gros Clark, as well as in that Avhich I have myself recorded. Treatment— Should the surgeon be able to make a differential diagnosis in a case where this accident has occurred, it may be advisable for him to pre- scribe the fluid extract of ergot in doses of thirty drops every four hours, or the acetate of lead in doses of two grains every hour or two, with a view to suppress the bleeding. In cases where the hemorrhage has ceased, it will generally be advisable to administer potassium iodide in doses of ten grains every eight hours in simple syrup, with a view to promote absorption of the effused blood. Quiet should be enjoined, and measures should be employed to prevent the occurrence of spinal meningitis and myelitis. 11. mJURIES OF THE VERTEBRAL COLUMK Dislocations of the Vertebra. The traumatic lesions to which the several pieces of the spinal column are exposed consist, (1) of pure dislocation, (2) of pure fracture, and (3) of disloca- tion combined with fracture. Experience has shown that, leaving gunshot wounds of the vertebrae out of the account, pure dislocation occurs quite as frequently as pure fracture, and that dislocation combined with fracture is met with much oftener than either of them ; and, perhaps, almost as fre- quently as both conjoined. For instance. Professor Porta found in 27 cases, pure dislocation in 7, dislocation complicated with fracture in 14, with 6 recoveries, so that there could not, by any possibility, have been more than 6 examples of pure fracture. Dissection was practised in 20 of the 21 fatal cases, that is, in all but one. The fracture complicating the dislocation was often so slight as not to be distinguishable until the autopsy revealed it. Again, Mr. Bryant found in 17 cases where the nature of the injury was verified by post-mortem examination at Guy's Hospital, during a period of five years while he was ofliciating as surgical registrar, that 6 were instances of pure dislocation, 3 of pure fracture, and 8 were examples of dislocation and fracture combined. Clear views on this subject are of practical importance, because pure dis- locations of the spinal column are, as a rule, more amenable to treatment than corresponding fractures with a like degree of displacement. In the latter cases, the spinal cord is apt to be scratched and torn by the sharp points and edges of the fracture-splinters and fragments, in addition to beino- compressed by the displacement of bone. The late Dr. D. S. Conant, of ]^ew York, reported a case of fracture of the twelfth dorsal and first lumbar ver- tebrae,* in which the patient lived six days, the spinal cord being divided by a splinter from the first lumbar vertebra, and not by displacement of the vertebra itself. It might well be that an apparently hopeless case of spinal dislocation could be saved by reducing the luxation, while a case of fracture involving the same part, with a similar amount of displacement of bone and paralysis of body, would not be saved by a like proceeding ; and that, too, ' American Medical Times, 1861, pp. 359, 360. 304 INJURIES OF THE BACK. because of the injury iiitiicted upon the cord by the splinters and fragments of broken bone. Moreover, in certain cases of cervical dislocation where the reduction proves to be difficult, although it is indispensable in order to save the patient from speedy death, the surgeon will be more likely to persevere until he accomplishes the reduction and thus frees the spinal cord from in- jurious compression, if his mind be clear in respect to the diagnosis, than he will if his opinion be unsettled. Many cases of this sort have already been recorded, some of which have been saved by a timely reduction of the dislo- cation, while others have perished from the lack of this proceeding ; and more cases of the same sort will hereafter be met with. The clearness of view and accuracy of diagnosis needful for their proper treatment, are nmch more likely to be attained by making a separate study of vertebral disloca- tions, than by considering them together with vertebral fractures — that is, than by discussing the traumatic lesions of the vertebrae, en masse, as practised by most writers and lecturers on surgery, at the present day, in England and America — and, therefore, I shall not follow their example. Until a recent date, yure dislocations of the vertebrae were held, by even the best informed surgeons, to be of very rare occurrence ; and some of equal eminence positively denied that dislocation of the body of a vertebra, unat- tended with fracture, ever occurred at all. Among the latter, Delpech was specially prominent. Abernethy likewise taught: "There can be no disloca- tion (of the vertebrae) surgically speaking — we do not take the word in its etymological sense ; in surgical language, a dislocation is a displacement of bone, with a laceration of ligament unaccompanied with fracture; for if there be a fracture, it is not a dislocation ; but, from their position, if one vertebra be knocked in, its articular surfaces must be broken " (South). Sir A. Cooper declared that he had never seen a pure dislocation of one vertebra upon another; but, at the same time, he admitted the possibility of its occurrence when he said : "If luxation of the spine ever does happen, it is an injury w^hich is extremely rare." In England, Mr. Lawrence was the first to dem- onstrate that vertebral dislocation, unattended by fracture, in reality did occur. He reported the following example : — A robust porter, aged 22, while " carrying a heavy barrel on the back of his head and neck, slipped on descending some steps, and fell on the buttocks, the burden resting on the head and upper part of the neck. He was immediately deprived of sensibility in the trunk and limbs, and of all power over the voluntary muscles of these parts. When brought to the hospital he was completely insensible, and incapable of voluntary motion below the neck." The respiratory movements were performed apparently by the dia- phragm alone. Priapism was noted. On the next day " there was pain in the lower part of the neck ; he could move the arms very slightly, and had a Httle feeling in the front and upper part of the chest." On the third day " he experienced a tingling sensation in the hands, and was sensible to impressions on the upper part of the arms and thighs." On the morning of the fifth day, very early, he died from asphyxia and exhaustion. Autopsy " No displacement or inequality could be discovered by external examina- tion, when the body was laid on the face. After cutting away the muscles from the back of the spine, the cartilaginous surfaces of the superior articular processes of the Iffth cervical vertebra came into view. They were exposed in consequence of the inferior processes of the fourth vertebra having been completely dislocated forwards, and re- maining fixed in their unnatural position. The yellow ligaments connecting the laminae of the two vertebrae [ligamenta subflava] were torn through, and the bifid apex of the fourth spinous process lay in close contact with the basis of the fifth. On the front of the column an unusual projection was observed, but the anterior longitudinal liga- mentous expansion [anterior common ligament] was entire. The body of the fourth was completely detached from that of the fifth vertebra, the coimecting fibro-cartilage being torn through, and the body of the former projecting by its whole depth in front of the DISLOCATIONS OF THE VERTEBRA. 305 latter. In consequence of this displacement, the antero-posterior diameter of the ver- tebral canal was lessened about one-third."^ The specimen was preserved, I believe, in the museum of St. Bartholo- mew's Hospital. In this case, then, there undoubtedly occurred " a displace- ment of bone with a laceration of ligament unaccompanied with fracture;" or, in other words, there Avas unquestionably a pure dislocation of the fourth cervical vertebra forward upon the tifth. The French surgeons had already ascertained that the atlas might be luxated on the axis without fracture; and that, occasionally, a luxation of the articular process on one side (unilateral dislocation) occurred among the last live cervical vertebrae.^ But these lesions were held to be of extremely rare occurrence ; and, as to luxation of the bodies of the vertebrae without fracture, the possibility of such an accident was scarcely admitted. On the latter point, Boyer says : " If we examine the facts upon which a belief of the possibility of their being luxated is founded, we shall find that the posterior laminae of the vertebrae are uniformly broken, often crushed, and reduced to splinters, and that, almost always, when the bod}^ of a vertebra is luxated, the separation of its ligaments tears off a piece of the bone itself Boyer has been blindly followed by most writers on spinal injuries since his day. (Ashhurst.) In 1865, however. Professor Porta's memoir on "Dislocations of the Ver- tebrae" was read before the Royal Lombard Institution of Science and Letters, and was summarized in Omodei's Annali Universali di Medicina, whereby the chief points made in it have become widely known. This memoir is founded on 27 cases — 13 in the cervical, 10 in the dorsal, and 4 in the lumbar region, case of luxation of the occiput on the atlas, nor of the atlas on the axis is included. There were only six recoveries. ^Tecro- scopy was practised in 20 out of the 21 fatal cases. Prof. Porta asserts that dislocations of the bodies of the vertebrae, which all authors (including Mor- gagni) have believed to be rare, are common enough, and met with every year in hospital practice. Experiments on the spinal column removed from the body, and denuded of its muscles, show that by vigorous torsion the intervertebral cartilage and ligaments can always be torn, and this dislocation be thus produced. He combats the opinion of Boyer that the dislocation is always accompanied by fracture, and mentions seven cases in which there was no such complication. Even Avhen fracture does accompany the luxation, the complexion of the accident is determined by the luxation and the extent of its displacement. As already stated, 14 cases were complicated with frac- ture — 5 in the cervical, 6 in the dorsal, and 3 in the lumbar region. He regards the concomitant fracture as a phenomenon secondary to the dislocation.''" In 1867, Mr. Bryant published some statistics of spinal injuries,^ in order to show ihsitpure dislocation of the vertebrae was less rare than was usually taught. During a period of five years, ending in 1858, while he officiated as surgical registrar at Guy's Hospital, 46 cases, of spinal injury were admitted ; "and, among the 46 cases, there were 24 examples of dislocation, or of fracture, or of both combined. In 10 of them, the dislocation, or the fracture, was in- the cervical region ; in 14, the injury was in the dorsal region. Moreover, the nature of the lesion was verified by a post-mortem examination, in 17 instances. Of these, 6 were pure dislocations, 3 were pure fractures, and 8 were examples of dislocation combined with fracture, as already stated. Of the pure disloca- 1 Medico-Chirurg. Trans., vol. xiii. part 2, pp. 394-397. 1827. 2 Boyer's Surgery, translated by Stevens, vol. ii. pp. 230-234. New York, 1816. s Ibid., p. 235. * New Syd. Soc. Retrospect, 1865-1866, pp. 281-283. ^ Lancet, April 6. VOL. IV. — 20 306 INJURIES OF THE BACK. tioiis, 5 occurred in the cervical and 1 in the dorsal region. The nature of the lesion was verified by a post-mortem examination in every one of the 10 cases in which a cervical vertebra was injured ; and thus, pure dislocation was found, beyond question, in one-half, or 50 per cservatioiis, Part ii., p. 145. DISLOCATIONS OF THE VERTEBRiE. 383 eWhth day convulsions occurred, and were followed by mania. On the eleventh day pa'J-alysis appeared, which afterward began to pass away. On the twentieth day death ensued. Dissection revealed diastasis of the seventh cervical from the first dorsal ver- tebra ; the intervertebral cartilage had disappeared from suppurative infiammation, and purulent matter had dropped to the bottom of the spinal sheatli (theca vertebralis). Outside of the injured vertebra a large abscess was found. In this case the vertebral lesion had given rise to a destructive inflammation of the intervertebral cartilage and the formation of much pus, together with a suppurative inflammation of the spinal meninges ; the latter condition, unless arrested by timely treatment, necessarily proves fatal. Charles BelP reports the case of a plasterer, aged 25, who fell forty feet, striking his back against a stone step. Depression between the spinous processes of the lower dorsal vertebrae was observed, but no paralysis. He had acute pain in the back. On the third day he was delirious, threw himself out of bed, etc. On the fifth day he had to be tied in bed, and, on the same day, he died. Dissection showed fracture of the body and spinous process of the eleventh dorsal vertebra ; the spinal cord was not com- pressed by the fracture ; but greenish pus was found between the cord and the theca vertebralis, and there was effusion on the brain. (Ashhurst.) From the vertebral frac- ture there evidently arose in this case traumatic cerebro-spinal meningitis, of a suppu- rative character, which caused death. It is not probable that this inflammation could have been successfully combated without the aid of local blood-letting by leeches or cups, and the continuous application of an ice-bag or an iced poultice, with opium and morphia in large doses, and potassium iodide, as well as absolute quietude of the injured and inflamed parts. Dupuytren^ mentions a case which, during life, was supposed to be concussion of the spinal cord only ; there was partial paralysis and sloughing ; but, in the end, death ensued. Dissection revealed fracture of the tenth dorsal vertebra; blood-clots and meningitis opposite the ninth, tenth, and eleventh dorsal vertebras. (Ashhurst.) Besides the spinal fracture and the spinal meningitis, the autopsy in this case revealed an eff'usion of blood between the cord and theca vertebralis. Such hemorrhages are fre- quent concomitants of the vertebral fractures and dislocations that occur in the dorsal and lumbar regions, as well as in those that occur in the cervical region. Dr. C. A. Lee» reports the case of a man, aged 48, injured by falling from a building across a plank. At first, he was stunned ; and, afterward, very restless. On the next day paralysis appeared ; and a projection in the middle of the back was noted. In five weeks death ensued. Dissection showed fracture of two dorsal vertebrae ; the spinal cord was softened ; and purulent matter was found in the vertebral canal. Here, too, spinal meningitis arose from fracture of the dorsal vertebrjE, and was attended by the formation of°pus. Obviously, such cases cannot be conducted to a successful issue, unless the occurrence of traumatic spinal meningitis in them be seasonably recognized, and the disorder itself combated by appropriate treatment. Many additional examples of spinal meningitis and myelitis arising from spinal dislocations and fractures might be cited from the records. But, enouo;h of them already have been presented to clearly show that, m every case of vertebral dislocation or fracture, where life continues, there exists a strong tendency for consecutive inflammation of the spinal membranes and cord to ensue ; that, not unfrequently, traumatic meningitis or myelitis is the proximate cause of death, in such cases; and that the surgeon should, m all such cases, employ remedial measures of known efficacy, from the outset, m order to prevent the traumatic irritation of the spinal membranes and cord from rising to the grade of inflammatory action. Symptoms and Prognosis. — When dislocation of the joints of a vertebra occurs in the dorsal or lumbar region, it is always attended by functional « Ibid., p. 138. ^^^^ 2 Diseases and Injuries of Bones. London, Sydenham Society, 1847. a American Journ. Med. Sciences, 0. S. vol. xvii. INJURIES OF THE BACK. disturbance and displacement of the bones which form the compound articu- lation ; and, generally, by ecch^miosis. Inasmuch as the vertebral joints are more superficial in the dorsal and lumbar regions than they are in the cer- vical, the displacement of bone is more easily recognized by sight and touch in the former regions than it is in the latter. The sj^mptoms by which luxa- tions of the dorsal and lumbar vertebrae may be known, are the deformity and the disturbances of function which arise from the displacement of the luxated bones, and the ecchymosis. The displacement is often denoted by a projec- tion backward of the lower vertebra. Sometimes a distinct gap can be felt between the dislocated vertebra and the bone next below it. Frequently their spinous processes are found to be separated by a considerable interval. Occasionally they are so widely separated that three fingers can be laid be- tAveen them. Oftentimes the patient has severe pain in the injured part of , the back, l^ot unfrequently the patient has also severe pain in parts far removed from the back, that is, in the parts where the spinal nerves that pass through the inter-vertebral notches at the place of injury, are distributed or have their terminal extremities. Should the spinal cord be much injured, there will be paralysis both sensory and motor (paraplegia) of all the parts supplied by spinal nerves that issue from the segment of the cord which lies below the lesion. Paralysis of the bladder will be denoted by retention or by incontinence of urine ; paralysis of the intestines by retention or by in- continence of feces, and by tympanites. The area of lost sensibility usually corresponds very closely to that of the motor paralysis, because the anterior and posterior roots of the spinal nerves emerge from the cord on the same level. The following example will serve to show how profound and durable the sensory paralysis, as well as the motor, may be : — Dr. W. D. Purple^ reports the case of a man, aged 22, injured from being struck by the limb of a tree. There was dislocation of the fifth and sixth dorsal vertebrse with permanent as well as complete paralysis, both sensory and motor, of the lower part of the body, or paraplegia. Six years afterward he had both thighs amputated high up, because the paralyzed limbs were useless appendages. He felt nothing whatever dur- ing the operation, although no anaesthetic was employed. Seven years after the injury he died from other causes ; no autopsy. But, in many cases of vertebral dislocation or fracture with injury of the cord, marked hypercBSthesia with intense pain is noted just above the paralyzed region. 2 The last-named symptoms, however, will be discussed in connection wUh the subject of Traumatic Myelitis, as it is the disorder from which they arise. Should the ganglionic nerves which lie along the spinal column, on each side thereof, and in close relation thereto, be much injured, especially in the cervical region, there may arise therefrom, as well as from injuries of the spinal cord, vaso-motor disturbances, denoted b}^ alterations of the pulse, by flushing of the face, and by a considerable increase or diminution of the body-heat. Paralysis of the vaso-motor nerves, thus induced, lessens the blood- pressure in the arteries, and modifies the character of the pulse accordingly. With each blood-wave, the condition of feeble pressure passes suddenly into a condition of forcible pressure at tl^e moment of the ventricular systole, and suddenly reverts to the former condition, for the blood flows too readily through the paralyzed capillaries from the arterial into the venous system. MM. Pousson and Lalesque found this forcible impulse or peculiar sensation of a strong pulse to be most marked in large arteries, e. g., the femoral and the abdominal aorta. The sphygmographic tracing presents, with pulse- 1 New York Journal of Med., 1853. 2 Med. News and Abstract, March, 1881, pp. 179, 180. DISLOCATIONS OF THE VERTEBR.^. 385 modifications of this kind, a very liigli and vertically ascending line, and a concave and prolonged descending line.^ . , . . . In regard to changes of the body-heat in consequence of spinal nijuries, 1 will briefiy mention'a few examples : — Dr. T. G. Mcrton^ found in a case wliere tlie fifth, sixth, and seventh cervical ver- tebrse were fractured, with paralysis, etc., that tlie temperature two hours after tlie acci- dent was 102° Fahr; in eleven days the patient died. Professor William Pepper^ relates a case in which there were fractures of the first and fourth cervical vertebrae, with anterior luxation of the latter, as well as compression of the si)inal cord, death ensuing 24^ hours after the injury ; the whole cutaneous surface was much warmer than normaf, and a thermometer in the axilla registered 108.5° Fahr. at the moment of death ; the cheeks were brightly flushed, and very hot ; but the pupils were about normal. Mr. Shaw* relates the case of a drayman, aged 35, injured by a bag of hops falling upon his head and shoulders, in which there were fracture of the fourth dorsal vertebra, paralysis, priapism, and a temperature of 103-100° Fahr. (Ashhurst.) Bro- die's case of spinal injury, in which the mercury rose to 111° Fahr., has already been mentioned. A number of cases are on record in which " calor mordicans" was noted. On the other hand. Dr. A. Nieden^ reports the case of a man, aged 60, injured by falling down fourteen or fifteen steps, in which there were temporary loss of conscious- ness, complete paralysis of lower extremities, bladder, and greater part of trunk, pro- gressive lowering of the temperature, and pulse of a remarkable character. He died on the eleventh day after the accident, with a temperature of 80.6° Fahr. He remained conscious until his temperature was 81° Fahr. and his pulse 30. T\\Q,autopsy showed luxation without fracture of the first dorsal vertebra, with compression of the spinal cord. A somewhat similar case was under the care of Mr. Hutchinson, at the London Hospital. There was complete paralysis as high as an inch above the nipples, with marked priapism ; temperature 98°. The next day the pulse was noted at 36 and small ; in the evening, the temperature in the rectum was only 95.8°, in the distended penis 93°. The patient's cheeks and lips were of very good color, remarkably so ; while to the touch they seemed as cold as those of a corpse. But he did not complain of feeling cold. The temperature sank to 95°, and, on the sixth day, he died. The temperature did not rise after death. The autopsy showed fracture of the fifth cervical vertebra, and severe injury of the cord.« Something like a "flushed face" appears to have been noted in this case, although the temperature was much below the normal. 1^0 clear explanation of cases such as this has yet been made. But par- alysis of the vaso-motor nerves may arise from lesions of the spinal cord, as well as from injuries of the ganglionic chain of nerves, or the great sympa- thetic. " Flushing of the face," in cases of spinal injury, is usually attended by lachrymation and contracted pupils, and is clearly due to vaso-motor paralysis. Mr. Erichsen says that he has seen unequivocal instances of continued low temperature of the body, taken in the mouth and axilla, in cases of spinal concussion— as low as 92° or 93° F., and continuing for many months from 2° to 3° F. below the normal.^ He also refers to Dr. I^ieden's case in which the first dorsal vertebra was dislocated, mentioned above. " More commonly the low temperature is confined to the extremities, especially the feet, which are sensibly colder than other parts of the body. Often the feet are as low as 80° to 85° F., and will remain so for very long periods of time."^ The -prognosis in cases where the dorsal or lumbar vertebrae are injured is usually much less unfavorable than it is in cases where the cervical vertebrae » Ibid., p. 181. 2 Proceedings of the Pathological Soc. of Philadelphia, vol. i. « American Journal Med. Sciences, April, 1867, pp. 437, 438. 4 Holmes's System of Surgery, vol. ii. ^ clin. Soc. Trans., vol. vi. 1873. 8 New Syd. Soc. Retrospect, 1873-4, pp. 351, 352. ' On Concussion of the Spine, etc., 1882, p. 65. * Ibid. 336 INJURIES OF THE BACK. have sustained similar lesions ; and, as a rule, the further the seat of injury is removed from the respiratory centres, the more favorable is the prognosis. In dorsal and lumbar dislocations and fractures, without intra-spinal hemorrhage, the chief sources of danger to life are the occurrence of spinal meningitis, of ascending myelitis, of trophic lesions such as sacral and gluteal eschars or bed-sores, and of vesical or renal inflammation. The appearance of either of these complications greatly increases the gravity of every case. There are some symptoms, however, which are especially bad prognostics. Among them may be mentioned persistent elevation or depression of the body-tem- perature, flushing of the face, great frequency or infrequency of the pulse, early appearing and rapidly spreading sacral or gluteal eschars or acute bed- sores, incontinence of urine and feces succeeding retention, enlargement of the paralyzed area in an upward direction and increase of the paralytic symptoms, especially when they are progressive, diaphragmatic breathing, and" dyspnoea. Incontinence of feces and urine succeeds retention in these cases, because the sphincter muscles have become paralyzed ; and this circum- stance denotes that the nerve centres upon which their action depends have become aftected. Progressive, upward extension and deepening of the para- lysis, generally indicate progressive, upw^ard disorganization of the cord. Diaphragmatic breathing coming on some days after the accident, is a most unfavorable symptom, and generally denotes that the compression or disor- ganization of the spinal cord has attained so high a point that the diaphragm alone of all the respiratory muscles remains unparalyzed. Dyspnoea occurring in this connection usually indicates that the aeration of the blood is quite imperfect, and that the induction of fatal coma in consequence thereof may be at hand. Priapism is generally a dangerous symptom, but not necessarily a fatal one ; for there are cases on record of recovery from spinal injury where this symptom had existed. The progressive diminution of paralysis, in these cases, is a most favorable symptom. The return of motor powxr is not unfrequently attended by in- voluntary contractions and twitchings of the muscles ; these symptoms, however, are not to be considered unfavorable at this stage, although they are supposed by Brodie, and probably with justice, to indicate compression or mechanical irritation of the spinal cord when they attend an earlier stage. Treatment — In no case of dislocation of the dorsal or lumbar vertebrfe, however clear the symptoms of the dislocation may be, can it be asserted with absolute certainty during life that no fracture is present. While pure dislo- cations of these vertebrse are quite rare, dislocations combined with fracture are quite common in the dorsal and lumbar regions ; but the treatment of both forms of injury should be conducted on substantially the same plan. The want of a strictly exact diagnosis in this regard is, therefore, not as essen- tial to the therapeusis of dorsal and lumbar dislocations as it is in those of the cervical region. The condition of the injured parts in dorsal and lumbar dislocations, as w^ell as in cervical, is usually as follows: The muscular and connective tissue around the displacement is extensively lacerated and infiltrated w^ith blood ; the intervertebral disk or ligament is torn through at the seat of displacement, so as to allow the body of the upper vertebra to be thrown forward from that of the lower ; the anterior and posterior common ligaments are much stretched and extensively detached ; the ligamenta subflava and the capsular ligaments are lacerated ; the laminae, or certain of the vertebral processes, are fractured ; the theca vertebralis is stained with blood, bruised, stretched, and perhaps somewhat torn; the spinal canal contains more or less blood; while the spinal cord is ecchymosed and abruptly bent, and sometimes presents a compressed DISLOCATIONS OF THE VEKTEBR.?:. 337 appearance, or is even divided completely, at a point corresponding to the displacement of the vertebrae. The victim of this accident should be taken up from the place where he has fallen, and removed to hospital or home with great care to avoid in- creasing the displacement of the luxated bone and the injury of the S})inal cord, as already described for cases of cervical dislocation. The patient should be placed in bed ; and then, for reasons ah-eady stated under the head of treatment of cervical dislocations, which, however, are equally applicable in cases of dorsal or lumbar dislocation, the replacement of the luxated bone into its normal position should be attempted. But before proceeding furtlier with the discussion, I will briefly describe the various methods which have been successfully employed, in practice, for accomplishing this result in the dorsal and lumbar regions ; and, probably, I cannot do it in a better way than by presenting abstracts of the cases themselves. Malgaigne^ mentions a case of Melcliiori's, in which a carter was injured in tlie dor- sal region by a wheel running against him. There was backward dislocation of the eighth dorsal vertebra, and paralysis. Reduction was effected by position in bed. Recovery ensued in six months. Slight deformity, however, remained. (Ashhurst.) When it is found that, by placing the patient upon his back in bed, the displaced vertebra is restored to its normal position, with the aid, perliaps, of moderate exten- sion and some pressure laterally applied, a good hair mattress or a water-bed (the latter is much preferable) should be arranged for his reception, and he must be kept lying upon it, as nearly immovable as possible, until firm union has taken place. Rudiger' is credited with the case of a musketeer, who was struck on the back by a falling wall, and sustained dislocation backward and to the right side of the twelfth dorsal vertebra. Reduction was effected by position (on the belly) in bed ; extension and pressure were continued for fifteen days. In six weeks recovery ensued. (Ash- hurst.) This case shows that the surgeon, by consulting his ingenuity, may some- times, perhaps not unfrequently, make the patient's posture in bed materially assist in reducing a vertebral dislocation of the back or loins, when the dorsal decubitus utterly fails to do it. Moreover, while the patient lies with the back uppermost, a free oppor- tunity is afforded for the efficient application of local treatment, to prevent the develop- ment of consecutive spinal meningitis and myelitis. Parker* mentions the case of a man who was struck on the back by a falling door, and sustained dislocation of the last dorsal on the first lumbar vertebra, with slio-ht fracture. There were paralysis, priapism, etc. Reduction was accomplished, with an audible sound, by making extension and counter-extension, under chloroform. After several months the patient recovered, and, when discharged, could walk with a cane. (Ashhurst.) It is important to note that, notwithstanding there was priapism in this case, recovery ensued. The dislocation was reduced by making extension and counter-extension, under chloroform. I think the best plan for the surgeon to pursue, on failing to reduce such a dislocation by the patient's position in bed, would generally be to relax the muscles completely by anjesthesia, and, then, to effect the reduction by means of extension and counter-extension steadily made by his assistants, with lateral pressure locally applied by himself. Brodie* refers to the case of a man, injured by a mass of chalk falling upon him. The first lumbar vertebra projected backward over the last dorsal. The dislocation was reduced with some difficulty by Mr. Hardwicke. The reduction was attended by a *' jerk or snap." The patient was relieved ; but, after two or three years, partial paral- ysis still remained. (Ashhurst.) No doubt, in this case likew'ise, the reduction was accomplished by making extension and counter-extension. Smith^ mentions a case of Schmucker's, in which a soldier was injured by a wall falling on his back. He w^as stunned ; there was displacement backward of the last * Traite des Fract. et des Luxat., t. ii. 2 Desault, Jouni. de Chir., t. iii. ' New York Journal of Med., 1852. * Med. -Chir. Trans., vol. x^c. p. 157. 6 New York Journal of Med., 1852. VOL. IV. — 22 338 INJURIES OF THE BACK. dorsal and first lumbar vertebrae, and dyspnoea. The displacement was reduced by extension and pressure. In six weeks the man recovered. (Ashhurst.) Crowfoot reports^ the case of a coachman, aged 42, who in driving under an arch struck the back of his neck against a beam. There was displacement forward of the ninth dorsal vertebra, and of the tenth, backward, with paralysis. He was treated by continuous extension with success, and resumed his occupation in one year; slight deformity, however, remained. (Ashhurst.) After reduction, should the displacement reappear, and particularly if the dislocated bone should manifest a disposition to slip out of place again, it will be advisable to make the extension continuous, which may be done in several different w^ays ; but, probably, with the least amount of trouble, by raising the head of the bedstead upon blocks so as to make of the bed itself an inclined plane sloping downward to the foot, when, by attaching with a suitable band the upper part of the patient's body to the head of the bedstead, the desired result would-be obtained. Continuous extension might also be advantageously employed in cases where attempts at immediate reduction had failed, with a reasonable hope that, under its influence aided by the patient's posture in bed, the luxated bone would be induced to slip into place again. -, n i To sum up this branch of the treatment— the surgeon should seek to restore the displaced vertebra to its normal position by some one of, or, should the occasion require, by all the means of effecting reduction which have just been pointed out, that is, by arrano;ing the patient's posture in bed, upon the back or upon the belly, according to the case ; by making extension and counter- extension, under anaesthetics, with the help of skilled assistants ; or by making continuous extension, which the surgeon can generally accomplish without skilled help. Having fulfilled the first therapeutical indication, the surgeon must at once take care that the paralyzed bladder does not become over-filled with urine ; for, should this occur, much harm would ensue. To this end, catheterization must be cautiously practised at least twice a day, with a soft instrument ; and, at each time, the surgeon should cautiously compress the paralyzed blad- der with his own hand, applied to the abdominal walls of the patient, m order to secure a complete evacuation of the viscus ; for any urine that might be allowed to remain in it would, by undergoing decomposition, cause unneces- sary mischief. Vesical and even renal inflammation may readily ensue in these cases. But this subject will be found to be more fully discussed under the head of Disorders of the Urinary Organs arising from Lesions of the Spinal Cord. . The surgeon must also take care that the patient is provided with such a bed as will least favor the occurrence of bed-sores ; the best is a water-bed, the next best a good hair mattress. The surgeon must at every visit examine the private parts and buttocks of the patient, in order to see, for himself, that they are kept dry and clean, and are not inflamed, and that no gangrenous bleb nor eschar is forming. Motions of the bowels, when needed, should be procured by enemata rather than by purgatives. Immediately after a motion, the parts should be completely freed from feces by carefully wiping them, and then they should be cleansed by applying a spirit-lotion containing two per cent, of carbolic acid. This topic, however, will be more fully discussed under the head of Sacral Eschars and Acute Bed-Sores arising from Lesions of the Spinal Cord. i i, • The occurrence of consecutive meningitis and myelitis must also be obvi- ated aft much as possible. I have already shown by a brief mention of seven 1 Trans. Prov. Med. and Surg. Assoc., 1853. DISLOCATIONS OF THE VERTEBRA. 339 examples, and by a reference to many others, that there exists, in every case of spinal dislocation or fracture, a more or less strong tendency for consecutive inflammation of the spinal membranes or spinal cord to ensue, and that in such cases the consecutive inflammation of the spinal membranes or spinal cord, by itself, not unfrequently causes death. Moreover, I shall presently show that consecutive inflammations of the spinal membranes and spinal cord, of this sort, always much increase the severity of the urinary symp- toms and of the bed-sores which are met with in cases of vertebral dislocation and vertebral fracture, and that the prevention of these inflammations must be ranked among the most efiicient means at our disposal for controlling these mihappy complications of spinal injury. Thus, one is enabled to perceive how important the fulfilment of the last-mentioned therapeutical indication really is. Xow, this indication is to be accomplished, that is, inflammation of the bruised and torn spinal meninges and spinal cord is to be obviated or con- trolled :^ (1) by reducing the vertebral displacement, as already directed ; (2) by keeping the spinal column in a state of perfect rest, or as nearly immovable as possible, after the reduction has been efi:ected ; (3) should the patient's pos- ture in bed permit, by drawing blood from the injured part by leeches or cups, and by applying dry cold, by means of an ice-bag, with compresses interposed, and, subsequently, by the employment of counter-irritants. But, whatever the patient's posture in bed, opium or morphia should be administered with suflicient freedom to allay pain and procure sleep, as already stated ; and by keeping the patient somewhat under the influence of this drug until nature has repaired the breaches, much good can be done in the way of controlling any inflammatory action which may arise in the injured meninges; and, probably, in the spinal cord also. Potassium iodide, in doses of five grains every four hours, belladonna in full doses, and fluid extract of ergot, half a fluidrachm three times a day, will often prove to be very useful remedies for . traumatic myelitis, as well as for traumatic spinal meningitis. But, in attempting to reduce dislocations of the dorsal and lumbar verte- br8e, is there not considerable danger that the spinal cord may be injured by the eflibrts of the surgeon himself? Many a person, doubtless, will be inclined to answer this question aflirmatively, without much reason or reflection. Experience, however, has shown that this danger is more hypothetical than real. For example, reduction was effected in fourteen cases of displacement from injury of the dorsal or lumbar vertebrae, Avhich are mentioned in Dr. Ashhurst's tables. In eleven instances the displacement occurred in the dorsal region ; in three in the lumbar. Seven patients recovered, two were relieved, and five died. Of the cases in which the issue was successful I will not fur- ther speak ; but the fatal ones I will briefly relate : — (1) Higginson^ is credited with the case of a man, aged 34, injured in the spine so that there was projection of the lumbar vertebrae one inch beyond the dorsaL Reduc- tion was accomplished by making extension, under chloroform, with relief to the symp- toms. In four weeks, however, he died ; no account is given of the autopsy. (Ash- hurst.) (2) Bryant^ mentions the case of a laborer under Mr. Ccck's care, aged 34, who fell from a scaffold across a wall. There were pain, paralysis, priapism, and delbrmity in the lower part of the spine. The last was removed by making extension and pres- sure. At the end of eight months deatli occurred. The autopsy showed dislocation for- ward of the eleventh dorsal vertebra and fracture of the twelfth; the cause of death is not stated. (Ashhurst.) (3) Holmes^ relates the case of a young man, aged 19, struck on the loins by faUing timber. The last dorsal vertebra was dfslocated. °It was reduced by extension, and the reduction was attended by an audible sound. No relief J British Medical Journal, 1862. ^ Ibid., vol. 2. 2 Proc. Path. Soc. London, vol. viii. 340 INJURIES OF THE BACK. ensued. Death occurred twenty-three days after the accident. The autopsy showed dis- location witli slight fracture of the twelfth dorsal vertebra, fracture of the first lumbar vertebra, and secondary deposits in both knee-joints. (Ashhurst.) (4) Luke^ refers to the case of a man having fracture of the seventh dorsal vertebra, with displacement, which was reduced by extension, the reduction being accompanied by an audible sound. Death from erysipelas occurred seven days after the injury. The spinal cord was found to be softened and disorganized ; there was purulent matter. (Ashhurst.) (5) Birkett^ relates the case of a man, aged 31, who fell into the hold of a ship, striking his back, and dislocating the lower part of the spinal column. The fascia was torn off from several dorsal spines, and there was paralysis, etc. Extension under chlo- roform gave no relief; it was followed by great pain. At the end of four and a half months death ensued. The autopsy showed displacement of the eleventh from the twelfth dorsal vertebra, with fracture of the articular processes ; spinal cord disorganized ; sup- puration of the kidneys. (Ashhurst.) In but one of these five, cases can it be asserted with any plausibility that the efforts at reduction were themselves attended by any misadventure what- ever. In the last case, the employment of extension did not relieve the symp- toms, and was followed by severe pain. Still death did not occur until four and a half months afterward; and, whether the advent of the pain was merely a coincidence, or not, it is certain that the use of extension was not, per se, attended by any destructive lesion. In the other four examples, death was caused by erysipelas, by septicaemia, and, probably, by myelitis. Moreover, three cases of vertebral fracture with considerable displacement are related by Professor Konig, of Gottingen, in the Centralblatt fiir Chirur- gie, No. 7, 1880, in each of which the deformity was corrected by suspending the patient, without any bad effect ; and, in No. 46 of the same journal, we find a paper by Dr. W. Wagner that tells of two similar cases. All five patients recovered.^ . . , . Thus, we perceive, that the experience recorded on this point is already rather voluminous, and that it decidedly favors the employment of judicious and intelligently directed efforts to reduce the displacements in cases of dorsal and lumbar dislocations and fractures, as well as in those of the cervical region. Fractures of the Vertebra. Men suffer from traumatic lesions of the vertebrae, from fractures as well as from dislocations of these bones, much more frequently than women, because the former, by their occupations, are much more exposed to the various acci- dents in life which cause these lesions, than the latter. Fractures of the vertebra may be, (1) simple, (2) compound, (3) comminuted, and (4) complicated. By a pure fracture is meant a simple fracture, which is not complicated with a dislocation. Compound fractures of the vertebrae are chiefly caused by the impact of gunshot missiles. Gunshot fractures ot the vertebrae are of frequent occurrence. They constitute a special class of inju- ries, and will be separately considered. All forms of spinal fracture are frequently, but not necessarily, complicated with injury of the spinal cord, as well as with dislocation. i . i An inspection of the recorded cases of spinal injury involving the vertebrae and not caused by gunshot missiles, that is, of the recorded cases which occur in civil life, shows that the lesions consist of pure fractures in about one-fifth of the instances, of pure dislocations in another one-fifth, and of dislocations combined with fractures in the remaining three-fifths. 1 Lancet, 1850. ^ British Medical Journal, 1859. 3 Medical News and Abstract, 1881, p. 105. FRACTURES OF THE VERTEBRA. 341 Pure fractures of the vertebrEe are of rather infrequent occurrence in the cervical region. Of 36 cases observed at Guy's Hospital, and mentioned by Mr. Bryant, in which the cervical vertebrae were injured, there ^^'as no ex- ample of pure fracture, while there were 11 examples of pure dislocation, and 25 examples of fracture combined with dislocation. Still, pure frac- tures of the cervical vertebrje are sometimes met with. ' I have already presented one instance, and shall mention several others. But it is in the dorsal and lumbar regions that most cases of pure fracture of the vertebrae are found, the very regions in which pure dislocations of the vertebrae least frequently occur. However, pure fractures fall much short of the ma- jority in even these regions ; for, of 18 cases in which the dorsal, and 2 cases in which the lumbar vertebrae were injured, that were observed at Guy's Hospital, and are mentioned by Mr. Bryant, nearly tw^o-thirds appear to have been examples of fracture and dislocation combined. In the 25 cases of cervical fracture combined with dislocation that were noted at Guy's Hospital, the lesion was below the third cervical vertebra in all but three examples. In one of these, it involved the second, third, and fourth cervical vertebrae ; in another, the arch of the atlas and the spinous processes of the second and third vertebrae ; and, in the third case, the bodies and laminae of the third, fourth, and lifth cervical vertebrae. In the 18 dorsal cases, of all sorts, seven were in the upper and eleven in the lower half of the dorsal region. Thus, it seems clear that the lower parts of both the cervical and the dorsal regions are much more liable to fracture and dislocation than the upper parts. The following case w^ill serve to illustrate the most common form of frac- ture combined w^ith dislocation, which is met with in the cervical region: — On the morning of November 10, 1852, an unknown man, but poorly clad, was found lying dead on the cellar-bottom of an unfinished house at the corner of Franklin Street and Broadway, where it seems that he had fallen from the street, some time during the previous night. Autopsy, by the writer, at the Sixth Ward Station House, at 11 A. M., for the coroner. — Rigor mortis strong. Head and neck bent far forward. Spinous processes of the sixth and seventh cervical vertebrae movable. On exposing them by a free incision, the muscular and connective tissue around the sixth and fieveuth cervical vertebrae was found extensively infiltrated with blood. The spinous process of the seventh cervical (vertebra prominens) was broken short off. The laminae of the sixth cervical vertebra w^ere fractured at a little distance from the spinous process of that vertebra, which accounts for the mobility of this s[)inous process also. The body of the sixth cervical vertebra was luxated forward from that of the seventh. The intervertebral substance, the anterior and posterior common ligaments, the capsular ligaments, and the ligamenta subflava were all torn tlu'ough. The spinal cord was crushed by the displacement, and the theca vertebralis contained much blood. Externally, the tlieca was coated with blood. The fractures of the laminae of the sixth, and of the spinous process of the seventh ver- tebra, were doubtless caused by striking the back part of the neck, at its root, upon the hard cellar-bottom ; the laceration of the ligaments, and tlie displacement forward of the body of the sixth vertebra from that of the seventh, doubtless resulted from the extreme degree of flexion to wiiich the spinal column was simultaneously subjected at the root of the neck. Death quickly ensued, because of the cerebral concussion which attended the fall, and because of the shock which arose from the crushing of the spinal cord; but prin- cipally because of the extravasation of blood within the theca vertebralis, which speedily paralyzed the cord, by compressing it, as high as the roots of the phrenic nerves above the third vertebra, and thus completely arrested the respiratory movements. This case is offered as an illustration, because, in most cases of fracture combined with dislocation that are observed in the cervical region, the laminae, or the spinous or transverse processes, are fractured, the ligamenta 342 INJURIES OF THE BACK. subflava, the capsular ligaments, and the intervertebral disk are lacerated (more or less), and the body of the upper vertebra is thrown forward from that of the lower. In the following example death suddenly resulted from falling upon the back in such a way as to crush three dorsal vertebrae, together with the spinal cord : — Peter Riley, a laborer, fell from the walls of Trinity Chapel, then being built, on Saturday, November 27, 1852. He went down perpendicularly a distance of about fifty feet, and struck his back squarely across a beam. When picked up by his com- rades immediately afterward, he spoke tenderly of his mother and sisters, and said " my back is broke." He died in about twenty minutes. At the autopsy I found the fourth, fifth, and sixth dorsal vertebrae much comminuted, that is, broken into many fragments. The muscles covering them were badly bruised and torn, and contained much extravasated blood. The skin, however, was not broken. An incision through the skin having been made, the soft parts investing these vertebrae were found so much disintegrated that, after picking out some fragments of broken bone, I thrust my fingers with ease directly through the spinal column into the right pleural cavity. The theca vertebralis and the spinal cord must also have been torn asunder. The speediness with which death followed the injury in this case was due to shock, caused by the extent and severity of the spinal lesion itself, and to internal hemorrhage from the intercostal arteries that were torn, and, per- haps, from other sources. Professor Ashhurst^ mentions a case taken from the Pennsylvania Hospital Eecords, which is somewhat similar to the last : — A laborer fell from the sixth story, and thereby sustained a comminuted fracture of the lumbar vertebras, fracture of the coccyx, and fractures of both legs. Death ensued in one day from exhaustion and internal (post-peritoneal) hemorrhage. But comminuted fractures of the dorsal or lumbar vertebrae may be attended by rupture of the aorta, and death from internal hemorrhage may follow in the course of a few^ minutes. Several examples of this sort are on record : — (1) Forster^ mentions a case of Roper's, in which a man, aged 55, was knocked down and driven against by an omnibus. He was stunned, and in five minutes he died. Fracture of the fourth lumbar vertebra and laceration of the aorta were found. (2) Curling^ mentions the case of a rigger, aged 54, who fell from masthead to deck, and died in fifteen minutes. The autopsy showed fractures at the first, second, and third lumbar vertebrse, with rupture of the aorta. (3) Curling* also reports the case of a wagoner, aged 46, supposed to have been run over by a wagon. He died in a few minutes. The autopsy showed fractures of the eighth, ninth, and tenth dorsal vertebrae ; the aorta was ruptured. In such instances, however, the nature of the accident can often be correctly surmised from the seat of the fracture and the grating of the frag- ments, together with the sudden appearance of the signs of internal hemorrhage, such as a wax-tike pallor of the countenance; lips bloodless, or dark-purple at their margins; cold sweats ; weak, frequent, small, fluttering pulse ; syncope, etc., ending quickly in death ; but without any external flow of the extravasated blood. Comminuted fractures of the dorsal or lumbar vertebrae are sometimes found to be compound, in consequence of the integuments and muscles being lacerated by the same exhibition of force which has caused the fractures them- selves. Such fractures, probably, result most frequently from being crushed in railway collisions. " Brief mention is made in the reports of some instances of compound fracture of the spine from railway accidents."^ ^o details, however, of these instances are published ; but, such cases must 1 Op. cit., pp. 116, 117. 2 proc. Path. Soc. London, vol. viii. 3 London Hosp. Reports, vol. i. ^ Ibid. 6 Circular No. 3, S. G. 0., Aug. 17, 1871, p. 129. FRACTURES OF THE VERTEBRiE. 343 almost inevitably prove fatal, and all that the surgeon can do for them is to mitigate suffering by administerining opiates and stimulants. The following example will serve to illustrate one dangerous sequel which sometimes, perhaps often, presents itself in cases of simple vertebral fracture, namely, traumatic myelitis : — Private John Hackey, Co. E, 6th Cavalry, aged 30, received, at Fort Waco, Texas, March 5, 1870, by falling from the second floor of a building occupied as barracks, a fracture of the fourth cervical vertebra. Complete paralysis, both sensory and motor, of the lower extremities, and of most of the trunk and upper extremities, immediately ensued. He was admitted to hospital without delay. But, on the morning of the 7th, he died of acute myehtis, about forty-eight hours after the accident. His intelligence remained unimpaired throughout. The treatment was sedative and stimulant.^ The paraplegia which immediately ensued, in this case, appears to have been due to concussion of the spinal cord, for no mention is made of com- pression of the cord from displacement of bone nor from any other cause. The symptoms of concussion ran quickly into the symptoms of acute inflam- mation of the spinal cord, and death soon ensued. In the following instructive case, there occurred simple fracture of the fifth cervical vertebra,"without displacement of the fragments, and compression of the spinal cord from extravasation of blood at and around the seat of frac- ture : — Private Emmet J., Co. A, 5th Infantry, aojed 19, in diving from the bank of the Arkansas River, near Fort Lyon, Colorado, July 3, 1868, for the purpose of bathing, struck his head against the bottom, and immediately became powerless in the legs and arms. He would have drowned had Fig. 860. no help been given. He was carried on a stretcher to the hos- pital, lying on his abdomen. Upon admission, at 1 P. M., the pulse, respiration, and temperature (although not counted) seemed normal; the pupils were unaffected; there was priap- ism. Power soon returned to his arms, although it was feeble. His extremities remained warm ; and, when touched, sensa- tion was found more acute, that is, less blunted, in the left than in the right leg. He complained of feeling dead below the neck. ^ No irregularity or distortion of the spine was revealed by a careful examination ; but, there was tenderness over the fifth cervical vertebra. A sinapism was applied to the nape of his neck ; and, in an hour, he asked to be turned over, that is, on to the back. At 5 P. M. the pulse was 104 ; respiration 18; temperature 105°. Ice was applied to the upper part of the spine, a saline aperient was prescribed, and small pieces of g^owin^ fracture, ^vithout ice given to be held in the mouth. At 9 P. M. the pulse was 100 ; displacement, of the body of respiration 24 ; temperature 102'^ ; he was catheterized, and the fifth cervical vertebra, placed on a water-bed. On the morning of the 4tli, the pulse, (Spec. 5724, Sect, i, a. m. m.) respiration, and temperature were all lessened. Cold applica- tions to the spine were continued in the form of iced water, and the catheter was used twice during the day. At 5 P. M. the bowels were moved involuntarily. On the 5th, the temperature sank considerably below the normal (Fig. 861); sensation in the lower extremities was abolished ; and the respiration was abdominal, that is, diaphragmatic. Dry rubbings were prescribed, with tonics, and nutritious food. On the 6th, sensation had partly returned to the left leg, and the breathing was better, there being more movement of the chest. By the 11th, the patient was able to pass his urine without a catheter, but sensibility did not return to the right leg. On the morning of the 13th, he had a chill, which recurred on the morning of the 14th, and again in the afternoon. After this, his countenance became dusky, and the temperature rose during the next 1 Circular No. 3, S. G. 0., Aug. 17, 18"1, p. 129. 344 INJURIES OF THE BACK. three or four days. He had not perspired since the injury. On the morning of the 18th, the urine became turbid, the stomach was irritable, and he complained of his lungs feeling like stone. By the morning of the 20th, the pulse had become so feeble that it could not be counted, the bowels were loose, the urine was ammoniacal and Fig. Thermograph of a fatal case of fracture, without displacement, of the fifth cervical vertebra. thick with mucus, and vomiting occurred. Increased respiration and a very high temperature (105°) followed. On the 21st, catheterization had again to be employed, but the instrument was used with difficulty, owing to the formation of coagula in the bladder. He also suffered from bed-sores. By the 24th, his stomach became so irritable as to retain scarcely anything. On the 25th, there was complete anorexia. On the 26th, the temperature was 91.8°. He died at noon on the 28th. Autopsy. Brain normal. The body of the fifth cervical vertebra was found fractured (Fig. 860). There was no displacement of the vertebra. It was ascertained that hemorrhage had compressed the spinal cord at and around the seat of fracture. In the dorsal reo-ion, the spinal canal showed no abnormity, excepting the spinal fluid which escaped. It was filled with transparent, floating globules, and resembled volatile-oil water. Lungs healthy, excepting the posterior portions, which were hypostatically congested ; liver slightly enlarged. Splenic extremity of stomach congested. The kidneys were enlarged and engorged with blood ; the pelvis of the left was filled with pus ; but no other abscess could be found. Tiie ureters were very dark m color, and one of them contained a clot at the entrance to the bladder. The walls of the bladder were dark-purple in color, inflamed, and thickened ; its mucous membrane was absent in patches. The pathological specimens were sent to the Army Medical Museum.^ Viewing the clinical history of this case in the light thrown upon it from the autopsy, the paralysis which instantly followed the injury appears to have been due to concussion of the spinal cord, and it may well be that injuries ot a similar character, involving the upper part of the spinal column, axe often attended by spinal concussion. However, the paralytic symptoms that were I Circular No. 3, S. G. 0., August 17, 1871, pp. 129-131. FRACTURES OF THE VERTEBRi?:. ^^^^ due to concussion soon began to pass away, and on the follownig day were succeeded by the symptoms of compression of the spinal cord, caused by hemorrhage into the spinal canal, which increased in severity until sensibdity as well as motor power was abolished in the lower part of the body, the res- piration becoming diaphragmatic from paralysis of the other respiratory muscles, and the patient's temperature sinking to 95.8° on the mornnig ot the second day. Then, the hemorrhage having ceased, the absorption ot the extravasated blood was immediately commenced, and it was continued with so much activity that on the following day, July 6, sensation had ijartly returned to the left leg, and the respiration was better, for all of the chest- muscles again participated in the respiratory movements. By the 11th, he was so much improved that his micturition was entirely voluntary. But the sensibility did not return to his right leg, and this circumstance showed that the conducting filaments of the spinal cord itself were considerably injured, probably by contusion and ecchymosis of the cord-substance. On the 13th, or two days later, consecutive spinal meningitis and myelitis began with a chill, after which the patient's temperature rose considerably above the nor- mal,'and his countenance became dusky from vaso-motor paralysis. By the 20th, the inflammatorv lesion of the spinal cord and membranes was attended by trophic lesions of the urinary bladder and kidneys, and of the soft parts over the sacrum and buttocks, which will hereafter be described under the head of Acute Bed-sores, and of Disorders of the Urinary Organs from Le- sions of the Spinal Cord. The blood found in the bladder on the 21st had probably flowed into that ora;an through the ureters from the kidneys. The patient's stomach soon gave out entirely, and in a few days more he sank ex- hausted from vesical and renal inflammation, and from acute bed-sores. The thernio2:raph of this case (Fig. 861) shows at a glance three remarkable periods of depression in the temperature, the first of which corresponded to the compression of the spinal cord by extravasated blood (July 3 and 4) ; the second, to the invasion of the spinal cord and spinal meninges by consecutive inflammation (July 12, 13, 14); and the third, to the occurrence of exhaus- tion as the end drew near. After the first and second periods of depression, the temperature rose considerably. ^ -i g -o By what symptoms externally perceptible was this fracture attended i By one only, to wit— by tenderness under pressure over the fifth cervical ver- tebra. In the absence, however, of distortion or deformity, or other evidence of luxation, the presence of fracture should be suspected in cases such as this. But the occurrence of spinal paralysis under such circumstances should not,2jer se, cause a fracture of the vertebrse to be surmised, since the paralysis might just as well result from concussion or contusion of the spinal cord, as it did in fact at the outset of this case. The spinal column was suddenly bent until it broke at the fifth cervical vertebra, but the fragments instantly sprang back into place again. At the same moment, the spinal cord was bent, stretched, and bruised ; the spinal arteries were ruptured, hemorrhage there- from ensued, and thus the symptoms of compression readily succeeded the symptoms of concussion of the spinal cord. Besides these dano:ers, that is, contusion and compression of the spinal cord, together with spinaf meningitis and myelitis, fractures of the upper cervical vertebra are attended by others. Should the cord be crushed, or even pierced, above the roots of the phrenic nerves by a fragment of displaced bone, the respiratory movements would at once cease entirely, because the respiratory muscles would all be paralyzed, and death from asphyxia would immediately ensue. This accident not unfrequently happens, and the victims thereof but seldom, comparatively, receive the attention of surgeons. Abernethy, how- ever, is credited with mentioning the case of a coal-heaver who fell from a 346 INJURIES OF THE BACK. wagon while drunk. There was no apparent injury ; still, he could not rise in bed ; and, in turning his head to be shaved, he suddenly died. Fracture of a cervical vertebra was found ; and the cord was penetrated by a splinter. The lesion must of course have been not lower than the third cervical vertebra. Professor William Pepper^ relates the case of a girl, aged 19, who broke her neck by falling from a pie-cherry tree, and was admitted to the Pennsylvania Hospital twenty- four hours afterward. All power to move the extremities and muscles of the trunk was gone. Sensation, too, was entirely lost from a little below the clavicle downward. There was retention of feces and urine ; the bladder was much distended, no urine having been passed since the accident. The respiration was entirely diaphragmatic^ and 32. The fades indicated great respiratory oppression. Pupils normal; intellect clear ; voice feeble, and frequently interrupted ; the tongue could be protruded at will, and moved in any direction. The cheeks were brightly flushed and very hot. The skin everywhere was much hotter than normal ; pulse, small and frequent ; temperature in axilla, 108.5°. "She abruptly asked to be raised in bed ; her breathing became gulping and imperfect, and in less than two minutes she fell back dead." Pulsation was still perceptible at the wrist almost one minute, and the cardiac sounds were yet audible between three and four minutes, after the last respiration. Autopsy The tissues surrounding the cervical vertebrae were ecchymosed, and infiltrated with bloody serum, but no blood had escaped into the pharynx. There was a comminuted fracture of the atlas, the lateral masses being separated and the arches broken in two places^ The fourth vertebra was luxated anteriorly from fracture of the articular processes. The paraplegia which attended the accident was due to the forward luxa> tion of the fourth cervical vertebra. The flushing of the face, and the great elevation of the body-heat were due to vaso-motor paralysis which resulted from injury of the sympathetic nerve. The sudden death was caused by punc- turing the spinal cord with fragments of the broken atlas, and compressing it against the odontoid process of the axis. E'ot improbably, the girl's head slipped forward on the summit of the spinal column, when she was raised up in bed. The same accident occurred to this patient, on being raised up in bed, as befell one of Mr. Hilton's patients and nearly happened to another (whose cases have already been mentioned), where the ligaments belonging to the articulatio capitis had been so extensively destroyed by disease, as to allow the head to slip forward and compress the spinal cord, with deadly effect, against the odontoid process of the axis. The sudden death of the patient w^hose case has just been related shows, that the same care is needed in cases of injury and in cases of disease of the first vertebra, alike, if the spinal cord be liable to sudden compression from the slipping or falling forward of the head, in consequence of the injury or the disease. The following example teaches the same important lesson : — Dr. H. F. Eberman,^ reports the case of a man, aged about 70, who, while descend- ing the steps from a hay-loft, slipped and fell, striking his occiput violently on the ground, and forcibly bending his head forward on to his chest. He lay insensible, for a considerable time. But, after recovering from the stunning, he arose, and placing both hands to his neck, walked to the bar-room of the hotel (half a square from the place of accident), where he remarked that he thought his neck was hurt, asked for a glass of whisky, and drank it. Then, he returned to the stable, and lay down on some hay ; in about half an hour he expired. Autopsy The transverse process on the riglit side of the atlas was found to be broken off ; the third cervical vertebra was fractured transversely through its body, the right arch was broken entirely through, and the articulating processes on both sides were fractured through the middle ; the inter-spinous and posterior vertebral ligaments were ruptured ; but the spinal cord remained intact. A Am. Joiirn. Med. Sciences, April, 1867, pp. 438, 439. « Ibid., October, 1879, p. 590. FRACTURES OF THE VERTEBRiE. 347 The sudden death of this man, too, was due no doubt to a compression of the spinal cord against the odontoid process of the axis, which w^as sudde:il caused by the elevating or thrusting forward of his head, and the subsidence of his neck, that would naturally occur when he turned over upon his back, as he lay flat on the hay, without a pillow to keep the nape ot his neck raised up sufficiently to avoid such a calamity. This displacement ot tlie frag- ments of the broken atlas, etc., could have been avoided by placing a small firm pillow under the patient's neck, when putting him to bed, and by confining his head and neck in a fixed position by means of heavy sand-bags so placed on either side thereof as to prevent all motion in the neck, as recommended by Mr. Hilton in analogous cases of cervical disease. Had such a procecd- ino- been instituted, in ' this case, and continued until consolidation of the fractures had been effected, recovery no doubt would have ensued. Lhe following example shows not only that this view is correct, but also that spontaneous recovery from similar fractures sometimes occurs : — A man, aged 32, fell from a hay-wagon, striking his occiput on the ground, and was stunned.^ He walked half a mile to visit a surgeon ; in three days he resumed work ; his neck was stiff, and there was tumefaction over the axis ; after several months, dys- phagia and tumefaction in the pharynx appeared. Nevertheless, he recovered ; and, about one year and a half after the accident he died of pleurisy. The autopsy showed fractures of the atlas and odontoid process of the axis. (Ash hurst.) As a symptom of the fractures of the atlas and third . cervical vertebra which had occurred in Dr. Eberman's case, it may be mentioned that the man walked with a hand placed on each side of his neck, apparently in order to support it. Sir Astley Cooper^ relates a case of simple fracture of the atlas, that was under the elder Cline's care, in which the same symptom was pre- sent : — " A girl received a severe blow upon her neck ; after which it was observed that, whenever she wanted to look at any object, either above or below her, she alw^ays sup- ported her head with her hands, and then gradually and carefully elevated or de- pressed it, according as she wished, towards the object. After any sudden shock she used to run to a table, and placing her hands under her chin, rest them against the table, until the agitation caused by the concussion had subsided. Twelve months after the accident the child died ; and on examination, a transverse fracture of the atlas was found, but no displacement. AVhen the head was depressed or elevated, the dentiform process of the second vertebra became displaced, carrying with it a portion of the atlas, and occasioning pressure on the spinal marrow, which was also produced by any violent agitation." Fractures of the odontoid process, as a rule, suddenly destroy life ; the vic- tims being literally pithed by that process. This accident often, but not always, proves instantly fatal. For example, Melcliiori^ mentions the case of a woman, aged 68, who was killed by falling from a ladder and striking her forehead on the ground. Death was instanta- neous. Dissection showed fractures of the atlas and odontoid process of the axis; and the atlas was displaced backward. (Ashhurst.) When, how^ever, it happens that the fragments of the broken odontoid process are not displaced sufficiently to injure the spinal cord, the patient may survive until such a displacement is produced by some accident or other, as doubtless occuii^-ed in the following instance : — Richet* relates the case of a man, aged 22, who attempted suicide by a pistol-shot in the neck. He survived the injury for seventeen days, during which time he could ' Am. Journ. Med. Sciences, 0. S., vol. xxiii. 3 Gaz. Medica Stati Sardi, 1850, 2 Lectures, vol. ii. p. 8. 4 These de Concours, 1851. 348 INJURIES OF THE BACK. move only by supporting his head with his hands. Death suddenly occurred. Dissec- tion showed fracture of the odontoid process. (Ashhurst.) Professor Willard Parker, of New York, some years ago, had the case of a milkman, aged 40, who was injured by being thrown from a wagon about fifteen feet, and striking his head and face on the ground. There was pain in the neck and a protuberance on the left side thereof. He could not turn his head, but supported it with his hands. He got so well that he resumed his milk business, and survived the injury for five months. He died suddenly, after a hard day's work, on the fragments becoming displaced by an accident, his head dropping forward upon his chest, at the table, to such a degree as to compress the spinal cord. Dissection showed fracture of the odontoid process ; and the lower end turned back to the spinal cord. This patient would have recovered had he but kept his head and neck at perfect rest until consolidation of the fracture had ensued. In the following example recovery did take place, and some time afterward the man died of a non-surgical disorder : — Mr. B. Phillips^ had under his care a laborer, aged 32, injured by falling head fore- most from a hay-rick. In a little while he was able to arise. In two days he went to work again. A month afterwards, he walked two miles to consult his surgeon. His neck was stiff, there was a protuberance at the back of the pharynx, with some difficulty in swallowing, but no paralysis. One year after the accident he died from dropsy. The autopsy showed fractures of the atlas and odontoid process, with displacement of some pieces forward against the pharynx ; the occipital bone had settled down on the axis, and formed a new joint ; the spinal cord was unhurt. The spinal foramen in the first and second vertebras is quite large ; and, therefore, these bones may be extensively damaged without seriously injuring the spinal cord. Mr. R. Debenham'^ also mentions a case in which the odontoid process was fractured, and recovery followed. The subject was a shoemaker, and the lesion was verified by dissection two years after the accident. Cases in which the odontoid process w^as spon- taneously fractured, that is, fractured in consequence of disease, have been reported by Hyrtl, by Else, and by Flint ; and, in each instance, death occurred instantaneously.^ Professor Stephen Smith, in an article on " Fracture of the Odontoid Pro- cess,"'^ has collected tw^entj-two cases. Six occurred spontaneously, in con- sequence of disease, and all ended fatally except one, in which a portion of the bone was discharged through the throat ; four were gunshot cases, all fatal ; seven were caused by external violence, all likewise fatal ; five were cases in which a portion of the bone had been discharged, w^ith four recoveries and one death ; aggregating but five recoveries and seventeen deaths. Dr. Smith has found, by experiment, that, although the odontoid process is not fractured by being driven against the transverse ligament on the anterior arch of the atlas, the odontoid ligaments combined are stronger than the odontoid process, and " that the efficient agents in this fracture are the odontoid ligaments." The odontoid process has been fractured from violence dii-ectly applied ; and from external violence indirectly applied, e.g.^ to the forehead, to the side of the head, and to the back part of the neck. The s3miptoms of this accident are pain and stiffness in the neck, swelling in the region of the first and second vertebrse, and a protuberance in the pharynx at the same region ; but, probably, the chief symptom is that the patient carries the head supported on the two hands. This symptom, however, has been observed in cases where the occipito-atloid articulation, that is, the articulatio capitis^ has been disrupted, » Medico-Chirurgical Transactions, vol. xx. p. 78. 2 London Hosp. Reports, vol. iv. p. 210. * P. Bevan (Dublin Med. Press, February, 1863) reports a case in which there was fracture of the odontoid process, perfect anchylosis of its apex with the occipital bone, and partial luxation forward of the atlas. (New Syd. Soc. Year-book, 1864, p. 280.) ^ American Journal of the Medical Sciences, October, 1871, pp. 338-58. FRACTURES OF THE VERTEBRiE. 349 as well as in cases where the bones forming the atlo-axoicl articulations have been broken ; and, generally, it denotes that either the atlas, or the axis, or both of these bones are fractured.^ " Latent Fracture of the Spine,'' as Mr. Simon has denominated an important lesion of the spinal column which occasionally presents itself to surgeons, must also be considered in connection with those fractures of the vertebrae which are attended by but little or no displacement of the fragments. In the examples of so-called latent fracture of the vertebrje, the spinal cord is not at all affected by concussion, nor by contusion, nor is it compressed by displaced bone, nor by extravasated blood. The breach, in these cases, usually consists of a linear fracture through the body of a cervical or a dorsal vertebra. On the withdrawal of the force which iissures the bone, the fragments at once sprino- back into place again. The patient complains only of pain, soreness, and stiffness in the injured part of the spine, for some days ; and, perhaps, havino- returned to work, continues at the same until the symptoms ol sup- purative inflammation present themselves at the seat of the fracture, and until an abscess forms in the spinal canal between the theca vertebralis and the bone, as well as external to the bone, in the same locality, ihese cases are strictly analogous to those of circumscribed abscess occurring between the dura mater and the bone, in consequence of a linear fracture ol the skull, which have often been observed in latent injuries of the head. As subcra- nial abscesses not unfrequently cause death, per se, by compressing the bram, even so these cases may terminate in death by compression ot the spinal cord, without the occurrence of that diffused traumatic spmal meningitis or myelitis which often supervenes, as we have already shown, in cases ot verteoral trac- ture or dislocation. Mr. Simon^ relates an instructive example ot the spmal lesion in question : — A crirl, ao-ed 18, injured her neck by faUing, in the dark, about twelve feet down an embankment. At first she was stunned. Afterward she walked home, a distance ot about three miles. She resumed work, and remained thereat for eleven days, bhe entered St. Thomas's Hospital on the fifteenth day after the accident, on account of severe pain in her neck, with fever, etc. No displacement nor irregularity of the spine could be detected. There was no anaesthesia nor paralysis. Her complaints of pain and tenderness were vague. She chiefly spoke of suffering between the shoulders ; turning over into a prone position in bed was accomplished slowly, stifily, and with cries. i.arly on the sixteenth day, she complained of numbness and twitching in her limbs, particu- larly in the lower ; in the evening, voluntary motion was lost completely in the legs, and nearly in the arms; sensibility was hkewise very much impaired in both. Delirium, " iumpino- of the le^^s," and tympanitic distension of the abdomen, as well as high fever now appeared. On the eighteenth day she died. Autopsy. 30 hours after death—'' A horizontal line of fracture was found traversing the body of the seventh cervical vertebra, just above its inferior surface. Beyond a very little gaping in front, which would allow the edo-e of a scalpel to be insinuated flatly between the fragments, there was not the slicrhtelt displacement ; and the posterior common ligament was untorn. Ihe spinal canal contained between the osseous walls and the dura mater [theca vertebralis] a large quantity of pus, which, from two inches below the foramen magnum, descended the whole lena-th of the cord. At the several intervertebral holes it had crept somewhat along the Issuing nerve-sheaths, and, between the first and second dorsal vertebras had I But fracture of the axis unattended by any notable displacement may prove quickly fatal, by causing hemorrhage into the spinal canal, and compression of the spinal cord therefrom, as happened in the following instance : Arnott (Lancet, 1851) reported the case of a man, aged 74, iniured in the neck by falling down stairs. There was paralysis of the upper extremities, but not of the lower. In one hour death ensued. Dissection showed fracture of the spnious pro- cess of the axis ; the fragment was wedged in between the axis and the third vertebra. There was effusion of blood in the vertebral canal. (Ashhurst.) « Transactions of the Pathological Society of London, vol. vi. p. 42. 350 INJURIES OF THE BACK. actually emerged, following the subdivision of the first dorsal nerve, so as to spread among the exterior parts. These burrowings of matter were cut into before the [spi- nal] canal was opened. . . . The outer surface of the [spinal] dura mater was roughened by inflammatory deposits ; but none were found within it ; nor was there any softening, or microscopical change in the spinal cord. No other disease was discov- ered." The fracture of the seventh cervical vertebra was called latent, or concealed, in this case, because it was not attended by deformity, nor by any other symptom of special import, for a considerable number of days. Meanwhile, the connective tissue lying between the theca vertebral is and the bone became inflamed, commencing at the fracture, and purulent matter in great quantity was formed and collected in this tissue, whereby the spinal cord was com- pressed through the medium of the theca ; but life was not destroyed until the intra-vertebral abscess had burrowed upward far enough to compress and paralyze the respiratory centres, thus arresting completely the respiratory movements and causing death by asphyxia. The abscess external to the spi- nal column was not large in this case. In other instances, however, the exte- rior abscess is found to be quite large, and to burrow extensively in the soft parts around the spinal column, as was noted in the following instance : — Sir B. C. Brodie^ mentions the case of a man, aged 45, who fell from a scaffold and injured his back. There was paralysis, foUow^ed by convulsions. Death ensued nine weeks after the accident. Dissection showed fracture of the fourth dorsal vertebra ; the spinal cord was compressed and softened ; an abscess arising from the seat of the fracture extended into the posterior mediastinum. (Ashhurst.) It is not the fracture itself which destroys life in these cases of latent ver- tebral injury, but the consecutive inflammation and abscess ; and, if these untowarcl consequences of such injuries be averted, complete recovery will ensue. The symptoms directly after the injury, in cases of. latent fracture of the spinal column, closely resemble those which are met with in sprains or wrenches of the vertebral joints, caused by blows on the back, falling, etc. Mr. Bryant^ mentions, in point, the case of a woman admitted into Guy's Hospital, under Mr. Cock's care, for some injury of the back caused by falling out of a window. Beyond the contusion, no injury could be made out." She died, however, of cerebral disease sixteen days after the accident. Dissection showed that the last dorsal and three upper lumbar vertebrae were fractured through their bodies, but not displaced ; one or two spinous processes were also fractured. The spinal marrow was uninjured. The fact of there being no displacement of the broken bones, and no injury of the spinal cord, had prevented the making of a correct diagnosis in this case. But examples, such as this, of vertebral fracture wherein the diagnosis is not made until the post-mortem examination, are not uncommon. It is, therefore, rather important for the surgeon to bear the latter fact in mind while treating cases of supposed sprains, wrenches, and twists of the vertebral joints, and to enforce, in all doubtful cases, that absolute quietude of body — that freedom from all movement, particularly in the injured portion of the spinal column — which is necessary in order to secure consolidation of the fracture without accident, should this lesion perchance be present. In cases of vertebral fracture occurring in the dorsal region, it should be stated that displacement of the fragments is measurably prevented by the ribs acting as splints placed on each side of the spinal column. In the lumbar region, likewise, the great lumbar muscles may act powerfully in the way of preventing and removing displacement, in cases of vertebral fracture, unat- tended by dislocation, as the following example will show : — 1 Medico-Chirurgical Transactions, vol. xx. 2 Op. cit., p. 202. FRACTURES OF THE VERTEBRAE. 851 Corporal John B., Company C, 10th N(nv York Volunteers, March 11, 1865, at Fig. 86'. Pure or simple transverse fracture of the first lumbar vertebra, caused by the limb of a tree falling upon the loins and back of a soldier. (Spec. 149, Sect. I, A. M. M. Hatcher's Run, Va., was struck across the dorsal and lumbar regions hv the fallinff limb of. a tree which liad been severed by a sl»ell. He was knocked senseless, and remained so an liour or more, until he Avas awakened by the jolting of the am- bulance that carried him to regimental headquarters. On regaining consciousness, he was unable to move the lower portion of his body, and complained of pain in the same parts. He was cupped, and had mustard applied to the calves of his legs and to the spinal rey other successful examples of the same sort, if time permitted, could doubtless be collected. !N"umerous other cases of vertebral fracture, in the dorsal and lumbar regions, in which the patients survived a long time, notwithstanding that the spinal cord was severed, or that the broken bones were much displaced, might like- wise be collected. But few of them, however, will be presented. Professor Hamilton ' mentions a case under Mr. Key's care, in which the first lum- bar vertebra was fractured. The patient, a boy, survived the accident for one year and two days. Necroscopy showed bony union, and the spinal cord completely divided. Sir A. Cooper^ gives the case of a man, aged 28, under Mr, Harold's care, with frac- tures of the first and second lumbar vertebrie caused by a mass of chalk falling upon him. There was spinal paralysis, which affected the bladder and intestines as well as ^ American Journal of the Medical Sciences, 0. S. vol. xvi. * London Med. Gazette, vol. xviii. p. 936 ; Trans. Patholog. Soc. London, vol. iii. p. 420. ' Brit, and For. Medico-Chirurg. Review, October, 1869, and New Syd. Soc. Retrospect, 1869- 70, pp. 247, 248. CEuvres Chirnrg., t. ii. 5 Dictionnaire de Medecine, t. ix. ; Maisonnabe, Journal des Difformit^s, t. i. 6 Op. cit., t. ii. ' Op. cit. 8 Dislocations and Fractures of Joints. 362 INJURIES OF THE BACK. other parts. He died from a slougli (bed-sore) on the nates, one year and eleven days after the accident. Necroscopy showed union by bone, and the spinal cord nearly severed by a fragment of bone which had pierced the theca vertebralis. An instance of dislocation of the first, and fracture of the second lumbar vertebra, in which the patient survived the lesion for three and one-half years, and the specimen from which was exhibited at the Pathological Society of London by Mr. W. WagstaflPe, has already been mentioned above. Professor Agnew^ gives, with a wood-cut illustrating the lesion, the case of a young man who was caught at the Kensington Depot, Philadelphia, between the platform and a car, in such a way as to fracture the spinal column in the mid-dorsal region, with comminution ; yet, notwithstanding that the spinal cord was completely divided by a permanently displaced vertebra, he survived the accident for six months, and perished at last from sloughing of the nates. Le Gros Clark ^ relates a very instructive case in which the fourth lumbar vertebra was fractured through both pedicles, while its processes were all comminuted, and its ligaments ruptured, so that the body of this vertebra was dislocated forward and down- ward, and took up a new position in front of the fifth lumbar vertebra, the upper and lower surfaces of both vertebrae being in the same planes ; although the injury was at first attended by complete paraplegia, the sensibility was restored entirely, and the motility partially, in five weeks. Death ensued in the seventh week, in consequence of sloughing or acute bed-sores. A highly suggestive feature of this case is the fact that, notwithstanding the enormous displacement which occurred between the fourth and fifth lumbar vertebrae, the spinal cord was not much injured, and the paraplegia soon passed away. The following is in the same vein : " In one case," says Mr. Hutchinson, "I found the trunks composing the cauda equina lifted a third of an inch on a bridge of bone, formed by the displacement of a fractured lumbar vertebra; but they were in no degree compressed, and, excepting a little ecchymosis in their pia mater, showed scarcely any trace of injury."^ A very practical inference from facts such as these is that, however great the displacement and the paralysis may be in cases of fracture or dislocation of the spinal column, we have no right to assume at the outset, during life, that the spinal cord is irreparably or even severely injured thereby. These clinical histories and accounts of autopsies have been presented, aside from their general value, with a special intent to show that, in cases of ver- tebral fracture and dislocation, the surgeon is justly entitled to approach the question as to what their treatment should be, with something more of hope for obtaining a happy issue by appropriate treatment, than most text- books on surgery would seem to encourage. Treatmeyd of Fractures of the Vertebrce. — The successful management of cases in which the spinal column is fractured, chiefly depends on the follow^ing points : (1) On preventing those intra-thecal extravasations of blood which destroy life by compressing the spinal cord. (2) On preventing or subduing spinal meningitis, and abscess between the theca vertebralis and the bone. (3) On preventing or subduing ascending myelitis, and all inflammatory dis- organizations of the spinal cord. (4) On conducting the bed-sores, and the vesical and renal inflammations, which are apt to complicate such cases, to a favorable issue. The victim should be carefully picked up, and carried from the scene of the accident home, or to a hospital, on a stretcher, on one extemporized from a settee or a shutter, etc., or in an ambulance, every precaution being taken against increasing the injury of the spinal cord, that was mentioned while 1 Op. cit., vol. i. pp. 827, 828. 2 British Med. Journal, October 3, 1868. 3 London Hospital Reports, vol. iii. p. 3G0. FRACTURES OF THE VERTEBRAE. 363 describing the treatment of luxations of the vertebrce, especially if the frac- ture be seated in the cervical region. The surgeon should make his diag- nosis as complete as possible, at his first examination of the case, in order to avoid the doing of harm by moving the imtient to make any subsequent examinations. The patient should be placed on a water-bed ; but, if it is not practicable to do that, upon a soft, thick hair-mattress. The fractured ver- tebrae should then be " set," that is, their fragments should be restored to as nearly a normal position as possible: (1) by attending to the patient's posture in bed, for sometimes a dorsal or even an abdoiaiiial decubitus will quite remove the deformity, as well as greatly lessen the patient's sufferings ; (2) by em- ploying extension and counter-extension (whenever necessary), made with the hands of skilled assistants, at the same time coaptating the fragments with the hands; and (3) by applying extension continuo\isly w^ith w^eights, in cases where there is shortening of the spinal column. The following ex- amples are in point : — Malo-aigne^ gives the case of a clerk, aged 22, who was treated by himself at the- Hopital des Cliniques, in 1843. The man had fjillen from a second story, alighting on his heels and buttocks. Both calcanea were fractured. The spinous process of the twelfth dorsal vertebra was also fractured, and displaced toward the right side. There was paraplegia with great pain in the back on motion, and it was thought that a lumbar vertebra was likewise broken. The patient was treated by rest in bed alone, and the paralysis gradually passed away. When he got up, the displaced spinous process had resumed its proper position. In some cases of vertebral fracture, the fragments readily subside into a nor- mal position when the patient is confined to bed \\\ dorsal decubitus. This doubtless occurred in the example just mentioned. In other instances the deformity has been removed by making the patient lie on his belhy, and a com- plete cure has been obtained by making him keep that posture until the frac- ture has united. Sir B. Brodie^ mentions the case of a boy, who was injured in the lower part of the back. There were fracture and displacement of the third and fourth lumbar vertebrae, and spinal paralysis. Attempts at reduction were made, and proved partially success- ful. After the first month, voluntary motion, as well as sensation, gradually returned. At the end of three or four months the patient was much relieved. Mr. Higginson' mentions a case in which there was fracture, with displacement, of a dorsal vertebra. The patient was treated by extension, and recovery ensued. Mr. Luke* relates the case of a man having fracture of the seventh dorsal vertebra. The displacement was corrected by making extension, and the reduction was accom- panied by an audible sound. Erysipelas, however, supervened, and caused death seven days after the accident. At the autopsy, the spinal cord was found to be softened and disorganized, and to contain purulent matter. The fatal issue of this case does not appear to have been in even the least degree due to making extension, and effecting reduction of the displaced frag- ments of the seventh dorsal vertebra. Moreover, I have not found a record of any case of spinal fracture in which the efforts at reduction proved at all hurtful. But reduction by extension is not to be employed in every instance ; certainly not in cases where the deformity can be removed hy adjusting the patient's posture in bed. Reduction by extension, however, is allowable when much deformity, and especially shortening, of the spinal column exists ; and, likewise, when severe pain arises from the fragments of bone pressing upon 1 Treatise on Fractures, etc., p. 342. Packard's translation. » Medico-Chirurgical Transactions, vol. xx. p. 159. 8 British Medical Journal, 1862. 4 Lancet, 1850. 364 INJURIES OF THE BACK. the spinal nerves. Bryant has seen several cases in which marked relief has been afforded by this means '} and the records of surgery contain many others. AVhen practised with discretion, the reduction of vertebral fractures b}' extension is undoubtedly a valuable mode of treatment. When the dis- placement shows a decided tendency to recur, and likewise when there is marked shortening, it will often be advisable to make the extension continu- ous by means of weights attached to the patient by strips of adhesive plas- ter, and suspended from the htad of the bed, in the manner already described while discussing the treatment of vertebral dislocations. When there is much pain at the seat of fracture, or in the terminal branches of the spinal nerves which issue from the spinal column through the intervertebral foramina at the seat of fracture, opium or morphia must be administered in full doses, and at sufficiently short intervals to subdue the pain and keep it in subjection. Afterward, the patient should be kept mode- rately under the influence of morphia as a precautionar\' measure against con- secutive spinal meningitis and m3'elitis, and, by the way, opium or mor- phia thus administered, is one of the most efficient agents for this purpose in the materia medica. If, in a few hours after the accident, signs of compression of the spinal cord from extravasation of blood within the theca vertebralis should a^Dpear, the fluid extract of ergot should be given in full doses, and at short intervals, and an ice-bag should be applied over the spinal column, with a view to suppress the bleeding. Efforts to abate the inflammation of the injured structures at the seat of fracture, and thus to prevent the occurrence of consecutive meningitis and myelitis, should be made by abstracting blood with leeches, by applying cold lotions, and by keeping the fractured bones as nearly immovable as possible. The attentive*^ reader, doubtless, has already noted that, in many of the suc- cessful cases of spinal fracture related above, blood was abstracted, either generally by venesection or locally by cupping, that cooling lotions were applied to the injured part, and that the patient lay quietly in bed. Should spinal paralysis begin one, or two, or more days after the accident, or should a pre-existing paralj- sis then begin to increase or invade new parts, or should any other symptoms denoting the presence of spinal meningitis or myelitis appear, the surgeon should seek to control the inflammation of the membranes and substance of the spinal cord, by administering ergot and potassium iodide in full doses, and by insisting on having perfect rest for the injured parts, if this remedial measure have not already been thoroughly enforced. Should there be inability to micturate, catherization must be employed morning and evening, and oftener if necessary. Should there be constipation, the bowels must be moved at appropriate intervals by giving senna, and by administering enemata. The alimentation of the patient must be attended to, and a nourishing but easily digestible diet allowed. Every possible pre- caution, in the way of cleanliness, etc., should be taken against the formation of bed-sores. In regard to the use of mechanical contrivances to keep the broken parts of the spinal column in apposition, and free from all motion, thus performing the offices that splints do in fractures of the extremities, it is obvious that it these ends could be accomplished by any mechanical contrivance, the patient's recovery would be considerably expedited, and the risk of consecutive menin- gitis and myelitis would be considerably lessened by employing it. As such an apparatus, the plaster-of-Paris jacket, devised by Professor Sayre, has 1 Op. cit., p. 204, GUNSHOT INJURIES OF THE VERTEBRAE. 365 recently been applied in a number of instances. Professor Konig, of Got- tingen, bas an article in No. 7 of tbe Cevtralblatt fur Chinirgic, for 1880, on the application of the " Thorax Gypsverband" for fractures of the spine, and recounts therein three cases, in all of which there was considerable displace- ment, with but very slight, if any, nervous symptoms. In each of these three cases,' the [)atient was suspended sufficiently to correct the deformity, and a long 'jacket reaching down to the trochanters was put on ; and every one of them' made a complete and rapid recovery. The cases were all recent and simple. Dr. W. Wagner, however, reports two similar cases in which, after the application of the jacket, intense pain in one instance, and paralysis in the other, appeared in the lower extremities, so that it was necessary to remove the apparatus. In one case it was reapplied subsequently, with comfort to the patient. Both patients recovered.^ Possibly, the failure' of the first application of the jackets, in the last two instances, was due to not exactly reducing the displacement of the fragments prior to fitting the jackets, so that the' apparent want of success was caused not so much by the apparatus itself, as by the failure to apply it properly. At all events, no great harm was done, for recovery was not prevented in either instance. Obviously, this plan of treatment is not appropriate for cases in which there are bed-sores, or hi which inflammatory disorganization of the spinal cord is already far ad- vanced. But, for simple, uncomplicated cases of spinal fracture, in which the injury is recent, it seems likely to prove of great service, and undoubtedly is in improvement on any of the old methods of treatment now in vogue for such cases. When the body-temperature rises to 102° F., or more, and persists, what is to be done? Possibly, in cases where the mercuiy stands at 102° or 103°, the trunk and extremities may be sponged with diluted alcohol, from time to time, with advantage; and, in cases where it rises to 105°, or more, and the extinction of life is threatened by the body-heat itself, it may be advisable to use the " cold-water pack," carefully noting its eftects, meanwhile. When the body-temperature sinks below the normal limit, whether the coldness be confined to the paralyzed parts or diftused over the whole system, care must be taken in applying artificial heat— e. g., bottles of hot-water, heated bricks, or sad-irons, etc.— lest the parts to which they are applied become burned from the negligence of the attendants. Gunshot Injuries of the Vertebra. Soldiers are sometimes killed in battle by gunshot injuries of the cervical vertebrae. Dr. Otis^ reports two instances of this sort that he had himself seen, in which the ball lodged in the cervical spine," among the bodies of those lying dead on the field of battle before Kew Berne. Gunshot injuries of the spinal column may thus quickly destroy life : (1) By dividing or crush- ing the spinal cord above the third cervical vertebra, that is, above the roots of the phrenic nerves, thereby completely and instantaneously arresting the respiratory movements ; and (2) By opening the vertebral artery, in some part of its course within the canal formed by the vertebral foramina in the trans- verse processes of the six upper cervical vertebrae. Mr. Shaw3 has placed on record, together with a wood-cut, the tollowing example, which admirably illustrates the first of these two modes in which ' Medical Times and Gazette, December 18, 1880. 2 Medical and Surgical History of the War of the Rebellion, First Surgical Volume, p. 603. * Holmes's System of Surgery, vol. ii. p. 395. 366 INJURIES OF THE BACK. gunshot lesions of the spinal column may destroy life with great sudden- ness : — A gentleman was wounded by a pistol-shot in the back of his neck while lying asleep on his side ; his mistress, who was awake at the time, stated that he did not stir a limb nor move in any way, although the report was loud. Death, therefore, must have been instantaneous. Necroscopy showed that the missile entered at the median line, passed horizontally forward between the arches of the atlas and the axis, severed the spinal cord, and stuck fast in the odontoid process near its base, having fissured the same. The specimen is preserved in the museum of Middlesex Hospital. In regard to the second of these two modes in which life may be suddenly destroyed, it should be stated that gunshot fractures, involving any of those transverse processes of the cervical vertebrse through whose foramina the vertebral artery runs, may readily lay the artery widely open, and that the primary hemorrhage therefrom would soon prove fatal; certainly, death would ordinarily ensue before a man thus wounded could be removed from a field of battle. In this connection it may be well to state also that gunshot frac- tures of these transverse processes are not unfrequently attended by secondary hemorrhage of a fatal character, which usually appears some ten or twelve days after the casualty has occurred. For instance. Baron Dupuytren^ mentions the case of a carpenter, aged 31, who re- ceived a gunshot wound of the face and neck. The ball entered his nose. The wound did well for ten days, when secondary hemorrhage set in, and caused death. Necro- scopy showed that a transverse process of the second cervical vertebra was fractured, and that the hemorrhage arose from the corresponding vertebral artery. Usually, in such cases, the laying open of the artery, so that the blood may issue therefrom, is caused either by the separation of a slough consisting of the tissues which have been bruised by the missile in its passage, or by the perforation of the arterial tunics by an ulcerative process. In the following instance, however, it was caused by the beating of the vertebral artery itself against a sharp fragment of the transverse process which had been fractured : — Samviel S. was wounded at the battle of Williamsburg, May 5, 1862, by a musket- ball which entered his face to the left of the symphysis of the inferior maxilla, smashed that bone, and carried away several teeth, with a part of the tongue and of the posterior wall of the pharynx, and lodged. He had extreme dysphagia. On the 13th, the ball and several teeth were removed from an abscess above the clavicle. On the IGtli, copious- hemorrhage from the original wound occurred, which was arrested by tying the common carotid artery under ether. Seven days after that, a fresh hemorrhage set in from the aperture through which the missile had been extracted ; an unsuccessful attempt was made to find the bleeding vessel. He died on the same day (May 23) of ansemic exhaustion resulting from the hemorrhage. Necroscopy showed that a trans- verse process of the third cervical vertebra had been fractured by the ball, and that the vertebral artery had rubbed against a spiculum thus produced until it was worn through ; hence the secondary hemorrhage arose. ^ The first hemorrhage, doubtless, sprang from some branch of the external carotid artery in the face, mouth, or throat, which had been injured by the missile, and, therefore, it was possible to suppress it by ligaturing the common carotid artery. Gunshot contusions of the spinal column were, I believe, first mentioned by Dr. Louis Stromeyer, while writing from his experience as surgeon-in-chief of the Schleswig-Holstein army, in 1849. He says : — In two cases the cervical vertebrae were contused by bullets which entered on the outer side of the sterno-mastoid muscle, and likewise bruised the brachial {)lexus of » Op. cit. 2 Medical and Surgical History of the War of the Rebellion, First Sul-gical Volume, p. 355. GUNSHOT INJURIES OF THE VEKTEBR.E. 307 nerves ; the paralysis of the corresponding arm was at first so complete tliat I considered the brachial plexus must have been torn by the bullet ; but, gradually, sensation and motion almost fully returned. " In a case of contusion of the cervical vertebrne by a similar shot, there has remained till this moment a period of four months — stiffness and pain in the neck on motion. In all these cases small sequestra escaped."^ In cases where the vertebrae are contused by gunshot missiles, the bodies are the portions thereof which are usually found to be affected. Indeed, I am not acquainted with any instance where this lesion was confined to the vertebral apophyses. Fig- ^64. The consequences of gunshot contusions of the vertebrae are: 1, necrosis of the bruised parts ; 2, caries of the same ; and 3, inflamrna- tton of the injured bone, which may spread to the membranes and substance of the spinal cord. 1. As examples of necrosis, Stronieyer's three cases just mentioned above, in each of which small sequestra escaped from the wound, may be appropriately cited. 2. As an instance of caries arising from this cause, the following abstract, together with the accompanying wood-cut (Fig. 864), may be presented : showing caries of the last two cervical vertehrse caused by gunshot contusion. Private George A. A., 20th New York Volun- (Spec. 1867, See i, a. m. m.) teers, aged 40, was wounded at Gettysburg, July 2, 1863, by a conoidal ball, which fractured the right lower jaw, struck the bodies of the sixth and seventh cervical vertebrae, and lodged. It is said that the missile was after- ward ejected by the patient from his mouth. But pyaemia supervened and caused death. It is stated that the patient had dyspna3a, but no paralysis ; that he walked about until a few days before his death, which occurred on the 21st (nineteen days after the casualty occurred) ; that he had complained only of a slightly uneasy feeling in the neck when turning his head ; and that the injury of the cervical vertebriB was not sus- pected during life. Necroscopy showed that the bodies of the sixth and seventh cervical vertebrae were carious in the parts where they had been struck and bruised by the mis- sile (see Fig. 864), and that a fissured fracture extended tlirougli the body of the sixth vertebra. Pycemic lesions, too, were found ; that is, the right lung was in a condition of recent pneumonia, and filled with a multitude of small abscesses, the presence of which fully accounted for the occurrence of dyspnoea. The oesophagus, the trachea, and tlie bronchial mucous membrane were inflamed.^ In this case, the contusion of the cortex or outer lamella of the body of the sixth cervical vertebra was complicated by a fissured fracture of the vertebral body; the body of the seventh cervical vertebra, however, was not fractured, but only bruised and carious. The carious condition of both vertebrte is well shown in Fig. 864. The specimen which it represents is pre- served in the- Army Medical Museum. 3. The spreading of inflammation from the injured bone to the membranes and substances of the spinal cord, with a fatal result in consequence thereof, may be illustrated in a useful maimer by presenting another example taken from Stromeyer : — " In a case where a bullet, entering laterally, severely bruised the third and fourth cervical vertebrte, and was not extracted, death followed in consequence of the advance of inflammation into the spinal cord and brain ; there was at first palsy of the arm » Stromeyer on Uaiishot Fractures, translated by S. F. Stathara, pp. 37, 38. Am. ed. « Medical and Surgical History of the War of the Rebellion, First Surgical Vol., p. 431. 368 INJURIES OF THE BACK. belonging to the injured side ; it was followed by incomplete paralysis of all the limbs, ending in stupor. Antiphlogistic treatment had been entirely neglected."^ Etiology, The impact of gunshot missiles upon the bodies of the vertebrae causes contusion thereof only when the force of the missiles is nearly spent, on the one hand, or when the direction of their flight is very oblique, so that they strike a glancing blow, on the other hand. When endowed with less force, they do no injury ; and with greater force they produce fractures. Treatment. — The principal indication in the therapeusis of gunshot con- tusions of the spinal column is to prevent the occurrence of inflammation in the injured bone, and the spread of the inflammatory process therefrom to the meninges and medulla spinalis. This can best be accomplished by the extraction of all foreign bodies from the wounds, by the employ ment of anti- septic dressings, by thorough drainage by means of appropriate tubes, inserted for the purpose whenever necessary to prevent the collection of purulent secretions, and by enforcing perfect rest of the injured spinal column. Gunshot fractures of the vertebra are caused by the impact of shell- fragments, spent cannon-balls, and small-arm missiles, but chiefly by the impact of the last named, after they have penetrated the integuments and other structures that cover the spinal column at the place of injury, or have reached it by passing through the great cavities of the body and organs which lie in front. In some rare instances, however, the fractures produced by cannon-balls and shell-fragments are simple, the integuments covering them being unbroken. Gunshot fractures of the vertebrae are usually com- minuted in character as well as compound ; and they are very often com- plicated with injury of the spinal cord and other important organs. For descriptive purposes, gunshot fractures of the vertebrae may advan- tageously be divided into two classes — namely, those which are restricted to the apophyses, and those which involve the Fig- vertebral bodies also. The former are some- times, perhaps frequently, unattended by in- jury of the spinal cord ; the latter are but seldom uncomplicated with such injury. The former, too, are less fatal, as a rule, than the latter. The chief characteristics pertaining to gun- shot fractures of the spinal column, in general, are well shown by the following abstract, and by the wood-cut (Fig. 865) which accompanies it:— Showing a gunshot fracture of the body and left transverse process of the ninth ^ soldier was wounded by a conoidal pistol-ball dorsal vertebra. The niissile and nine frag ^^^.^^^ ^^^.^j^ ^ j^^j^ -^^j^^^ ments of bone are also shown, (bpec. 5738, V , , , , . . , /• i i p. • i Sect. I, A. M. M.) below and a httle to the inner side of the left nipple, passed backward, grazing the apex of the heart, through the left lung, and onward through the body and left transverse process of the ninth dorsal vertebra ; it lodged in the subcutaneous tissue of the back, from which it was extracted, together with some small fragments of bone, through a small incision. The patient was paralyzed below the middle. He died of traumatic pericarditis and j)neumonia, four days after the wound was inflicted.^ The deep groove across the spinal column which was punched out by the missile, and the comminution of the injured bone, are well depicted. The occurrence of paraplegia, of course, denotes that the spinal cord was also injured. I Op. cit., p. 38. 2 Circular No. 3, S. G. 0., August 17, 1871. GUNSHOT INJURIES OF THE VERTEBRA. 360 Sometimes the missile punches a ragged hole through the vertebral colunm obliquely from behind forward, and emerges from the body of a vertebra, having crushed the spinal cord in its course; as, for instance, it did in a specimen which the writer con- Fig- ^66. tributed to the Army Medical Museum, and which is represented by the annexed wood-cut (Fig. 86()) : The missile entered through tlie left intervertebral foramen between tlie third and fourth lumbar vertebrce, chipping the superior articular process of the iifth and the adjacent portion of the spinous process of the fourth, and fracturing the left transverse process of the fourth, passed obliquely forward and toward tlie right, and emerged from the body of the third lumbar vertebra on its right side. The patient 'survived long enough for incipient caries to appear in the injured bones.* In the celebrated and historical case of President Garfield, the ball penetrated the first lumbar ver- tebra in the upper part of the right side of its body (Fig. 867):- The aperture by which it entered involved the inter- vertebral cartilage next above, and was situated just below and anterior to the intervertebral foramen, from which its upper margin was about one-fourth of an inch distant. Passing obliquely to the left and forward through the upper part of the body of the first lumbar vertebra, the bullet emerged by an aperture, the centre of which was about half an inch to the left of the median Hne, and which also involved the intervertebral cartilage next above (Fig. 807). Showing gunshot fracture of the third lumbar vertebra with the mis- sile (a conoidal musket-ball) attach- ed. (Spec. 2.532, Sect. I, A. M. M.) Fig. 867. 12th Dorsal vertebra. 1st Lumbar vertebra. 2d Lumbar vertebra. Showing the hole made by the missile (a conoidal pistol-ball) through the body of the first lumbar vertebra, in the case of President Garfield. A probe penetrates each orifice. 2.^ The cancellated tissue of the body of the first lumbar vertebra was very much com- minuted, and the fragments were very much displaced. Several deep fissures extended from the track of the bullet upward into the lower part of the body of the twelfth dor- sal vertebra. Others extended downward through the first lumbar vertebra into the intervertebral cartilage between jt and the second lumbar vertebra. Both this cartilage and that next above were partly destroyed by ulceration. A number of minute frag- ments from the fractured lumbar vertebra were driven into the adjacent soft parts. On sawing through the vertebme from behind, a little to the right of the median line (Fig. 868), it was found that the spinal canal was not involved by the track of the mis- sile. The spinal cord and other contents of the spinal canal presented no abnormal ^ Medical and Surgical History of the War of the Rebellion, First Surgical Volume, p. 446. VOL. IV. — 24 370 INJURIES OF THE BACK. appearance. The fractured spongy tissue of the vertebrse was suppurating. The mis- sfle was lodged behind the pancreas. Secondary henaorrhage from the splenic artery had luperve^ed, causing death seventy-eight days after the infhct.on of the wound.' .Fig. 868. Fig. Interior view of the last dorsal and first two lumbar ver- Showing two lumbar vertebrae that were per- tebr^ in the case of President Garfield. They have been laid forated from behind forward and were fissured open 'from behind by sawing vertically through their lamin. vertically, through thexr bod.es by a cono^a and bodies, a little to the right of their spinous processes. musket-ball which passed :nto the perxtoneal The intervertebral substances have been destroyed by the in- cavity. ( Spec. 3583, Sect. I, A. M. M. ) flammatory process. The cancellated tissue of the bodies is extensively disorganized by suppurative osteomyelitis, as well as by the impact of the missile. |.. In the case of President Garfield, the shot fractures of the last dorsal and first two lumbar vertebrK were followed by suppurative osteo-niyehtis and de- struction by ulceration of the corresponding intervertebral disks, from which disorders arose the symptoms of septicaemia that presented themselves at one time in the history of his case, and, finally, the secondary hemorrhage that destroyed his life. The prognosis in cases of suppurative osteo-myehtis arising from vertebral fractures is always very bad ; in fact, such cases are scarcely amenable to any treatment. , ^ j i.i i i,„.. In the following example, a conoidal musket-ball penetrated the lumbar portion of the spinal column from behind, passed forward through the bodies of the vertebrai, having crushed the spinal cord, and entered the abdominal cavity, where it wounded the liver, and likewise caused peritonitis, which proved fatal in four days: — A corporal, having been wounded in front of Petersburg, on July 30 1864, was sent to Washington,\nd admitted to Douglas Hospital, on August 3, with complete paraplegia and peritonitis. He died on the same day Necrosc. Small-arm missiles, as, for instance, musket and pistol balls, etc of ten lodge in the bodies or apophyses of the vertebrse, m such a manner that e t ier heii position cannot be emctly ascertained, or they cannot be extracted in eonse- auence of the firmness of their impaction. This important class of spmal ?njurLs will be illustrated in a useful mariner by the next half dozen abstracts and wood-cuts : — A soldier, aged 20, was wounded in the back at Monocacy, Md., July 9, 1864, and admitted to hospital atFrederick, on the next day. The missile (a conoidal musket-ball) GUNSHOT INJURIES OF THE VERTEBRiE. 371 i t7 ^ iii i ik ' held entered at the inferior border of the left scapula, passed inward and backward, struck the spinal column, and lodged, having instantaneously caused complete paraplegia below the wound, with inability to micturate. On the 12th, the urine began to dribble away spontaneously, and defecation occurred involuntarily. He made no complaint of pain. Bed-sores over the sacrum, etc., depending upon the mal-nutrition of the parts which resulted from the injury of the spinal cord, soon followed. Nevertheless, he survived until October 13, and then died of pleuro-pneumonia. Necroscopy showed that the missile had passed through the left intervertebral foramen between the ninth and tentli dorsal vertebras, pro- ducing only a very slight fracture ; and, turning upward in the spinal canal, had lodged in it opposite the body of the fifth dorsal vertebra. The upper end of the spinal cord was much softened. The lodgment of the missile is well shown in the adjoining wood-cut (Fig. 870).^ A soldier, aged 26, was wounded at Cold Harbor, Va., June 3, 1864, by a conoidai musket-ball, which penetrated the right side of his back, shattered the right transverse and articular processes of the eighth and ninth dorsal vertebra?, and entered the spinal canaL He immediately lost all sen- sation and voluntary motion below the wound. On the Uth, he was admitted to general hospital. There was then psy- chical depression, with slow pulse, labored respiration, cold, clammy, and cyanosed skin, and involuntary passage of the excretions. Gastric irritability supervened, with rejection of all kinds of nourishment, and he died on July 2. 'Necros- copy revealed the missile imbedded in the spinal canal, as shown in Fig. 871. The spinal cord was severed and disorganized above and below the missile.^ Corporal G. W. M., aged 19, was wounded at Cold Harbor, Va., June 3, 1864, and admitted to general hospital on the 7th. He was suffering from paraplegia with reten- Showing the fifth, sixth, seventh, and eighth dorsal ver- tebrae, with the body, etc., of the fifth horizontally divided, and a conoidai musket-ball (also divided) lodged in the spi- nal canal. (Spec. 3984, Sect. I, A. M. M.) Fig. 871. Fig. 872. Showing a conoidai musket-ball lodged in the spinal canal between the eighth and ninth dorsal vertebra;. (Spec. 2939, Sect I, A. M. M.) Showing gunshot fracture of the left transverse pro- cess and body of the seventh dorsal vertebra, with the missile in situ. (Spec. 3030, Sect. 1, A. M. M.) tion of urine and traumatic pneumonia. A conoidai musket-ball had entered his back near the inferior angle of the left scapula, and passinir downward, inward, and forward through the left lung, had fractured the transverse process of the seventh dorsal verte- bra, and lodged in the body of the same. Owing to his extreme prostration, no anti- » Medical and Surgical History of the War of the Rebellion, First Surgical Vol., p. 440. 2 Ibid., p. 439 372 INJURIES OF THE BACK. Fig. 873. phlogistic measures of an active character were employed. Stimulating frictions were frequently applied to the legs and hips, and the chest was enveloped in an oil-skin jacket. He died on the 19th. Necroscopy The ball was found imbedded in the body of the seventh dorsal vertebra, encroaching upon the medulla spinalis, as represented in the accompanying wood-cut (Fig. 872). The lungs were hepatized at their bases ; and, near their apTces, were filled with a dark, frothy liquid.^ A colored soldier, aged about 25, was wounded at Brownsville, Texas, January 28, 1866, by a pistol-shot%nd died in thirty-eight hours, from shock and internal hem- orrhage. Necroscopy showed that the missile had entered two inches below and outside of the left nipple, gouged its calibre from the upper border of the eighth rib, passed downward, inward, and back- ward, through the lower lobe of the right lung, the diaphragm, and the right lobe of the liver, and had lodged in the body of the last dorsal vertebra, frac- turing it as shown in the adjoining wood-cut (Fig. 873), which represents the specimen now preserved in the Army Medical Museum.^ A quartermaster's sergeant, aged 36, was wounded at Compton, La., April 4, 1864, by a grape-shot, which entered his loins one inch to the right of the spinous processes, and about two inches below the last rib, and, passing forward and slightly downward and inward, struck the spinal column, and, lodging, was not extracted. On the 10th he was admitted into University Hospital, at New^'Orleans. There was no paralysis. The symptoms of pyaemia, however, supervened, and he died of that disease on the 18th. Necroscopy revealed a round iron ball, about one inch in diameter, lodged on the left psoas magnus muscle. The spinous processes and laminae of the last dorsal and first lumbar vertebra were frac tured and displaced, and thus the spinal canal was laid open. The specimen is repre- sented by the accompanying wood-cut (Fig. 874). Purulent infiltration was found in the psoas muscles, with their investments, and Showing a pistol-ball (calibre 37) lodged in the body of the last dorsal vertebra, hav- ing fractured the same with much commi- nution (Spec. 3780, Sect. 1, A. M. M.) Fig. 874. in the peritoneal cavity. Tw^o small circum- scribed metastatic abscesses were found in the right lobe of the liver. There were no signs of paralysis present during life.^ A sergeant of infantry was wounded at Opequon Creek, near Winchester, Va., Sep- Fig. 875. Showing fractures of the spinous processes and laminseof the last dorsal and first lumbar vertebrae, caused by a round iron ball about one inch in diam- eter. (Spec. 3739, Sect. I, A. M. M.) Showing a conoidal musket-ball imbedded in the intervertebral substance between the third and fourth lumbar vertebrae. (Spec. 3796, Sect. I, A. M. M.) tember 19, 1864, by a conoidal musket-ball, which penetrated the lumbar region through the erector-si)inae muscles, a few inches above the posterior crest of the ilium, and lodged. 1 Med. and Hiivg. History of the War of the Rebellion, First Surgical Vol., p. 438. 2 Ibid., p. 441. ' Ibid., p. 443. GUNSHOT INJURIES OF THE VERTEBRA. The left ankle and lower third of the femur were shattered, for which amputation of the thigh was performed. The only symptom, indicating that the spinal cord or spinal nerves were injured, was paralysis of the right leg. Necroscopy.— The missile was found imbedded in the intervertebral substance between the third and fourth lumbar vertebra?, as shown in the adjacent wood-cut (Fig. 875), which represents the speci- men. There was very little pus in the wound.* Prognosis. — Gunshot lesions of the sphial cokimn are very serious injuries. They proved fatal in more than one-half of the instances which came under treatment during our late civil war ; and many who sustained such injuries must have perished on the tield before any treatment could be adopted. Six hundred and forty -two cases of gunshot injury of the vertebrpe were reported by our military surgeons during the late civil war. Of these, three hundred and forty-nine, or 55.5 per cent., proved fatal; one hundred and seventy-five soldiers were discharged from the service; one hundred and four were returned to duty ; while, in fourteen instances, the result is not known. Again, of these six hundred and forty-two cases, the cervical vertebnie were injured in ninety-one, with a mortality of sixty-three, or 70 per cent. ; the dorsal vertebrge, in one hundred and thirty-seven, with a mortality of eighty- seven, or 63.5 per cent. ; the lumbar vertebrae, in one hundred and forty-nine, with a mortality of sixty-six, or 45.5 per cent. ; the cervical and dorsal, in two instances, of which one proved fatal; and the dorsal and lumbar, in three instances, which all proved fatal. In two hundred and sixty cases, where the injured vertebrae were not specified, one hundred and twenty-nine, or 49.4 per cent., proved fatal. . , . . . . , The percentaa:e of mortality above stated is, for vertebral injuries in the cervical region,"70, for those in the dorsal region, 63.5, and^ for those in the lumbar region, 45.5. Other things being equal, the prognosis is less unfavor- able in cases where the dorsal vertebrae are wounded by gunshot missiles, than it is in cases where the cervical vertebrae are injured in this manner ; and, in cases wdiere the lumbar vertebrae are affected, it is much less unfavor- able than it is in cases where the dorsal vertebrae are involved, and very much less unfavorable than it is in cases where the cervical vertebrae are injured. Gunshot fractures of the cervical vertebrae, when attended by complete paraplegia, are almost always fatal ; and, generally, death occurs before the fourth day in such cases. I had under my care at the battle of Fair Oaks, May 31 and June 1, 1862, two cases in which there were fractures of the lower cervical vertebrae caused by musket-balls. In both cases, the upper as well as the lower extremities, and all the parts and organs that were suppUed with spinal nerves which issued from the spinal column at or below the seat of the lesions, were completely paralyzed in respect to both sensation and voluntary motion. There was retention of urine and feces, and catheterization iiad to be resorted to. The respiration was entirely diaphragmatic, for all the respiratory nerves, excepting the phrenic, were paralyzed. The inferior margin of the thorax was also drawn inward, whenever the diaphragm contracted, thus reducing the antero-pos- terior and lateral diameters of the chest, as well as increasing the vertical diameter thereof, at the end of every movement of inspiration. The muscular wall of the abdo- men was relaxed and flaccid till tympanites supervened, which added much to the respiratory embarrassment. Both patients died asphyxiated ; one of them on the third, and the other on the fourth day after the injury was inflicted. The intellect was clear in both cases, and there were no head-symptoms w^hatever, until the stupor of asphyxia approaching a fatal termination appeared. No autopsies were held, from want of time to make them. 1 Ibid., p. 450. 374 INJURIES OF THE BACK. A. M. Soteldo was wounded, on Thursday night, February 9, 1882, at the editorial rooms of a Washington newspaper, by a cylindro-conoidal pistol-ball, which entered the back of his neck four inches below the occipital protuberance and slightly to the left of the median line, passed forward and slightly upward, fractured the lamina of the fourth cervical vertebra a little to the left of the spinous process thereof, penetrated the spinal dura mater (theca vertebralis), and imbedded itself in the left intervertebral foramen between the fourth and fifth cervical vertebrae, having bruised and slightly lacerated the spinal cord, and driven into its substance a small splinter of bone. He immediately became " paralyzed from the head down," that is, all of his extremities and the whole of his body below the neck, were completely deprived of sensibility and voluntary motility. The respiratory movements were performed by the diaphragm alone. He died at 10 h. 25 m. on the night of Saturday, the 11th, about forty-eight hours after the casualty occurred. The autopsy revealed the course and place of lodg- ment of the missile, and the injuries done by it, which have just been described. The missile weighed, after extraction, eighty-seven grains. There is, however, recorded in the first surgical volume of the Medical and Surgical History of the late Civil War, at page 430, a case of gunshot fracture of the body of the third cervical vertebra, with lodgment of the missile and complete paraplegia, in which recovery was secured by persevering treatment A brief abstract of this case should be presented in this place, because it will encourage surgeons to give more attentive treatment to such cases, by show- ing that they are not always hopeless : — An infantry soldier, aged 20, was wounded at Gettysburg, July 2, 1863, by a conoidal ball, which entered the right upper Hp at the second incisor, destroyed all the teeth save the last molar, on the same side of the upper jaw, passed below the soft palate into the pharynx, and penetrated the body of the third cervical vertebra, where it lodged and was not extracted. But in the following August, the position of the ball was ascer- tained by a Nekton's probe, and it was then extracted. " There was paralysis in all four hmbs, from which, however, he rapidly recovered ; and, for a time, did duty as hospital attendant." On March 14, 1864, this patient was transferred to Turner's Lane Hospital, at Philadelphia. Acting Assistant-Surgeon W. W. Keen, Jr., on duty at that hospital, states that " nearly the entire body of the third cervical vertebra has come away, including the anterior half of the transverse process and the vertebral foramen. No injury to the vertebral artery has been disclosed. What supports his head ante- riorly I cannot conceive. On May 3, he was transferred to Washington to be assigned to a company in the Veteran Reserve Corps. The only remnant of his paralysis is some rioss] of sensation over a surface, say three by four inches, at the back of ricrht neck. Some bone still is occasionally discharged." In April, 1871, this man was yet alive ; and the pension-examiner reports that the right side of his tongue is distorted, leaving his speech affected ; that the right side of his throat is contracted ; and that his right shoulder and arm are diminished in size and partially paralyzed. Disabihty three-fourths and permanent. But gunshot fractures of the spinal column, and particularly those in the cervical and upper dorsal regions thereof, are generally mortal, unless the lesions be confined to their apophyses.^ In the Schleswig-Holstem campaign of 1849, Stromeyer observed that "injuries of the spinous processes frequently occurred without serious consequences— without accidents from concussion of the spinal marrow."^ During the late civil war I saw a considerable number of cases in which the spinous processes alone had been broken off by the im- i In the British army, during the Crimean war, "all the fractures of the vertebra were promptly fatal, except two among the officers and two among the men, all of which were either fractures of the transverse processes in the neck, or of the spinous processes only. (Medical and Surgical History of the British Army in the War in the Crimea, etc., vol. ii. p. 33/.) Ihus it appears that the only cases of shot fractures of the vertebrae which terminated m recovery among the British soldiers and officers wounded in the Crimean war, were those in which the lesions were restricted to the spinous and transverse processes. « Op. cit., p. 37. GUNSHOT INJURIES OF THE VERTEBRA. met of small-arm missiles, withovit any apparent Assuring of the Jaminae or Cdies etc., of the i.yured vertebra, and without any serious lesion of he sr inal cord These mtients all recovered.' In some of these case., 4>mal mralvBis too, was prLent at the outset, but it probably arose from coucus- fon Klie spi^^^ c^ord, for it soon passed away. Professor Ashhurst men- t onsrin point, the case of a soldier, seen by himself, who was wounded by a murket-ball in the lumbar region. The missile entered to the left side of the rnal eolumn, carried awav°the spinous process of a lumbar vertebm, and lodS ; t was extracted f^m the right hip many months afterward At fiSere was spi.ial paralysis. This soldier recovered to the Veteran Reserve Corps. Near y two y-ears ^o jj| '^^^l his back was yet stiiF, and occasionally pamtul. Most ot the T04 patients Savin- -uI4o^t lesions of the spinal column, who recovered and were returned to duty m our army during the late civil war, doubt ess sustain turefof the spinous or transverse processes. Indeed, the abstracts ot the uccesstl cL^ belonging to this oategoryswhich are P-^tef - die sur- gical history of the war, strongly support this view. It is, tlieietoie, Dui feasonable to conclude, that in cashes of gunshot fracture ot the vertebra the pro.'nosis is verv much less unfavorable when the lesion is restricted to the sDinous or transVerse processes, than when other parts are involved. '^^A few, however, of the on^ hundred and four patients having gunshot fratturel of the vertebrae got more or less completely well again when he SeTor the lamiu., or fhe vertebral pedicles were broken -he^^J^^ sDinal cord was at the same time considerably injured. For, in httj-tour ca es of ^uiilhot injury of the vertebra, complicated by traumatic lesions of ?he cord °forty-two were fatal, and twelve partially recovered and were dis- SarS-^th various degrees'of physical disability. The -^e^ of eontusK,n and Sommotionof the spinal cord are not included in this °f W.' .^,f at least of those who were returned to duty must have been attected with contuti^n and commotion of the spinal cord, and with lesions oi the vertebrae more severe than fractures restricted to their apophyses. Professor Paul F. Eve' reports two cases of gunshot injury of the spinal column, whTcU the Vict ms long survived, and in which the missiles remamed lodged n, he nine A^ain! Surgeon C. S. Tripler, U. S. Army ,^ relates the case of an otHcer who, rr839 dSg the'last Seminole'campaign in Florida, -""/tction'orAe iLt rifle-ball, which penetrated on the right side, ,n a line w, h the junction ot the last dorsal and first lumbar vertebrae, struck the spinal column, lodged, and There were complete paraplegia and pr aprsm w,tl> ■''''^f T '"'oved The He survived for welve years. The paralys.s, however, but slightly ™1'™^'^';'. catheter, and laxatives o/enemata, had to be used for fout two years ha - "t^U m 1841, h^ found that he could stimulate th«Wadder and rectum t^coM^^^^^^ the side of his penis behind the corona glandis ' M. Hulin, ot the F;"^'' "^'^y' tions the case of a soldier, aged 20, who, in 183o, was wounded in ' « " ^'f^^^^ The ball entered on the right side, near the first and second lumbar «^ and lod^^ therein, was not extracted. There was immediate paraplegia. In t ee jn*= he wound healed. This soldier survived the injury burteen years ^"f f ^^'^^ ^ American Journal of the Medical Sciences, July, 1868, pp. lOd-107. p. 438, of the First Surgical Volume of the Med. and Surg. History of ^^^^^^^^f^^^J^J^f^^^^^^^^^ in which tickling of the glans penis likewise produced i"-;"ation f "^/^^f .^^.^"'''^^^ bladder, by exciting the detrusor urinse muscle to contract, (bee page 40/. e«/ra.) ^ Lancet, 1849. 376 INJURIES OF THE BACK. disorganized. M. Louis, the most celebrated French surgeon of the eighteenth cen- tury,^ relates the case of a soldier who, in 1762, received a gunshot wound of the dorsal spine, in consequence of which he became completely paralyzed in the lower limbs ; the wound was enlarged at once, and the ball taken out. Louis saw the patient on the fifth day after the casualty ; he found that there were several fragments of bone press- ing upon the spinal cord. He removed these fragments ; and, although there was a considerable suppuration after this operation, the paraplegia slowly but gradually disap- peared, and the patient was completely cured, excepting a slight weakness which remained in his lower limbs. Twelve years afterward, however, he still had to walk with a cane. These facts and examples are mentioned niainly with a view to encourage surgeons to conduct in a thorough manner the treatment of gunshot fractures of the spinal column, in all instances which come under their care, by showing that, even in cases where re- covery is impossible, life may be greatly prolonged by careful treatment. The prognosis of these cases is rendered much more unfavorable by the occurrence of inflammation of the spinal membranes or spinal cord, as doubt- less happened in the following instance : — A soldier, aged 19, was admitted to Emory Hospital, Washington, August 25, 1862, for a gunshot wound of the back, received on the night of the 22d. He was then in great pain and very restless, but not paralyzed in any part. Fig. 876. An anodyne was prescribed, with cold applications to the wound. He passed a restless night, and morning found him wearied and anxious, very restless, with an occasional tetanic spasm, though not severe. An anaesthetic was administered, the wound was enlarged, and the missile (a conoidal musket-ball) was found impacted between the laminae of the first and second lumbar vertebrae, the spinous process of the second having been broken ofi*, as shown in the accompanying wood-cut (Fig. 876) which represents the specimen. The missile was extracted with much difficulty. All spiculae of bone were then carefully removed, the wound was drawn together by adhesive straps, and cold-water dressings were applied. The oper- ation of an enema of assafoetida and turpentine left the patient in a profound sleep, disturbed occasionally, how- ever, by slight spasms of short duration. His bowels acted twice that night ; the micturition was free, and there were no symptoms of paralysis. On the 27th, there was marked increase in the severity of the tetanic symptoms. The enema was repeated, but without effect. Chlorolbrm was now brought to his relief, and its use continued until 10 A. M., when he died. Necroscopy. — The ball was found to have destroyed the spinous process of the second lumbar vertebra, and to have buried r.self, apex foremost, between the laminae of the first and second, in the spinal canal, braising and pressing upon the spinal cord.^ The condition of the spinal membranes does not appear to have been noted at the autopsy. Nevertheless, the symptoms which characterized this case, e. g., the intense rachialgia, the extreme degree of restlessness, and the tetanic spasms, are symptoms which often present themselves in cases of idiopathic, as well as in cases of epidemic, spinal meningitis ; and, no doubt, there was traumatic spinal meningitis of an acute character in this case. The patient survived the onset of the acute symptoms, less than two days. It also ap- pears that chloroform was administered continuously for several hours before death occurred. Was the proximate cause of death the disease, or the chlo- 1 Mcmoire postlmmo. Archives Gen. de Medecine, etc., Aout, 183G, p. 397 ; Brown-Sequard's Lectures on the Central Nervous Hystem, p. 251. 2 Medical and Surgical History of the War of tlie Rebellion, First Surgical Volume, p. 444. Showinsf gunshot fracture of the spinous process of the second lum- bar vertebra, with the missile im- pacted between the laminae of the first and second. (Spec. 611, Sect. I, A. M. M.) GUNSHOT INJURIES OF THE VERTEBRA. 377 roform which was administered in order to relieve the symptoms? In six additional cases of gunshot injury of the vertebral column, during the late civil war, analogous symptoms were reported ; and it appears that these cases were all fatal. Another bad prognostic in gunshot injuries of the spinal column is the occurrence of bed-sores^ especially wlien they arise from the trophic disorder of the tissues which results from lesions of the spinal cord. A still more evil poi'tent in such cases is the appearance of metastatic abscesses, especially when they spring from the septicoemia that results from suppurative inflammation of the cancellated tissue (osteo-myelitis) of the fractured vertebree. A considerable number of instances of this sort were reported during the late civil war; and metastatic abscesses arising from this cause were more recently observed in the case of President Garfield, already mentioned above, where it is stated that the fractured spongy tissue of the injured vertebrae was suppurating, and that the adjoining intervertebral car- tilages were partly destroyed by ulceration. Diagnosis. — The presence of an open wound that has been made by a gun- shot missile, the track of which extends in a direct line to the vertebral column, the impairment of function evinced by the stricken portion of the Vertebral column, and the exploration of the wound with a finger, whenever practicable, by which the fragments of the broken vertebrae themselves can be felt, usually suffice to establish the diagnosis in a satisfactory manner.^ Treatment.— If the missile has lodged, it should be found and extracted, if possible. All foreign bodies, e. g., bits of clothing and of accoutrements, blood-clots, and detached or quite loosened splinters or fragments of bone, should likewise be extracted. The utmost cleanliness should be observed, antiseptic dressings should be applied, drainage-tubes should be used to pre- vent any collections of matter from being formed in the wounds, and necrosed fragments of bone should be removed as soon as they become detached. Fragments of the vertebrae were extracted, after gunshot fractures thereof, in twenty-four instances during the late civil war. Of these cases only ten were fatal.^ In all of the fourteen cases which did not prove fatal, there was recovery more or less complete. In seven of the nine instances in which the spinous process alone, or portions of it only, were extracted, the patients recovered speedily as well as completely, and were returned to duty, or ex- changed. In one instance belonging to this category, which was under my care for two and a half months at Stanton Hospital, there was paraplegia from concussion of the spinal cord, as well as gunshot fracture of the spinous pro- cess of the second lumbar vertebra. Several fragments which became detached were promptly removed, and the paralysis, all things considered, rapidly passed away.^ This man's recovery was complete, for his name is not on the pension-list, nor have his heirs made application for pension.''^ But, in five successful cases wherein portions of the laminae or of the transverse pro- cesses w^ere removed, the results were much less satisfactory ; nearly all of these patients were still suffering from serious disabilities in 1872.^ ^ There is, however, on record the case of an officer, in which a pistol-ball, after fracturing the right humerus, passed into the chest, and, lodging, was not extracted ; fifteen days afterwards, he died of pneumonia and secondary hemorrhage. Necroscopi/ showed the missile firmly imbedded m the body of the fifth dorsal vertebra, nearly the whole of which was shattered. Nevertheless, no spinal symptoms had been develoj^ed, and the lesion itself had not been suspected during life. The specimen is preserved in our Army Medical Museum (No. 3515, Sect. I). (Medical and Surgical History of the War of the Rebellion, First Surgical Vol., p. 436.) '•^ Medical and Surgical History of the War of the Rebellion, First Surgical Vol., p. 459. ^ American Journal of the Medical Sciences, October, 1864, p. 327. * Medical and Surgical History of the War of the Rebellion, First Surgical Vol., p. 459. 5 Ibid. 378 INJURIES OF THE BACK. A2:ain, in order to prevent the occurrence of inflammatory lesions in the spinal membranes and spinal cord, absolute quietude should be enjoined on the patient. Catheterization, and laxatives, or enemata, as well as the pre- cautions against bed-sores and vesical and renal inflammation which have already been mentioned, should be promptly employed whenever their use is indicated. Whatever complications may arise, e. g., osteo-myelitis of the fractured vertebra, spinal meningitis, spinal myelitis, septicaemia, bed-sores, nephritis, cystitis, etc., should be promptly met by appropriate treatment. On Trephining (so called), or Eesection of the Spinal Column. The operation of excising parts of the vertebrae with a trephine, a saw, a bone-forceps, or a chisel and mallet, and removing the same, when they are fractured and displaced so as to cause paralysis by compressing the spinal cord, has been sug2:ested by many surgical writers, the earliest of whom was Paulus ^gineta. ^It was 'flrst perforaied, however, by Henry Cline, at St. Thomas's Hospital, June 16, 1814, in the case of a man, aged 26, who, by falling from a second-story window, on the previous day, had received an injury of the dorsal vertebra, with considerable displacement, and had become paraplegic. The man having been put upon the operating table with his face downward, an incision was made through the skin over the projecting spinous processes, of sufficient length to expose them completely. The muscles were then divided on each side, and, being drawn outward, two spinous processes, which were broken at their roots, were removed. It was attempted (but ineffectually) to remove the eleventh vertebral arch by sawing it through with Machell's circular saw ; a chisel and maflet were then em- ployed, and also a trephine, by means of which the separation was effected, and the arch lifted out with an elevator. The operation was considerably embarrassed by the unfitness of the instruments, and occupied considerable time, but afforded no relief. In the evening he complained of pain in the wound; pulse 114. June 17, 2 P. M. Had not slept since the operation ; pulse 130. At 6 P. M. he had a fit, and was thought to be dyincr. June 18, 1 P. M. Had another fit ; had great difficulty ot breathing, with much restlessness; pulse 140 ; upper part of body in a cold sweat, lower part warm, but not perspiring. At 4 P. M. the spasms had abated. June 19. He was more tranquil, but gradually sank, and died at 5 P. M. without convulsions, and sen- sible to the last. Autopsy The fore and upper part of the body of the twelfth dorsal vertebra was fractured obliquely from above and behind, downward and forward. The upper fragment remained attached by the intervertebral substance to the body of the eleventh dorsal, which had moved forward and a little downward, tearing off the pos- terior haff of the intervertebral cartilage from the top of the twelfth dorsal vertebra. The theca vertebralis was lacerated, opposite the seat of injury, in four places, two of which would admit the little finger. The spinal cord was three-fourths torn through, and the remaining portion was bruised.^ Mr. Cline himself candidly stated that he thought the operation had hast- ened the death of his patient. The lesions for which he operated consisted of fracture of the body of the twelfth dorsal vertebra with displacement (partial dislocation) of the body of the eleventh (to which the fragment ot the twelfth still adhered), forward and slightly downward, and extensive, laceration of the spinal cord. He removed two spinous processes, and the laminai of the twelfth dorsal vertebra. The foregoing abstract shows the true character of this operation, the difiiculties which attend its performance, and its positive harmfulness as well as its inutility, more clearly and m fewer i South's Notes to Chelius's Surgery, vol. i. pp. 590, 591, Am. ed. GUNSHOT INJURIES OF THE VERTEBRA. words, than any (lisquisition on the subject could do. Moreover, this opera- tion has been repeated many times, without success. Trofessor Ashhurst has collected and tabulated 41 cases in which it has been performed. Of the whole number of patients, 30 died, 3 were relieved, and 3 received no beneht, while of 5 cases the result is unknown. There is no example of a cure achieved by it on record. Surely the general results in these cases would ^ have been much better if the operation "had not been performed. It is not improbable that even the few who were apparently relieved by it would have done better w^ithout it. The operation of resection or trephining the vertebnie is unjusti- fiable, because it does not offer a reasonable prospect of improving the patient's condition in any case, while, on the other hand, there is always reason to fear that it may increase the chances of a fatal termination. M. Louis's operation, w^hich was performed in 1762, is sometimes referred to as the first instance in wdiich the spinal column was resected, but it w^as not a resection at all. It consisted merely in extracting some loose fragments of bone, on the fifth day, in a case of gunshot fracture involving a dorsal vertebra. The patient improved, but, twelve years later, still had to walk with a cane, as has already been stated above. Moreover, the same operation w^as performed in twenty-four instances during our civil war, and with quite satis- factory results. But resection of the vertebrae is not admissible in gunshot in- juries of the spine. Mr. G uthrie ' mentions a patient Avho had received a pistol- shot which lodged in the last dorsal or upper lumbar vertebra, and caused complete paralysis of both limbs, and who searched London and Paris, in vain, to find a surgeon willing to operate on him. Professor Paul F. Eve, of ^^'ashville, Tenn., however, once did attempt to perform such an operation,^ in the case of a Confederate soldier, who had been wounded by a pistol-ball that entered to the left of the spinal column, about one inch from the spinous process of the sixth dorsal vertebra, in the cavity of which, or of the seventh, it was supposed to be lodged. Paraplegia immediately ensued, and the para- lysis proved to be permanent. Concerning the operation of resecting the dorsal vertebra, which was attempted, Profi Eve says: "After due prepara- tion, a free incision was made through the cicatrix, and an attempt made to follow this into the vertebral cavity ; but so deep was the vertebral groove down to the transverse processes, so indistinct the track of the missile — indeed, we could not trace it — so deceptive the intervertebral foramina, etc., but, above all, so great the risk of exciting infiammation by wounding the sheath of the spinal cord, that we concluded, after using one crown of the trephine, of medium size, over what all believed to be the hole made by the bullet, to desist from further application of it. I am satisfied," he continues, "that this operation, in the dorsal vertebrae, if not almost impracticable, is certainly one of the most difficult in surgery." That the operation of trephining the spinal column or resecthig the verte- brae will not relieve the spinal cord from compression, when it is exerted by the extravasation of blood, is proved by the case of a derrick-man, aged 41, in whom the laminae of the tenth dorsal vertebra were resected, at P>ellevue Hospital, by Dr. Stephen Smith; for, notwitlistanding that from 8 to 12 ounces of extravasated blood, having a dark color, escaped from tbe spinal canal after the depressed bone had been extracted, the compression of the cord from extravasated blood, and the paraplegia, steadily crept upward, and finally caused death by asphyxia.^ 1 Commeutaries, etc., p. 541, Am. ed. 2 American Journal of the Medical Sciences, July, 1868, p. 106. 5 New York Journal of Medicine, 1859, pp. 87, 88. 380 INJURIES OF THE BACK. III. Il^JUEIES OF THE SPIRAL MEMBKA^N-ES, SPmAL CORD, AND SPmAL iTERYES. Injuries of the Theca Vertebralis, and Meninges of the Spinal Cord. The spinal dura mater, although but loosely connected with the bodies of the vertebrse, is elsewhere strongly attached to the vertebral walls, at frequent intervals, by means of processes sent out through the intervertebral foramina around the spinal nerves. Consequently, when the vertebrae are fractured, or displaced in luxations, the spinal dura mater is extremely liable to be stretched, bruised, or torn. I assisted, on one occasion, at the autopsy in a case in which there were fissured fractures of the fifth, sixth, and seventh cervical vertebrae; there was little displacement, yet the theca vertebralis was found smeared with blood opposite the fractures, and torn open so widely as to allow the index- finger to pass through with ease. (See page 301.) So too, in Mr. Cline's case, which has just been related, the theca vertebralis, at the autopsy, was found lacerated in four places, two of which would admit the little finger. But to multiply examples of this sort would be useless ; for it is quite obvious that, in all fractures of the vertebral rings with displacement, whether the frag- ments spring back into place again or not, and in all luxations of the vertebrae, the theca vertebralis mast be correspondingly injured by the stretching, bruis- ing, or tearing which it of necessity sustains from the sudden displacement, or from the sharp edges and splinters of the broken or dislocated bones. ^ But aside from strains, bruises, and lacerations, the theca vertebralis may be penetrated by incised and punctured wounds of the back. Many instances are on record in which such wounds of the theca vertebralis were made by knives, daggers, swords, lances, arrows, and bayonets, and with such imple- ments of industry as chisels, etc. Several examples have already been men- tioned in this article. (See page 270.) When such wounds are attended by a discharge of cerebro-spinal fluid, there is no doubt that the theca vertebralis has been opened. When the wound is situated in the loins, and the discharge of the cerebro-spinal fluid is profuse, the nature of the lesion may be mis- taken, and it may be supposed that the ureter has been laid open. There is published in the sixtieth volume of the Medico-Chirurgical Transactions, a case in which a copious flow of limpid fluid occurred from a wound in the back, and in which it was believed that the ureter had been laid open, although it was admitted to be possible that the fluid might be cerebro-spinal.^ Mr. T. Holmes^ relates two cases in which a similar copious discharge of watery fluid was caused by a wound of the spinal membranes, which did not involve the spinal cord nor the large nerves, as was proved by the post-mortem examination in one case, and by the position of the puncture in the other. Incised or punctured wounds of the back, which open the theca vertebralis without injuring the spinal cord or spinal nerves, do not, of themselves, pro- duce any nervous phenomena, inasmuch as the loss of the cerebro-spinal fluid is usually but gradual, and the fluid itself is rapidly resecreted. Secondary inflammation of such wounds, however, may interfere ^yith the functions of the spinal cord or spinal nerves, and may even destroy life in that way. But when such wounds are uncomplicated, the prognosis is generally favorable. There may, however, be great difficulty in getting permanent closure of the wound in such cases ; but there will be more chauce of getting it if treat- 1 Lancet, April 29, 1882; American Journal of the Medical Sciences, July, 1882, p. 294. INJURIES OF THE SPINAL CORD AND SPINAL NERVES. 381 merit to that end be employed at once, than if it be postponed to a later period. Gunshot wounds of the spinal dura mater not unfrequently occur. ^ In cases where they are present, the vertebne are always fractured, and the spinal cord, likewise, is generally injured. Many examples have been presented in the foreo-oino; pai^^es in which the theca vertebralis was torn by gunshot mis- siles? Sometimes, as in the case of Soteldo (p. 374), the bullet penetrates the theca and lodges tberein. In others, it perforates that membrane, and leaves behind an orifice of emergence as well as of entrance. In others still, it tears a furrow transversely across the tube which the theca vertebralis forms when in situ, and partially divides the same. The amount of thecal inflamma- tion aroused by gunshot injuries is in most instances, I think, not great. At an autopsy which I made some years ago, in a case in which the last-named form of injury was found, I was rather surprised at the absence of inflamma- tion, although the patient had survived the casualty twelve days, and I made the following note at the time concerning it : "There was moderate hiflani- matory action, adhesive in character, of the theca vertebralis. It was confined to the immediate neighborhood of the wound. There was no pus." It is my belief that the spinal dura mater is normally endowed with a wonderful ability to resist traumatic lesions and their consequences. But injuries of the spinal arachnoid and pia mater not unfrequently cause inflammations of a destructive character therein, which will be discussed under tlie head of Traumatic Spinal Meningitis. Moreover, suppurative inflammation of the connective tissue, and^ abscess, may occur between the spinal dura mater and the vertebral column, in conse- quence of the injury thereof, especially when the latter has sustained a simple fracture without displacement ; two examples of this have already been pre- sented under the caption of latent fractures of the vertebrse. (See p. 349.) Injuries of the spinal meninges are often attended by extravasation of blood within the theca vertebralis, and compression of the spinal cord result- ins; therefrom. Many instances have been mentioned in the foregoing pages, and eight additional examples will be presented in the next section of this article Treatment. — Incised and punctured wounds of the back, which penetrate the theca vertebralis and let out the cerebro-spinal fluid, should be treated by immediate closure and antiseptic dressings for the wounds themselves, and by absolute quietude for the patients. Gunshot wounds involving the theca vertebralis require for treatment the removal of all foreign bodies, such as blood-clots and loose fragments of bone, as well as bullets and bits of clothing, the employment of antiseptic dressings, with drainage-tubes, and perfect rest for the injured spine. Simple fractures or dislocations of the vertebrae, which do injury to the theca vertebralis, should first be "set" or reduced if possible, and then in- flammatory action in the injured parts should be restrained by abstracting blood with leeches or cups, by applying cold, and by securing perfect rest for the injured structures. Injuries of the Spinal Cord and Spinal ITerves. The histological elements of the spinal cord, its nerve-fibres, ganglion-cells, minute bloodvessels, and connective tissue, are so lacking in strength and solidity that, were the cord as a whole not protected from the eflfects of exter- nal violence by an elastic medium, the cerebro-spinal fluid, Avhich everywhere surrounds it, the elementary structures that compose it would be disintegrated 382 INJURIES OF THE BACK. by every sudden shock, as well as by every sudden pressure and the impact of every vulnerating body, which might be brought to bear upon it. The traumatic lesions to which the spinal marrow is exposed are (1) con- cussion^ (2) contusion^ {S) compression^ and (4) wounds (incised, punctured, and lacerated), which partially or completely sever it. Concussion of the Spinal Cord. — As the symptoms of concussion of the brain result directly from cerebral " shock,'' so the symptoms of concussion of the spinal marrow result directly from sudden " shock" Fig. 877. of that organ ; as concussion of the brain is nearly always attended by minute extravasations of blood, or ecchymoses, so probably concussion of the spinal marrow is usually accompanied by minute effusions of blood into its substance and as the symptoms of concussion of the brain consist of a more or less complete suspension of the cerebral functions, so the symptoms of concussion of the spinal marrow consist of a more or less complete spinal paralysis, which, however, is usually ephemeral in character. But concussion of the spinal cord, when extremely se- vere, may instantaneously destroy life. For instance : — Major Mills, an officer serving on the staff of Major-General Humphreys, then commanding the Second Army Corps, was killed, March .31, 1865, during a reconnoisance, by a cannon- ball (round) which grazed his left lumbar region in such a way as to open the abdominal cavity and let out some intestine. General Humphreys says "he rolled up his eyes and fell from his horse dead." Surgeon Charles Page, U. S. Army (Medical Director, 2d Corps), to whom I am indebted for the case, thinks he must have died from " shock," for there was no solution in the continuity of any organ found on post-mortem inspection which would cause immediate death per se. While this view is doubtless correct, it is not improbable that the " shock" itself caused death by producing concussion of the spinal cord of so severe a kind, that all the respiratory muscles, including the diaphragm, were at once completely paralyzed thereby. Again, death from this cause may ensue in a few hours. For example : — Morgagni'^ relates the case of a man injured by falling from a vine. He was speechless and paralyzed, and bled from the nose and mouth. The urine and feces escaped involuntarily. Death ensued in four hours. Necroscopi/ revesded fractures of the six upper dorsal vertebrae, ribs, and skull. (Ashhurst.) Ordinarily, in cases of vertebral fracture or disloca- tion attended with spinal paralysis, there is at first retention of urine and feces, because the sphincter muscles still remain active, while the muscular coats of the bladder and intestines are paralyzed. I^ot so in Showin-g the spinal cord and the roots of the 31 pairs of spinal nerves, with the cervical, axillary, lumbar, and sacral plexuses. Also one of the two chains of ver^ tebral ganglia (nervi syni- pathici), and the commu- nicating threads. 1 There is, however, a case of concussion of the spinal cord on record in which there was para- plegia that persisted (for three weeks) until death was produced by other causes, and, on autopsu, no lesion of the cord could he discerned. " No fracture of the vertebra existed, nor were any appearances found in the spinal column sufficient to account for the persistent para- plegia." Medical and Surgical History of the British Army in the Crimean War, vol. 11. pp. 337, 338. 2 De Sedibus et Caisis Morborum, t. iii. INJURIES OF THE SPINAL CORD AND SPINAL NERVES. 383 this case, however, for the sphincter muscles, too, weie i>aralyze(l from the outset; and this circumstance shows that tlie nervous centres upon wliich their activity depends, together witli the syini)athetic ganglia — tlie iiervl sympathici — suffered from concussion as well as the spinal cord. Fractures of the spinal column are often attended hy concussion of the spinal cord, much oftener, I fancy, than dislocations are. Occasionally, concussion of the spinal cord is attended hy a peculij^iy violent shock to the nervi syinpathtci^ as was noted hi the following iiighly instructive example : — Surgeon A. F. Mechem, U. S. Army, was injured by jumping from a railway train while Tn motion, June 21, 1870. The fall caused partial concussion of the spinal cord, and severe shock to the sympathetic nervous system. Wlien seen, shortly afterw^ard, slight reaction had come on ; still, there was extreme hyperajsthesia of the chest, neck, and upper extremities, which were of a cyanotic hue ; cerebral functions undisturbed. The heart's action, almost suspended when first seen, rose under stimulants. Wlien reac- tion had fairly taken place, there was violent arterial action at the wrist, but unaccom- panied by similar action in the temporal and carotid arteries ; in fact, the action of these vessels coincided in neither force nor frequency with that of the radial and ulnar arte- ries. Nor was the action of the heart, at any time after the pulsations became normal, other than healthy, although the extraordinary throbbing at the wrist continued several days. Excepting slight paralysis of the bladder, there was no loss of motor power. At first, the terrible hyperaesthesia of tlie hands and arms caused a suspicion that there might be a fracture or a dislocation of the cervical vertebrae, which, by pressing upon the spi- nal nerves, produced the terrible pain. However, a careful examination showed that there was neither fracture nor dislocation, but that the cause of the symptoms was to be found only in the spinal cord and sympathetic nervous system. Morphia was adminis- tered hypodermically, and afforded much relief. Cupping, with hot applications of lead- water and laudanum, alternating with fomentations of hops and laudanum, to the arms, hands, and thorax, assisted materially in mitigating the pain. Some three days after the injury, the use of morphia was in a great measure dispensed with, Indian hemp and hyoscyamus being substituted. The hop-fomentations were superseded by applications of chloroform and camphor, alternated witli morpliia and simple cerate. Tonics, nour- ishing diet, and stimulants, contributed much toward recovery ; but his health remained delicate. In January, 1871, he availed himself of a leave of absence for one month, which was extended six months longer, for the benefit of his health. He died July 14, 1871, in consequence of the accident; no autopsy reported.^ Concussions of the spinal cord are often caused by gunshot injuries. I have reported three examples in the American Journal of the Medical Sci- ences,2 in an article on Injuries of the Spine. In one of them the spinous process of the second lumbar vertebra was fractured. The symptoms were spinal paralysis (paraplegia), both motor and sensory ; the former being more pronounced than the latter, which gradually subsided. Dry cups applied daily over the spinal column were found useful. The abstract of another case, taken from my field note-book, will consider- ably aid in illustrating the symptoms of this accident : — April 6, 1865, I examined a fine cavalry soldier, aged 19, at the field hospital near Jetersville, Va., who had been wounded at Amelia Court House, on the 5th, by a conoidal musket-ball, which passed through the back part of his lumbar region, obliquely from side to side, injuring the spine. He had paralysis, as to motion, of the parts below. The sensibility, too, was diminished, but not entirely destroyed. He complained of hypersesthesia in the front and inner part of each thigh. He said that he had been hurt in these parts by the fall of his horse, and by being trampled upon, during the cavalry charge at Amelia C. H. on the 5th. He said that both lower extremities felt benumbed. His bladder was paralyzed, and catheterization indispensable. He also said that he did 1 Circular No. 3, S. G. 0., Aiisnst 17, 1871, pp. 112, 113. 2 No. for October, 1864, pp. 325-328. 384 INJURIES OF THE BACK. not feel the catheter in the urethra until it reached the prostatic portion. He told this while the instrument was being introduced. Evacuation of the bladder afforded much relief from distress, for which he expressed his gratitude. Was the disorder in this case concussion of the spinal marrow ? Yes ; for the persistence of sensibility in both lower extremities, when the primary injury was caused by a minie ball, shows that the con- tinuity of the spinal marrow was not seriously impaired. April 8. Saw this patient again at Bul k's Junction ; condition as to paralysis unchanged. April 11. Still no change ; he was sent to-day to the depot field hospital at City Point, and thus passed out of my sight. Professor Ashhurst^ relates the case of a soldier, who had sustained a gunshot fracture of the spinous process of a lumbar vertebra, with concussion of the spinal cord. At first, there was spinal paralysis ; but the man recovered and was transferred to the Veteran Reserve Corps. Dr. George McClellan^ mentions two cases, in which gunshot missiles entered the small of the back and lodged, where their impact caused concussion of the spinal cord and "total paraplegia of all the parts below." The paralysis, however, was but tem- porary ; for both patients got perfectly well again under the use of laxatives" and counter-irritants. The symptoms vary greatly with the case, and according to the severity of the concussion itself, from simple motor enfeeblement of the lower extremities, with numbness" and " pins and needles," on the one hand, to complete para- plegia both motor and sensory, with priapism and retention of urine and feces, on the other. Not unfrequently, intense hypersesthesia is also present, as was noted in the following very instructive case of concussion of the spinal cord in the cervical region, with ecchymosis of the left posterior horn of gray matter, of the right anterior horn, and of the posterior columns. The inju- ries resulted from a fall, and the case is related by Sir W. Gull :^ — A coal-porter, aged 33, slipped and fell down some cellar-stairs, with a sack of coal falling upon him. He was admitted at 3 P. M., June 22, atter the accident; there was loss of motion in both legs and in left arm ; the sphincters were paralyzed ; sensation was entirely lost in left arm up to deltoid ; sensation and motion in right arm perfect ; in the lower extremities, he could feel about the feet and on the outer side of thighs, but not on the anterior and inner surface ; slight priapism ; breathing diaphragmatic. Sen- sation returned in every part after a few hours ; the most distant parts apparently recov- ered first. As the skin became warm he complained of pain when lightly touched (hyper^esthesia). For instance, when the finger-nail was lightly passed over the skin he exclaimed, " Don't prick me ; don't hurt me !" Next day, the cutaneous sensibility appeared to be excessive, judging from his exclamations when the skin was touched or pinched. This was noticed especially in the right arm. The priapism disappeared in two hours after admission, but returned on the day following ; power to move the right arm remained ; thirty -four hours after the accident the patient died. Autopsy — There was no external trace of injury. The membranes of the cord were healthy. The substance of the cord was contused opposite the fourth and fifth cervical vertebrae. On section, there was found ecchymosis of the posterior horn of gray matter on the left side, and of the adjacent part of the lateral and posterior columns. There were also limited spots of ecchymosis on the right side, one in the right posterior column, and one in the right anterior horn of gray matter. The gray substance generally was hyperaemic. On removing the spinal cord and membranes, nothing abnormal was discovered in the ver- tebrae until the posterior ligament had been dissected off, when it was seen that the body of the fourth w^as separated from that of the fifth, and that the left articular process of the fourth had been chipped cfi\ The essential features of this instructive case are : (1) the cord-substance was injured by concussion, and not by any displacement of the parts ; (2) the 1 Op. cit., pp. 116, 117. 2 Principles and Practice of Surgery, p. 177. 8 Guy's Hospital Reports, 1858, pp. 191, 192. INJURIES OF THE SPINAL CORD AND SPINAL NERVES. 385 injury was attended by a number of minute extravasations of blood (ecchy- moses) in the gray substance ; (3) there were aniesthesia and loss of motion in both lower extremities and in the left arm ; (4) there was paralysis of the sphincter ani and sphincter vesicae, which denoted that the reflex motor appa- ratus was also paralyzed ; (5) the anjesthcsia passed away in the course of some hours, the return of sensibility being noted first in the parts most distant from the injury; (6) hypenesthesia appeared synchronously with the reaction from "shock," and steadily increased in severity; (7) hypenemia of the gray substance was found as well as ecchymosis. It should be remarked that the hyperresthesia was more severe in the right arm than elsewhere, and that this part had not at any time been paralyzed. It should also be noted that the byper?esthesia was coincident in its appear- ance with the hypeniemia of the cord-substance which followed the injury, and that as the inflammatory excitement caused by the sanguinolent extrava- sations of blood into the cord -substance, or the hyper«imia, etc., increased or progressed, the hypen^esthesia also rapidly increased until thirty-four hours after the accident, Avhen death occurred. Treatment. — Inability to urinate and defecate will necessitate the employ- ment of catheterization, and of enemata, or laxatives. When hypersesthesia is present, it must be subdued by the administration of belladonna, or of opium or morphia. Dry-cupping the dorsal and lumbar regions has, in my own experience, proved very useful in cases of gunshot concussion of the spinal cord. At a later stage, counter-irritation by issues or setons has appeared to do good. But, quietude or rest for the injured spinal column and cord is an important reparative measure, in such instances, fully as important as any other. ISTot only should the patient be debarred from attempting to over- come his " numbness" and his " pins and needles" by exercise, which caprice or habit might lead him to do, but he must be kept in bed until these s^-mp- toms have passed away. Mr. Hilton^ mentions the case of a gentleman who had sustained a moderate concussion of the spinal marrow from falling upon his back at Epsom, which resulted in irremediable paraplegia, from inatten- tion to this curative measure. Should the symptoms of myelitis supervene, they must be combated by the remedies for that disease which will be men- tioned further on. Contusion of the Spinal Cord. — Bruises of the spinal marrow, like bruises of the cerebrum, are attended by disintegration of the elementary tissues thereof, and minute extravasations of blood, or ecchymoses. There is, how- ever, this important difference between them ; for, inasmuch as the cineritious substance is mostly found on the exterior of the cerebrum and within the interior of the spinal marrow, so the ocular evidences of contusion are usually seen, most distinctly, on the exterior or cortex of the former, and within the interior of the latter ; and it frequently happens that contusions of the spinal marrow are not discernible by the unaided eye, until the parenchyma thereof is laid open by an incision, and until the cineritious substance is thus exposed to view. The slighter examples of contusion of the spinal cord, those in which the ecchymoses are not large nor numerous, are commonly, and almost unavoid- ably, classified, in practice, with the cases of concussion of the spinal marrow which have just been described, and in wdiich the symptoms of spinal con- cussion constitute the chief clinical phenomena, and among which, at the bed- side, no differential diagnosis between concussion and contusion of the spinal VOL. IV. — 25 » Op. cit., p. 33. 386 INJURIES OF THE BACK. marrow can be made. The following case, observed by Mr. Savorj,i ^.^li serve to show what the symptoms are in severe contusions of the cord : — A man fell upon his head from a railway van. During the first few minutes he was stunned, but this soon passed off. When admitted to hospital, there was complete loss of motion and sensation in the lower and upper extremities, and in the trunk nearly as high as the clavicles. The respiration was entirely diaphragmatic, the thoracic walls sinking inward at each inspiratory effort. No reflex action could be excited in the lower extremities, nor elsewhere. The pupils were moderately and equally dilated, but sluggish. There was partial priapism. Death ensued in about thirty hours. Autopsy. There was no fracture nor displacement at any part of the skull or spinal column ; there was also no hemorrhage nor material congestion at any part on the surface of the brain or spinal cord. But a longitudinal section of the spinal cord revealed, opposite the fourth cervical vertebra, a clot of blood which was extravasated in its substance to the extent of about half an inch. This extravasation was well defined, and nothing wrong could be perceived in the adjoining or in other parts of the cord. In this case the functions of the spinal cord were completely abolished in two important particulars: 1. There was entire loss of sensation and volun- tary motion. 2. There was also total absence of any reflex action. While the clot of blood, the product of contusion, which w^as found in the substance of the spinal cord at the autopsy, accounts satisfactorily for the former, it does not for the latter ; for while the blood-clot might completely destroy the power of the spinal cord as a conductor of impressions, it could not destroy its functions as a reflector of impressions or as a nervous centre. And inas- much as the loss of reflex action, observed during life, was due to destruction or impairment of the spinal cord as a nervous centre, it must, as pomted out by Mr. Savory, have arisen from the concussion to which the spinal cord was subjected by the accident, although it produced no efiect on the structure of the cord that was visible after death. This loss of reflex action in the spinal nerves, in consequence of concussion of the spinal cord, mentioned above by Mr. Savory, I had myself previously observed; and I specially noted it at the time of making* the observation, although I did not then understand its rationale. The following abstract is taken from the note-book in which the minutes of the case were written at the time : — Private John H. Rhodes, Company A, 16th Pennsylvania Cavalry, aged 22, was ad- mitted from our front before Petersburg to the Depot Field Hospital, at City Pomt, December 14, 1864, for injury of the spine and paraplegia. On the 15th, I examined him with much interest. It appeared that he had been hurt, while lying face down- ward on the ground, on Sunday, the 11th, by the falling of a tree, some branches belonaint^ to the top of which struck him violently across the back and shoulders. He was imm^'ediately deprived of the use of his legs and the lower half of his body. When I saw him, all the parts below the umbilicus were completely paralyzed, both as to sen- sibility and voluntary motility. The bladder required a catheter to be introduced twice a day ; the urine was more abundant in quantity than natural. He passed a consistent stool unconsciously in bed on that day. " I failed to excite any sensibility or any reflex action by tickling the soles of bis feet, or by pulling the hairs of his legs, thighs, or groins. Both extremities were ahke in these respects." Above the umbilicus, sensi- bihty gradually appeared in the skin, at first indistinctly, but increasing with the upward procuress of the examination, until it became normal on the upper part of the thorax. The respiration was abdominal (diaphragmatic), and superior thoracic (superior inter- costal). He liad good use of both upper extremities, and made no complaint of them whatever. He was cautiously turned upon his right side, so as to permit an examina- tion of his back. The consistent stool, above mentioned, was then found m bed. Before this, his bowels had not acted at the hospital. There was no appearance of contusion » St. Bartliolomew's Hospital Reports, vol. v. p. 45. INJURIES OF THE SPINAL CORD AND SPINAL NERVES, 387 nor ecchymosis on the integuments of his back and shoulders. There was no deformity nor abnormal mobility found in the spinal column. There was moderate tenderness under pressure when made upon the vertebrae, at the upper part of the dorsal region. He did not complain of being hurt in any part while being turned over in bed. He had considerable cough, with expectoration ; sputa unstained. His face had a dusky hue (not deep). He swallowed both solids and fluids without difficulty. Did not complain of distress in any part ; no priapism. He died on Saturday the 17th, six days after the accident, from failure of the respiratory function. Autopsy Among the muscles, near the upper dorsal vertebrae, a small quantity of blood was found extra vasated, but no cutaneous ecchymosis. The laminae of tiie first dorsal vertebra and the body of the second were fractured, with but little if any dis- placement ; that is, there was a fissured fracture which extended through the laminiB of the first and the body of the second dorsal vertebra. The anterior common ligament was torn partly through, and the posterior common ligament was loosened or detached to some extent at the seat of fracture. Between the theca vertebralis and the bone, on the left side of the spinal canal, in the same neighborhood, a thin blood-clot was found. It was about two inches long by one-fourth of an inch in breadth, and did not compress the spinal cord. There was no extravasated blood within the theca vertebralis. The spinal cord, externally, presented no abnormal appearance whatever. It was not dis- colored, nor notciied, nor lacerated. But, on making a longitudinal section, the gray substance of the interior was found to present an ecchymosed and contused appearance opposite the fracture, but not elsewhere. Here it was dark-brown in color from the ex- travasation of blood, and pulpefied in consistence from the force of the contusion. These lesions were symmetrically developed. The spinal membranes and spinal cord were not inflamed. The lungs (both) contained more than the normal quantity of blood, that is, they exhibited passive hyperaemia, but in other respects they were sound. This abstract touches all the essential points pertaining to concussion and contusion of the spinal cord. The blow struck by the falling tree upon this man's spinal column, as he lay face downward on the ground, suddenly bent it downward (that is, forward) at an acute angle, by severely stretcliing and so partly rupturing the anterior common ligament, and by making a rent or fissured fracture which extended upward through the body of the second and the laminae of the first dorsal vertebra. The fragments immediately sprang back into place again. But the blow and the abrupt bending of the spinal column mortally injured the spinal cord. The elementary tissues composing its interior were disintegrated, or reduced to a pulp-like consist- ence, and were deeply stained with blood extravasated from the ruptured capillaries. ^ The conducting power of the cord was totally destroyed either by the force of the blow itself, or by the pressure which the extravasated blood exerted upon the conducting fibres of the cord. Moreover, the con- cussion or " shock," which the spinal cord received from the blow, abolished its ofiice as a distinct centre of the nervous system, over a large space, with- out leaving any alterations of structure whatever to account therefor, that were visible after death. Thus, the man was wholly deprived of reflex motor activity, as well as of sensibility and voluntary motion, in all the parts supplied with spinal nerves which depart from the cord below the lesion of its substance just described. The loss of reflex motor action in the paralyzed parts was as complete in this case, as it was in that which precedes it, and in both alike the post-mortem examination failed to reveal any anatomical cause. From the autopsies of cases such as these, the statement appears to be well founded, that concussion of the spinal marrow, unless it be compli- cated with contusion, is not attended by any structural change of the marrow which is discernible after death, with the unaided eye. Anatomical Lesions attending Bruises of the Spinal Cord. — In such cases, the theca vertebralis is very rarely found torn ; and, on laying it open, one might imagine the cord to be uninjured, in many instances, because the pia 388 INJURIES OF THE BACK. mater of the cord remains entire and without ecchymosis, as it did in the cases just related. On slicing the cord, however, its substance is found to be crushed more or less completely through and through, and blackened by extravasated blood. Sometimes the co^rd-substance is utterly smashed and broken down into a diffluent pulp throughout a space one inch or more in length, while the pia mater over it remains entire. In other instances, ecchy- mosis is plainly visible on the outer surface of the cord. Occasionally, this ecchymosis is very considerable in degree and extent. For instance, Lasalle^ reports the case of a man, aged 36, and a maniac, who injured his neck by violently throwing his head forward, while struggling against restraint. His head remained bent forward, and there was spinal paralysis. Death ensued thirty- six hours afterward. Necroscopy showed that the intervertebral substance between the bodies of the fifth and sixth cervical vertebrae was torn through, without any frac- ture, and with but slight displacement of the implicated bones. Great ecchymosis, however, was found on the spinal cord. Symptoms. — Besides the signs of spinal paralysis already mentioned, e. g., the destruction of sensibility, of voluntary motion, and of reflex motor action, in the parts supplied by spinal nerves which issue from the cord below the bruise, another important symptom, namely, hypersesthesia, is not unfre- quently observed. For example, Mr. Bryant ^ relates the case of a coal-porter, aged 33, who fell down stairs with a sack of coal on top of him, and broke his neck. He had spinal paralysis, priapism, and diaphragmatic breathing ; but, after a few hours, hyperaesthesia came on. In thirty-four hours death ensued. Necroscopy revealed fracture and displacement of the fourth and fifth cervical vertebra. The cord was contused but not compressed. The hyperaesthesia does not appear to have been caused by injury of the spinal nerves, but by changes that were taking place in the bruised part of the spinal cord. There are not yet on record so many examples of contusion of the spinal marrow, with a full account of the symptoms and post-mortem appearances observed in each, that we can safely trust to generalizations drawn from them, and thus dispense with giving the particulars of the cases, when discussing the subject. The details of the following example are very instructive :— Mr. South^ relates the case of an old man, aged 68, who was injured and stunned by falling down stairs, and who was admitted to St. Thomas's Hospital a few hours after- ward? He had pain at the back of his neck, which was increased by pressure ; all his limbs, except the left lower extremity, which still retained sHght motion, were palsied ; the sen- sibility of the whole right side of the body was morbidly acute, that of the left totally destroyed, excepting on the belly, where he felt slightly, and to which he referred a sensation of numbness when "the left thigh was pinched. Next day he complained of pain in the right arm ; the skin on the left side of the belly was less sensible. On the third day the morbid sensibility of the right side had diminished, and sensation had shghtly returned on the left. He complained of pain in the right hypochondrium, and fancied that his arms lay across his chest. On the following day the belly became tym- panitic. On the fifth day there was slight motion of the left arm, and the capability of moving the right leg had increased; but he ^vas rapidly sinking, although in good heart, and died late at night. On examination, it was found that the atlas was broken in two places, the line of fracture being diagonal, and traversing the left vertebral hole. The pivot of the axis was broken off at its root, and a small piece of the body also. The fifth vertebra was fractured through the body. With neither fracture was there sufficient displacement to produce pressure. On cutting through the spinal cord a central cell was found, containing a small quantity of blood, and the substance of the spinal cord was broken down and disorganized opposite the fifth vertebra. i*Gazette Medicale, 1841. ^ Guy's Hospital Reports, 3d series, vol. v. 3 Notes to Chelius's System of Surgery, vol. i. p. 585, Am. ed. INJURIES OF THE SPINAL CORD AND SPINAL NERVES. 389 This patient survived the accident something less than six days. Both the hypereesthesia and the spinal paralysis that were observed in his case, arose from the contusion of the spinal marrow, that is, from the disintegration of its elementary tissues, and the extravasation of blood therein, and from the secondary lesions of the marrow, hyper^^mia and hyperplasia, which w^ere induced by the injury. Still, as the absorption of the blood extra- vasated in the bruised part of the spinal cord progressed, the symptoms of spinal paralysis, e. g., the loss of sensibility and voluntary motion, decreased in corresponding degree. The hyper^esthesia also varied from day to day. To sum up the" symptoms which present themselves in cases of contusion combined with concussion of the spinal cord, they are : loss of sensibility, loss of voluntary motion, and loss of reflex motor action in all the parts supplied by those filaments of the spinal cord which are direcUy or indirectly injured by the contusion of the cord, or which issue from the spinal cord below the seat of contusion, occurring suddenly and coincidentally with the injury of the cord itself; also hyperoesthesia which, not unfrequently, comes on some hours, or even days, after the injury has been inflicted. Furthermore, concussions and contusions of the spinal cord, like disloca- tions and fractures of the spinal column, may be attended by very consider- able deviations of the body-heat from the normal, both above and below, as was pointed out on page 335. Mr. Erichsen, in particular, has seen spinal concussion attended by marked and prolonged lowering of the vital tem- perature. Contusions of the spinal marrow with extravasations of blood into the substance thereof, are of not unfrequent occurrence. Besides the foregoing examples, M. Brown-Sequard^ mentions a case by Walker, in which there was dislocation of the fourth cervical vertebra ; an incision showed that there was no fracture. The dislocation was reduced, and the patient was improved thereby. Death, however, ensued in six days. Necroscopy revealed hemorrhage in the spinal €ord. Mr. Luke^ relates the case of a laborer, injured by being knocked against the side of a ship, with which the back of his neck came in contact. Projection of the vertebrae in the neck, spinal paralysis, priapism, etc. were noted. In two days death occurred. Necroscopy showed fracture of the sixth cervical vertebra ; the spinal cord was en- larged and softened ; it also contained a blood-clot. Mr. SoUy^ reports the case of a plasterer, aged 40, who fell from a scaffolding, strik- ing his head, and being stunned. There were paralysis of the right side, a scalp-wound, and a fractured clavicle. He died in forty hours. Necroscopy revealed fractures of the fourth and fifth cervical vertebrae ; also hemorrhage into the spinal cord, which was soft and bruised. M. Colin* reports a case of hemorrhage into the spinal cord. Treatment. — The therapeutical indications to be fulfilled in contusions of the spinal marrow are the same as in concussions of the spinal marrow, which have already been described. Compression of the Spinal Cord. — The nerve-fibres, ganglion-cells, and bloodvessels of the spinal cord, may be fatally compressed by blood when it is extravasated into the substance of the cord itself, into the spinal menin- ges (by intra-thecal hemorrhage), or into the spinal canal external to the theca vertebralis ; also by the displacements of bone which arise from dislo- cations and fractures of the veitebrse, and by foreign bodies when they have 1 Op. cit. » Ibid., 1851. 2 Lancet, 1850. < L'Union Medicale, 1862. 390 INJURIES OF THE BACK. entered the spinal canal ; finally, the spinal marrow may^ be mortally com- pressed by the products of inflammatory action which are liable to be eflTused in all cases of spinal meningitis or myelitis. Compression of the filaments and other elementary structures of the cord from blood extravasated into its substance, not unfrequently occurs, and ex- amples in considerable number have been presented. But this subject has already been sufiiciently discussed in connection with contusion of the cord. Compression of the spinal marrow from hemorrhage within or upon its membranes has likewise been illustrated in many instances that have been presented in the foregoing pages. As extravasations of blood between the cranium and the cerebral dura mater, or into the cerebral meninges, often destroy life by compressing the brain, so extravasations of blood between the spinal column and the theca vertebralis, or inside of the sheath formed by that membrane, not unfrequently destroy life by compressing the spinal mar- row. Mr. Hutchinson ,1 however, asserts that although much has been said about large efiusions of blood into the spinal canal as a cause of paralysis, such efiusions are, he believes, the rarest of occurrences, for he has " never seen auy eff'usion to the extent of possible compression, and in the majority of cases there is little or none." That this eminent writer's belief on this important point is singularly inaccurate, many cases, already mentioned in this article, in which large efi'usions of blood were found in the spinal canal, on examination after death, bear strong testimony ; and this evidence can be corroborated by presenting many others of a like nature. For instance: — (1) Dupuytren^ mentions the case of a soldier having a gunshot wound of the neck. There was almost complete paralysis. Death ensued twenty-four hours after the injury. The autopsy showed fractures of (he fourth and fifth cervical vertebrae ; cord unhurt ; much blood effused in the spinal canal, and at the base of the brain. (2) Murney^ reports the case of a laborer, aged 22, who fell from a scaffold twenty- feet, striking his back. He walked to a neighboring house. In two hours paralysis began ; priapism with retention of urine and feces followed ; skin hot. Death occurred in lour days. The autopsy revealed fractures of the fifth, sixth, and seventh cervical, and of the first dorsal vertebrae ; no displacement ; blood-clots on the spinal cord, which also was softened. (Ashhurst.) In this case, the coming on of paralysis some hours after the accident, and the gradual increment of the symptoms, kept pace with the sanguinolent effusion in the spinal canal. (3) Hutton* records the case of a man, aged 35, thrown from a cart into a ditch. There were " stunning," paralysis, and dyspnea ; and death ensued in four days. The autopsy revealed dislocation of the fifth from the sixth cervical vertebra, with shght fracture ; cord softened ; and extravasated blood. (Ashhurst.) In respect to symptoms and spinal-cord lesions, this case strongly resembles the last. (4) A very great extravasation of blood occurred within the theca vertebralis in a case under the care of Dr. Stephen Smith, at Bellevue Hospital, some years ago- The patient was a healthy, temperate, and well-nourished derrickman, aged 41, injured by being thrown from a cart and striking his back upon the pavement ; he was not ren- dered unconscious, and did not feel hurt until some one attempted to raise him ; then he found that he was paralyzed, and that motion caused him intense pain. On October 12, P.M., he was admitted to the hospital, two hours after the injury, in a state of collapse; pulse too frequent and feeble to be counted; respiration 18. There were complete sensory and voluntary-motor paralysis of the lower extremities and body up to the sixth intercostal space ; moderate priapism ; normal temperature. The subjective symptoms were severe pain in the back of the neck, and pain, numb- ness, and tingling in the arms. Objectively, nothing abnormal was found in the cervical region ; but, in the dorsal region, a depression was discovered between two spinous 1 London Hospital Reports, vol. iii. 1866. • Dublin Medical Journal, vol. xxiv. 2 Op. cit. * Ibid., vol. xvii. INJURIES OF THE SPINAL CORD AND SPINAL NERVES. 391 processes in which two fingers could be laid ; no corresponding abrasion or ecchymosis visible. A free administration of stimulants, with an anodyne and catherization, were ordered. On the 13th, A.M., pulse 112; respiration 26, and mainly abdominal ; temperature of trunk and lower extremities exalted.' The anaesthesia had progressed upward, having risen to the fifth rib. The pain and numbness of the neck and arms had decidedly in- creased. The penis was not erect, but it was easily excited on irritating the spine. P.M., sloughs had commenced upon the heel and upon the ball of the great toe of the left foot, and over the external malleolus of the right ankle. A consultation was held, and resection of the depressed dorsal lamina? was agreed upon, and at once performed under chloroform. An incision six inches in length, made in the line of the spinous processes, showed a depression of the arch upon the right side of one of the lower dorsal vertebrse. After some difficulty, the arch was divided on the opposite side, and then the depressed lamina3 were pulled out by a duck-billed forceps. Through the opening thus made, from six to twelve ounces of dark-colored, extravasated blood flowed out of the spinal canal. No benefit resulted from the operation, and death occurred soon afterward, apparently from compression of the spinal cord. The autopsy revealed fracture of the body of the tenth dorsal vertebra upon the right side, extending from the base of the transverse process half way to the mesial line an- teriorly, without displacement ; fracture of the arch of this vertebra upon the right side, with depression ; extravasation of blood within the theca vertebralis to a large amount, and extending from the lower cervical vertebrae to the sacrum. From the increasing paralysis it was inferred that this extravasation was still extending upward when the patient died.^ This man's accident showed so many things clinically and experimentally, that the history of it is well worth the space consumed. It illustrated compression of the spinal cord, with ascending paralysis from intra-vertebral effusion of blood ; it proved that neuropathic sphacelus may simultaneously appear at several different points in the extremities within twenty-four hours after the injury to the spinal cord ; it illustrated the inutility of vertebral resection; and it proved that the operation of trephining the spine will not relieve the cord from compression arising from blood effused upon it. (5) J. Jardine Murray^ reports the case of a woman, aged 62, thrown from a car- riage. There were paralysis and retention of urine, and next day coma ; in twenty -four hours death occurred. The autopsy showed fractures of the fifth and sixth cervical vertebr£e ; spinal canal filled with clotted blood ; cord unhurt. (Ashhurst.) (6) Ch. D. Doig^ relates the case of a porter, aged 37, who fell into the hold of a steamboat, and hurt his neck. There were pain, paralysis, dyspnoea and dysphagia, retention of urine and feces, and insomnia ; in four days, death ensued. The autopsy revealed fracture and dislocation of the fifth cervical vertebra ; clotted blood effused on the spinal cord; cord itself unhurt. (Ashhurst.) (7) W. T. King* reports the case of a laborer, aged 25, thrown from a cart with his neck across a hamper. There were par;j.lysis, etc. ; death occurred in fifty hours. The autopsy showed dislocation forward of the sixth cervical vertebra ; no fracture ; and blood extravasated around the spinal cord. (Ashhurst.) (8) Holt^ records the case of a man, aged 45, injured by a horse falling upon him. Paralysis came on in the following night ; but no cerebral symptoms. In seven days death ensued. The autopsy revealed fracture of the fifth, sixth*, and" seventh cervical vertebrse ; blood effused into the spinal canal, and had fallen tP the bottom of it ; spi- nal cord uninjured ; a tumor in the cerebellum. (Ashhurst.) (9) Charles Bell® mentions the case of a man who fell from a barge into the Thames, at low water. His head stuck in the mud, and he died instantly. Subluxation of the 1- New York Journal of Medicine, January, 1859, pp. 87, 88o 2 Edinburgh Medical Journal, N. S., vol. vii. 8 Ibid., vol. ix. 4 Lancet, 1849. s Ibid. 1850. 6 Observations on Injuries of the Spine and Thigh-bone 392 INJURIES OF THE BACK. seventh cervical upon the first dorsal vertebra was found, and effusion of blood. (Ash- hurst.) (10) Malgaigne^ refers to the case of a carter, injured by a wheel passing over his neck and shoulder. There were pain, paralysis, etc. In thirty-one hours death occurred. The autopsy showed subluxation of the sixth cervical vertebra, with slight fracture. The spinal cord was stretched, and blood effused. (11) Sir W. Gull relates the following case •? A man, aged 40, fell backward from a moderate height with a plank on top of him, and was at once brought to the hospital (4 P. M., July 7). He was collapsed, but sensible, and partially paralyzed in the. upper as well as in the lower extremities. No injury of spine discoverable. As reac- tion came on, and he grew warm again, the paralysis wore off. At 10 P. M. he said he was comfortable. He passed a restless night. At 8 A. M. (July 8) he was en- tirely paraplegic in the upper as well as in the lower extremities ; sensation lost as well as motion ; priapism ; abdomen tense and tympanitic ; the breathing was wholly dia- phragmatic ; the ribs scarcely moved in inspiration ; deglutition difficult ; temperature of the surface increased ; during the day the skin became intensely hot, but the actual temperature was not noted ; fifty-five hours after the accident death ensued. Autopsy. — No external evidence of spinal injury. "Extravasation of blood outside the theca vertebralis, on its anterior aspect. The effused blood compressed the cord, which other- wise was uninjured. After careful examination there were not found any signs of bruising of its tissue. The extravasation apparently arose from injury to the lower part of the body of the fourth cervical vertebra, which had been fractured, and the inter- vertebral substance torn. The calibre of the canal was slightly encroached upon by the displacement of the fourth vertebra, but not so as to press on the cord. The extrava- sation, though not abundant opposite the injury, extended downward to some distance. The membranes of the cord were uninjured." The interspinous and capsular ligaments between the fourth and fifth cervical vertebrae were torn through, and the articular pro- cesses dislocated. It is worthy of remark (1) that the symptoms of paralysis which arose from the " shock" or concussion of the spinal cord, in this case, passed ofi' in a few hours ; (2) that there supervened a paralysis, both motor and sensory, which gradually increased until it became complete and extended up to the neck, and which was shown by necro- scopy to have resulted from the effusion of blood in the spinal canal between the theca and the bone ; and (3) that the substance of the cord did not exhibit any appreciable lesion, notwithstanding the compression it had sustained from the sanguinolent effusion. Were it essential to a correct exhibit, additional examples might be cited, but these eleven cases, together with some twenty others which have already been related or referred to above, are enough to prove beyond a doubt that compression of the spinal marrow arising from hemorrhage into the spi- nal canal is not a rare occurrence, as asserted by Mr. Hutchinson ; and, fur- thermore, that any surgeon, however large his practice may be in this class of injuries, is liable to fall into errors of belief concerning them, when he generalizes solely from his own experience. The diagnostic symj)tom of cord-compression, when it arises from the extrava- sation of blood in the spinal canal, is paralysis of sensation and voluntary motion, commencing in the legs a few hours after the accident, and gradu- ally extending upward to the chest and neck, as the extravasation progresses upward in the spinal canal, and joari passu with the same. M. Brown-Sequard states, in his Dublin Lectures, that hemorrhage into the substance of the spinal cord may be distinguished from hemorrhage around it, by the sensibility gradually decreasing, and by there being no convulsions. When the hemorrhage is merely around the cord, and compresses the roots of the spinal nerves, there are-convulsions, as well as paralysis of voluntary motion.^ 1 Traite des Fractures et des Luxations, t. ii. * Guy's Hospital Reports, 1858, p. 193. 3 New Sydenham Soc. Year-Book, 1859, p. 41. INJURIES OF THE SPINAL CORD AND SPINAL NERVES. 393 Compressions of the spinal marrow, ai'ising from the displacements of dislocated and frac- tured vertebrae, have already been mentioned with sufficient particularity while presenting il- lustrative examples of the spinal dislocations and fractures which produce them. Compression of the spinal cord by foreign bodies which have entered the spinal canal, will be sufficiently illustrated by the subjoined ab- stract and wood-cut (Fig 878): — A soldier, aged 40, wounded May 8, 1864, was ad- mitted to a General Hospital on the IStli, in a para- plegic condition, and died a few hours afterwards. Necroscopy. — A conoidal musket-ball entered over the lower ribs on the left side, and, penetrating deeply, had lodged between the laminae of the second and third lum- bar vertebra? and partly in the spinal canal, compress- ing and bruising the cord. (Fig. 878.) The bladder was distended.^ Compression of the spinal marrow by the products of inflammatory action, as, for example, by serous and by purulent effusion, will presently be discussed under the heads of Traumatic Spinal Meningitis., and Traumatic Myelitis. Wounds of the Spinal Cord. — Incised and punctured wounds of the back, w^hich penetrate the spinal column, as well of those made by gunshot missiles, sometimes involve the spinal cord also, and divide it either partly or wholly. Three cases, in which incised or punctured wounds of the back extended into or across the spinal cord, have already been related. (See pp. 269, 270.) In all of them the parts supplied by the cut filaments of the cord were paralyzed. Two recovered (one completely, the other partially) and one died. Inasmuch as the patient who recovered completely, had, for some time after the wound was inflicted, entire loss of voluntary motion and partial loss of sensibility in the right leg and thigh, it was believed that the divided portion of the cord had grown together again, or united, in the course of about two months, when the paralysis ceased in toto, and the cure was perfect. Li the fatal case there was complete paraplegia, both motor and sensory, from the moment the vv^ound was inflicted. Acute bed-sores (sphacelus) soon supervened, and caused •death in thirty-six -days after the injury. The cord had been completely divided by the knife, and there was no attempt at reunion. Dr. Eli ITurd^ reports a remarkable case of recovery from an incised wound of the spinal cord : — In jumping from a wagon, the man's feet slipped, and he fell on his back. In at- tempting to rise he found his lower extremities paralyzed. Calling for help he stated that a chisel, which he had carried in his coat-tail pocket, was sticking in his back ; to extract it, required the united efforts of several men. It measured five inches in length to the shoulders, was seven-eighths of an inch in width, and from one-fourth of an inch at the shoulders tapered to one-eighth of an inch in thickness at the cutting end. It had entered to the shoulders. During the extraction, the patient suffered very little, but said that he saw apparently vivid fiashes of light, which were followed by total darkness. The wound was opposite the spinous processes of the lower dorsal vertebra?. Total loss of cutaneous sensibility below the wound, with total loss of voluntary motion 1 Medical and Surgical History of the War of the Rebellion, First Surgical Volume, p. 447. ^ New York Journal of Medicine, 1845. Fig. 878. Showing the second and third lumbar vertebrae, with a conoidal musket-ball lodged between their laminae, projecting into the spinal canal, and compressing the cord. (Spec. 3523, A. M. M.) 394 INJURIES OF THE BACK. in the corresponding parts, and paralysis of the bladder and rectum, were the imme- diate consequences. The patient was prostrated for forty hours, and then reaction was followed by fever for several days. The wound healed rapidly. The urine was with- drawn by a catheter for eight days. Cutaneous sensibility returned on the fifth day, and imperfect use of the limbs about the fifteenth. After five years he still walked with crutches. Dr. Hurd fully believed that the spinal marrow was divided in this case, and that afterward it united or grew together again. Dr. T. Peniston ^ relates another successful case : — A man, aged 34, received a stab-wound from a dagger between the eleventh and twelfth dorsal vertebrae, on the right side. It was attended by paralysis of the right leg. In eight months he recovered so far that he walked with a cane or crutch. (Ash- hurst.) The following example is very instructive as well as interesting : — M. Vigues^ reports the case of a man, aged 28, who was admitted into Professor Nelaton's ward, at the St. Louis Hospital, on February 4, 1850, shortly after he had been wounded in the back with a sword by a poHce-officer. The point of the weapon, entering three centimetres (one inch) from the line of the spinous processes and to the right thereof, and making a transverse cut one centimetre and a half (half an inch) in length, passed obliquely toward the left and a little upward, between the ninth and tenth dorsal vertebrje, into the spinal canal, and wounded the spinal cord. There were paralysis of the lower extremities, with retention of urine and feces, and marked hyper- sesthesia of the left lower limb and genital organs. On February 20, a slough was found on the right side of the sacrum ; the patient had not felt anything there. ^ In April, voluntary motion had returned in both limbs, but sensibility was still deficient in the right. On June 15, the patient could walk with the help of a cane ; and he left the hospital, although the sensibility was not yet fully restored in his right limb. Three years afterward the patient was again seen ; he stated that he was quite well, and that he could walk without difficulty or fatigue ; but, a year later, having walked a distance of many leagues, he found a large eschar, produced, he said, by the friction of his pants on his right knee ; he had felt no pain, and was surprised when he found this sore. Although the sensibiHty was still deficient in this hmb, its movements were all executed freely and without fatigue. Without doubt the weapon, in this man's case, gashed the spinal cord ex- tensively, and the severed nerve-filaments reunited in a comparatively brief time. Here is still another successful case of the same sort, which was recorded by Morgagni : — ^ A young man was struck with a quadrangular and acute poniard, which entered his neck below the left ear, and passed into his spinal cord. Immediately, sensibility and voluntary motion were lost in all the parts below the head. The respiration was en- entirely diaphragmatic. He complained of being cold ; and, without his feeling it, the application of a hot metallic vase caused burns on his thighs, legs, and feet. On the seventeenth day, he began to recover some feehng in the left side of his body ; and, on the twentieth, he began to move the toes and fingers of the same side ; these faculties gradually increased. On the thirty-second day, there was a return of some feehng in the right side of his body ; movement also, but at a later period, returned slowly there. On the fortieth day, there was sensibility and movement everywhere, but not enough to allow the patient to stand up. The recovery was so slow that, four months after the casualty, he was just beginning to get out of bed, and to walk as a child learning to walk ; and, even then, there was less capacity for feeling and movement in the right than in the left side of his body. 1 New Orleans Med. and Surg. .Journal, 1851, 2 Moniteiir des Hopitaux, 3 Septembre, 1855, p. 838 ; Brown-Sequard, op. cit., pp. 97-100. 3 De Sedibus et Causis Morborum ; quoted by Brown-Sequard, op. cit., pp. 103, 104. INJURIES OF THE SPINAL CORD AND SPINAL NERVES. 395 Tt should be observed that the complete loss of sensibility and voluntary motion, which occurred at the outset of this case, arose from the intra-thecal extravasation of blood and consequent compression of the spinal cord, as well as from the section of certain parts of the cord itself by the poniard. No doubt, the severed nerve-fibres reunited in this case also ; and the clinical history clearly shows how very slow the process of reunion sometimes is. But incised and punctured wounds of the spinal cord may give rise to inflammation of the cord and its membranes, and so cause death, as happened in the following instance : — M. Gama^ relates the case of a soldier who received a bayonet wound between the twelfth dorsal and tirst lumbar vertebra?, which injured the spinal cord. On the seventh day he died, without having had any paralysis. There was at the outset pain, which dinriinished after several venesections. On the second day, however, he had the most excruciating pains and violent cramps in all the parts below tlie wound, and they con- tinued until his death. There was also extreme hypersesthesia, and the skin on the lower part of his trunk and inferior extremities was so sensitive that one did not dare to touch him, and he had to keep himself on his knees and hands. Necroscopy revealed a wound of the spinal cord. There was an inflammation of the spinal cord and its membranes, and also of the brain. The pains and cramps in the legs, etc., arose from the meningeal inflam- mation involving the contiguous spinal nerves. The hyper?esthesia, however^ arose in part from this cause, and in part from the inflammatory lesion of the spinal cord, but mostly from the latter. Brown-Sequard has ascertained by experiments upon animals, that a wound on the posterior surface of the cord is followed by a greater hyper^esthesia, in the lower limbs, when made at the middle of the enlargement whence the spinal nerves proceed to these limbs, than when it is made higher. In unilateral injuries of the spinal cord, there is often observed a loss of voluntary motion on the same side of the body, with a loss of sensibility on the opposite side. This point is an important one, and can best be illustrated by presenting the abstracts of a few cases : — Dr. F. RiegeP records the case of a man, aged 22, who was stabbed in the neck with a knife. After being insensible for some time, he presented the following symp- toms : On the left side of the body, there were paralysis of all tlie muscles excepting those of the head and neck, augmented sensibility to touch, changes of temperature, and pain, and increase of reflex irritability ; at a later period, there was atrophy of the paralyzed muscles, with corresponding thermometric changes. On the right side of the body there was almost entire anesthesia as regards all forms of sensation, with com- plete power of motion. From the symptoms, Riegel concludes that the left half of the spinal cord was divided in the neck. The tremors and reflex irritability were success- fully treated with hypodermic injections of arsenious acid. M. Bernhardt gives a case of the same kind.^ Boyer* mentions the case of a drummer who was wounded in the back of the neck by a sword thrown at him, which penetrated the upper part of the right lateral half of the neck. An incomplete motor paralysis ensued in the right side of the body ; and, it was accidentally discovered some time afterward, that sensibility was lost in many parts of the left side. After twenty days, the wound was cured and the man left the hos- pital, but he was still paralyzed. Dr. J. Hughlings Jackson^ reports a stab-wound of the cervical region involving one side of the spinal cord. There were loss of motion and ptosis on the same side as the lesion, and loss of sensation on the opposite side. ^ Traite des Plaies de la T6te et de TEncephalite, 1830, p. 318 ; Brown-Sequard, op. cit., pp. 60, 61. 2 Berlin klin. Woch., 1873. s New Sydenham Soc. Biennial Retrospect, 1873-74, p. 123. * Traite des Maladies Chirurgicales, t. vii. p. 9 ; Brown-Sequard, op. cit., p. 101. 5 London Hospital Reports, vol. 1. p 337. 396 INJURIES OF THE BACK. Treatment. — Incised and punctured wounds of the spinal marrow should be treated by closing them immediately with antiseptic precautions, and with antiseptic dressings applied on the outside, in order to get union of the external wo and by " the lirst intention," and thus stop the outflow of cerebro-spinal fluid as soon as possible. To promote the same end, the injured parts should be kept in a state of rest, as nearly perfect as possible. By employing these means, too, the occurrence of spinal meningitis or myelitis may be obviated. It will be remembered that, in a case, mentioned above, of bayonet-wound of the spuial cord, traumatic meningitis supervened, and destroyed the patient. , All pains that arise in such cases should be subdued by administering opium or morphia. Gunshot wounds of the spinal cord are of frequent occurrence. In nearly all the examples of gunshot fracture of the spinal column, which have been above presented to the reader, traumatic lesions of the spinal cord also existed. In the case of Soteldo (p. 874), the missile slightly lacerated the cord, and deposited in its substance a spiculum of bone. In the soldier's case reported by M. Hutin, where there was survival of the injury for fourteen years, death resulting from Bright's disease, the missile divided the right half of the cauda equina, displaced the left half, and became itself firmly impacted in the spinal canal, where it remained innocuous for the time specified. In several instances above mentioned, the missile completely divided the spinal marrow. To illustrate the phenomena which result from gunshot wounds of the spinal cord, it is advisable to narrate the history of a case that came under my own observation : — Sergeant A. S. Girt, Co. E, 4th Pennsylvania Cavalry, aged 23, was wounded December 1st, 1864, by a pistol-shot which entered the root of his neck about an inch above the inner end of the left clavicle, passed backward, downward, and inward to the spinal column, perforated the body of the first dorsal vertebra, wounded the theca ver- tebrahs and the spinal cord, fractured the laminae of the second dorsal vertebra, and lodged on the right side of its spinous process. He was standing at the time, but instantly fell to the ground in a helpless condition from paraplegia. The wound bled considerably at first, but the bleeding soon ceased spontaneously. On the 2d, I saw him at the field-hospital of the Cavalry Division in front of Petersburg, Va. The orifice of the wound was remarkably small, and the integuments surrounding it were considerably swelled and tender, that is, inflamed. There was complete paralysis, both sensory and motor, of the lower extremities, and of the abdomen as high as the umbiU- cus. He had no power of voluntary motion whatever in those parts. Likewise, I failed to excite any reflex movement whatever by tickling the soles of his feet, and did not produce any sensation by violently pulUng the hairs on his legs, thighs, etc. The urinary bladder also was paralyzed, and catheterization was necessary. He had priapism. There was faint cutaneous sensibility just above the umbilicus ; and, proceeding upward, this gradually increased until on the thorax it appeared to be normal. His respiration was superior-thoracic and diaphragmatic, or abdominal, but principally the latter. The sensibility of the upper extremities did not appear to be impaired, but the muscular power was considerably diminished, as I readily ascertained by grasping his hands and allowing him to pull. The left arm was weaker than the right. His intellect was un- disturbed, and he did not complain of any pain, excepting when the wound and its vicinage were manipulated. On the 5th, I again saw him. He was smoking his pipe as he fay in bed ; countenance cheerful, and free from any sign of distress ; he said his appetite was good, and that he swallowed without difliculty. The wound was scabbed over, and the parts were less swelled and inflamed. His bowels acted spontaneously in the bed, and he had no control over them whatever, for the sphincter ani had ceased to act. The priapism had disappeared, but the condition of the bladder and other parts, as to paralysis, was unchanged. The respiratory function was quite successfully per- formed. On the 10th, he was transferred to the Depot Field Hospital at City Point. On INJURIES OF THE SPINAL CORD AND SPINAL NERVES. 397 Fig. 879. wmi the 11th, a dusky hue of the countenance was observed, as if the blood were imper- fectly aerated. On the 12th, the breathing became labored and attended with moist rales. The dyspnoea increased ; and, on the 13th, he died. An autopsy was made by myself on the 15th. The missile had penetrated the root of the neck as stated above, g;one through the sterno-mastoid muscle, and, avoiding the great vessels, struck tlie body of the first dorsal vertebra well in front and slightly to the left of the middle line, bored a hole through the body of this vertebra backward, downward, and toward the right, penetrated the spinal canal, lacerated the theca vertebralis on its front and right sides extensively, cut the spinal cord partly in two, fractured by its impact the riglit lamina of the second dorsal vertebra, with comminution (it had also fractured indirectly the left lamina), and lodged on the right side of the spinous process of the same vertebra, having passed through the spinal column from before backward, and somewhat obliquely from left to right and from above downward. The fragments were small and did not press uDon the cord. The lungs held somewhat more blood than normal, were also moderately oedematous, and the air-passages contained a quantity of frothy unstained liquid. Tliere was moderate inflammatory action, adhesive in character, in the theca vertebralis. It was confined, however, to the immediate neighborhood of the wound. There was no pus. The undivided portion of the cord was pulpefied (contused), and stained with blood, but it did not appear to the unaided eye to be inflamed. The autopsy of this patient shows that gunshot wounds of the spinal cord are essentially contused and lacerated in their nature, while his clinical history exhibits the symp- toms of concussion, contusion, and laceration of the cord, as might reasonably be expected. The loss of sensibility and voluntary motion below the cord-lesion, indicates that the functions of the cord as a conductor of impressions to and from the sensorium were entirely destroyed by the wound, and the loss of reflex motor action shows that the functions of the cord as a nerve-centre were likewise sup- pressed by the concussion. When bronchial eflusion with moist rales occurred in this case, the man could not get rid of it by coughing and spitting ; and, therefore, his dyspnoea rapidly increased until death from suffocation took place. It is worthy of remark that, when complete paraplegia results from Injury of the spinal cord at the root of the neck, the power of inspiration is generally preserved, but the power of expiration, as needed particularly for coughing and shouting, is entirely lost. The traumatic lesions of the spinal cord that result from simple fractures and dislocations of the vertebrse, consist of contusion, stretching, laceration, and complete division. Many examples have already been presented. In Mr. Oline's famous case of resection or trephining the spinal column, the cord was found to be three-fourths torn through, and the remaining portion was bruised. Occa- sionally, the cord is found to be lacerated in the manner depicted in the accompanying wood-cut (Fig, 879). It represents the appearance which the spinal cord and mem- branes presented in the case of a soldier whose spinal column was fractured by the limb of a tree falling across gj^^^^.^ laceration of his loins. A wood-cut to illustrate the vertebral lesion ""^^^^ ""mJmlnLL (transverse simple fracture of the first lumbar vertebra) and cord caused by sim. was given on p. 351, supra, Fig. 862, together with the traosverse fracture clinical account of the case. Xecroscopy showed that the ""^[^l!^^ ^s^pel" isotVecI' spinal meninges were torn entirely across, excepting a few i, a. m. m.j. 398 INJURIES OF THE BACK. fibres anteriorly and posteriorly, and were congested above and below the rent. Clots of blood were found diffused near the fracture. The lower por- tion of the cord, severely lacerated, was drawn up into a bundle at the seat of injury, entirely deprived of the membranes. The tubular nerve filaments were seen to be curiously dissected out by the pus in which the cord was bathed, forming a leash which is well shown by the preceding wood-cut. Briefly stated, the vertebral lesion consisted of a transverse fracture extend- ing through the body and pedicles of the first lumbar vertebra, with its spin- ous and left transverse processes impinging upon the cord. The latter may have been driven into that position by the force of the original blow, as well as by injuries sustained in transportation. ^ The cause of death apparently was septicaemia arising from gangrenous bed-sores. Occasionally, too, the cord is completely severed by a vertebral dislocation or fracture. For instance : — Malgaigne^ mentions a case by Melchiori, in which a mason fell from a height upon his back. There was complete forward bilateral dislocation of the tenth dorsal vertebra. He survived the injury for one day only. The autopsy showed that there was no frac- ture, but that the spinal cord was divided. (Ashhurst.) Dr. Parkman' presented to the Boston Society for Medical Improvement, a specimen in which the third, fourth, and fifth dorsal vertebrae were fractured ; the third and fourth were also displaced or projected in front of the sixth and seventh, and were co- ossified in that position. The cord was completely divided ; still the patient survived for two months. In very rare instances, a splinter from a fractured vertebra severs the spi- nal marrow, as happened in a case related by Abernethy, already mentioned, and in the following : — Dr. D. S. Conant* reports the case, already mentioned above, of a man, aged 55, who was blown off from rigging by wind, and who struck on his shoulders. There were frac- tures of the last dorsal and first lumbar vertebrae, paralysis, chill, and dehrium. Blisters formed on both thighs, before death, which occurred in six days. The autopsy showed that a splinter from the first lumbar vertebra had divided the cord. (Ashhurst.) It may be of interest to state that, in nearly all the fatal cases of disloca- tion or fracture of the spinal column collected by Mr. Bryant at Guy's Hospi- tal, the vertebral injury was complicated with some structural lesion of the spinal cord ; and that, in at least three-fourtiis of these fatal cases, the cord was irreparably injured by the mechanical pressure of the displaced bones, or by the effusion of blood into its structure.^ It is believed, however, that, under favorable circumstances, the nerve- fibres when divided in lacerations (incomplete) of the spinal cord from simple fractures and dislocations, as well as in incised wounds, may unite again, pro- vided that they are not displaced too much, just as the filaments unite again m the nerves of the face and extremities, when divided by accidental wounds or by surgical operations. To support this view, the condition of the cord which was revealed by post-mortem examination, several months after the ongmal accident, in a case recorded by Dupuytren of vertebral fracture with injury of the cord and paralysis, where recovery had taken place, may here be cited :— Charles Millie, aged 21, was admitted to the Hotel-Dieu, in 1825, with paralysis of the extremities and bladder, caused by a fall upon the back of his neck. After two months and a half of entire rest, combined with venesection, cupping, and leeching, he recovered, 1 Medical and Surgical History of the War of the Rebellion, First Surgical Vol., pp. 426, 450. * Traite des Fractures et des Luxations, t. ii. 3 American Journal of the Medical Sciwces, N. S., vol. xxv. 1853. 4 American Medical Times, 1861. ^ Lancet, April 6, 1867. INJURIES OF THE SPINAL CORD AND SPINAL NERVES. 399 and left the liospital with only slight weakness in the left leg, and with the head bowed slightly forward. Subsequently he fell and broke his spine again. Thirty -four days after that he died exhausted from bed-sores and colliquative diarrhoea. The autopsy revealed fractures of the fourth and fifth cervical vertebrae, which had united ; the callus had been broken by the second fall. " Opposite the point of com- pression, the cord exliibited an annular constriction, abrupt and well-marked, and very analogous to that presented by the inteshne in some cases of strangulated hernia. When incised longitudinally at this spot, the color and consistence of the cord were found altered to a brownish hue, and to the density and firmness of fibrous tissue ; a small circumscribed spot, about a line in extent, was especially characterized in this way. The membranes were also more adherent here than elsewhere." It was inferred that the seat of this peculiar change was that of the original lesion of the cord, and that the morbid appearance constituted a true cicatrix of the spinal marrow.^ Moreover, this case shows that the process of re-uniting the filaments of the spinal cord, when lacerated by vertebral fractures or dislocations, is not a rapid one, and that certainly several months, and possibly several years, must elapse before it can be accomplished. M. Brown-Sequard's experiments upon animals prove that in them reunion may take place after a wound of the spinal cord, so that its lost functions may return.^ Furthermore, this eminent observer has sometimes seen a nota- ble return of lost functions (rachidian) in animals, when their spinal columns had been fractured and their spinal cords crushed.^ The investigations of MM. Masius and Van Lair,"* in regard to the regeneration of the spinal marrow, show how great the reparative power of this organ really is. These experi- menters divided the spinal marrow in frogs, and at the end of from two to four months obtained undoubted evidence that these frogs had regained sensi- bility and voluntary motility in their hind legs. In other frogs, histologi- cal examination showed a more or less complete regeneration of the spinal marrow. The fact that cases of long-standing infantile spinal paralysis are cured — cases in which there can be no doubt of the existence of the spinal lesion (atrophy of the anterior cornua) — is of itself sufficient evidence to prove that the reparative power of the spinal cord is very great. (Hammond.) Like- wise, it will be remembered that four examples of reunion of the spinal cord in the human subject, when it had been gashed by cutting instruments, were presented on pages 393, 394 (supra). There can therefore, be no doubt, that the nerve-lilaments of the spinal cord may reunite when they have been severed by simple fractures and dislocations of the spinal column. The treatment which such wounds of the spinal cord require, has already been laid down while discussing the simple fractures and dislocations of the spinal column that cause them. Briefly stated, it consists, (1) in withdrawing the vulnerating body from the cord-wound by reducing the fracture or dis- location ; (2) in placing the severed cord-filaments in the condition most favorable for reunion by maintaining perfect rest of body ; and (3) in turning aside any phlogosis which would retard or prevent their reunion, by leeching or cupping, cold applications, and counter-irritants, lised externally, and by opium or morphia, potassium iodide, and ergot, given internally, according to the indications for their employment. Injuries of the Spinal ^^'erves.^— In fractures and dislocations of the vertebrae, whether simple or compound, the roots of the spinal nerves are 1 Op. cit., pp. 358, 359. 2 Experimental Researches applied to Physiology and Pathology, p. 17. New York, 1853. 3 Lectures on the Physiology and Pathology of the Central Nervous System delivered before the Royal College of Surgeons of England, p. 250. Appendix. Philadelphia, 1860. ^ Archives de Physiologic, t. iv. p. 268. 5 gee Figure 877. p. 382. 400 INJURIES OF THE BACK. liable to sufter injury during their passage through the intervertebral fora- mina." Such lesions were undoubtedly present in many examples of these fractures and dislocations which have been mentioned in the foregoing pages; but there is special ground for believing that such lesions were present in those cases of spinal fracture or dislocation where great pain was experienced by patients in the regions of body supplied by the spinal nerves which leave the spinal column at the seat of the displacement {e.g., in the walls of the abdomen at the pit of the stomach, when the sixth or seventh dorsal vertebra is broken or displaced, etc.) ; for when the peripheral nerves in general are mechanically irritated in any part of their course, painful sensations or in- creased sensibility (hypersesthesia) are usually produced in the parts where they terminate, and, when they are divided, these parts immediately become paralyzed, and their paralysis lasts until the severed nerves have grown to- gether again. The traumatic lesions which the spinal nerves most frequently sustam at the intervertebral foramina, are such prickings and scratchings of their com- ponent threads as cause pains (often severe), or increased sensibility, in the integuments and muscles of the back, where the posterior branches of the injured nerves are distributed, as well as in the integuments and muscles which are supplied by the anterior branches of the injured nerves. Some- times cramp and other signs of convulsive action are experienced in the parts supplied by the injured nerves. Occasionally the spinal nerves are severed by the displaced bones in cases of vertebral fracture or luxation, and then the parts supplied by them are at once deprived of all sensation, as well as of all power of both voluntary and reflex motion. Stromeyer mentions an interesting case in which the phrenic nerve must have been contused by a bullet, for during eight days great dyspncea was present, and the patient was obhged to remain in a sitting posture ; it was at first supposed that the lung had been injured, but there were no physical changes on the corresponding side of the chest.^ This matter of severe pain being felt in the peripheral extremities of the spinal nerves, when they are injured by fractures or dislocations of the spinal column, is beautifully illustrated by the case of a colored soldier of our army, who received from the conoidal ball of a Colt's navy revolver, January 28, 1866, fractures of the spinous processes of the sixth and seventh dorsal ver- tebrae, laying open the spinal canal between these processes, and lacerating the cord ; for he had great pain in the epigastric region, as well as complete paralysis below the seventh dorsal vertebra.^ Traumatic Inflammation of the Membranes and Substance of the Spinal Cord. There are at least two considerable errors which have been long and widely taus^ht by surgeons in En2:lish-speaking countries, as well as in others, namely : (1) that when the verteb'i^se are displaced in luxations and fractures of the spinal column, no effort should be made to restore them to a normal position, that is, that a dislocated or broken spine should not be " set;" (2) that when the spinal membranes and spinal cord, whether separately or collectively, are injured, they are by no means liable to take on inflammatory action, that is, that traumatic inflammation of the spinal cord-substance, and traumatic > stromeyer, Gunshot Fractures etc. : translated by S. F. Statham, p. 37. Am. ed. « Circular No. 3, S. (I. O., August 17, 1871, p. 38. TRAUMATIC SPINAL MENINGITIS. 401 inflammation of the spinal meninges, occur so veiy rarely in cases of verte- bral injury, that no special thought nor pains need be taken to avert them while conducting the treatment of such cases. The first-mentioned error has already been sufliciently refuted in the foregoing pages. It is now our duty to inquire into the second. In the first place, it should be said that the last-named mistake can have arisen only from the comparatively great infrequency with which the precise condition of the spinal cord antl spinal membranes is exactly ascertained by a thorough examinatiou of these struc- tures, after death, in fatal cases of spinal fracture or dislocation. Indeed, it often is no easy matter to make such an examination, or even to get per- mission to make it, especially in private practice. But, as the membranes and substance of the brain are liable to become inflamed when they are wounded in any manner, so the membranes and substance of the spinal mar- row, when similarly injured, are liable to become inflamed, (1) because the anatomical formation of these structures is identical in both ; (2) because they extend continuously from one region to the other, the continuity of each structure being preserved intact throughout; and (3) because those inflamma- tions which are essentially dift'usive, spread readily from one region to the other, from the spinal canal to the cranial cavity, and vice versa. Cases of traumatic spinal meningitis and traumatic myelitis have been recorded much less frequently than cases of traumatic cerebral meningitis and traumatic cerebritis, it may be because post-mortem examinations have much less fre- quently been made in traumatic lesions of spinal column than in traumatic lesions of the head. The following account of traumatic spinal meningitis and traumatic mye- litis is largely drawn up from the examples reported by our military sur- geons during and since the late civil war, as well as from other reliable observations. In practice, it has been found that both diseases often occur together ; but even then, either the one or the other usually predominates, and, therefore, the phenomena presented by individual cases will vary not only in accordance with the severity of the attack, but also in accordance with the disease which predominates, or the anatomical seat of the inflamma- tory lesion. Traumatic Spinal Meningitis. — A considerable number of cases in which this lesion caused death have alread}^ been mentioned in the foregoing pages. Symptoms. — This disorder, when acute, is often, but not always, ushered in by rigors or chilliness ; pyrexia generally ensues, and the pulse rises as w^ell as the body heat. There are pain more or less severe in the aflfected part of the spinal column (rachialgia), which is increased by motion ; tenderness of the same part under pressure, with increase of temperature above that of the unaflected parts of the organism ; and restlessness, sometimes great, with general cutaneous hyperaesthesia, the patient feeling " sore all over." i^ot unfrequently, pain with cutaneous hypersestbesia exists in one or more of the extremities ; occasionally, when paraplegia is present, the hyperpesthesia of the integuments occupies a band-like space, extendhig around the body just above the line of paralysis ; in some rare instances, where the sensory filaments of the spinal nerves are greatly irritated by the inflammatory process in the adjacent membranes, the hyper?esthesia becomes very severe, and so distress- ing that w^ords cannot describe the suft'ering; at the same time, the eflfects of this inflammatory irritation upon the motor filaments of the spinal nerves are manifested by stiflfness and contraction of the posterior cervical and dorsal muscles, whereby the patient's head becomes drawn backward or recurved, so as to deeply indent the pillow ; the patient may feel " stifl'," as well as VOL. IV. — 26 402 INJURIES OF THE BACK. "sore all over." When the motor filaments are greatly irritated in this man- ner all the muscles supplied by these filaments are aftected with tonic or tetanic spasms, and the case may be mistaken for one of tetanus • when the disease spreads to the cranial membranes, there is marked headache with other signs of cranial meningitis ; as the case progresses from bad to worse, delirium followed by coma supervenes, and usually death soon ensues; but, occasionally, the tetanic spasms are so severe and extensive as to entirely stop the resi)iratory movements, thus causing death by sudden as^jhyxia, and then the mind may remain clear until the last moment. The examples of this dis- order are, by their symptoms, clinically separable into three distinct groups : (1) the foudroyanU embracing those in which life is destroyed a few hours after the attack, as it were by a thunder-stroke ; (2) the tetanic, embracing those in which tonic spasms of the muscles constitute the most striking part of the phenomena ; and (3) the group embracing those in which hyperesthesia is the predominating symptom. ^ It should be remarked, however, that the sign which is most characteristic of this disorder, is recurvation of the head and neck from tonic contraction (spasm) of the posterior cervical muscles. ^ The phenomena of each of the three clinical groups just mentioned will be exemplified by presenting, as briefly as may be consistent with clearness, some abstracts of appropriate cases. . . , • The following abstract of a foudroyant case of traumatic spinal meningitis and myelitis is very instructive, as well as interesting : — A cavalry soldier was wounded, October 14, 1868, in an affray, by a pistol-ball, which entered the right side of his neck, half an inch above, and somewhat external to the crreater cornu of the hyoid bone, lodged, and was not extracted. On the 18th he entered the post hospital at Atlanta, Ga. There were complete motor and sensory para- lysis of the lower extremities and the right arm, and partial paralysis of the left arm, with spasmodic movement when used ; intercostal muscles paralyzed ; respiration abdo- minal, and slow; pulse slow and regular; bowels partially, and bladder completely paralyzed ; sensation lost throughout the abdominal region, but normal on the upper part of the chest and the face; intellect clear; patient complained of coldness of the surface, although the skin and extremities were hot to the touch. The track of the ball could not be ascertained, as the wound had nearly healed ; but injury of the spinal cord was surmised. , t • • Durino- the first week in hospital, mucus constantly accumulated in the air-passages, threatening suffocation, which was averted by the use of stimulating expectorants The bowels were relieved by injections and purgatives, and the bladder by the catheter There was" no perceptible improvement in the paralysis. A large bed-sore xormed over the sacrum. n • • • u.. u„4- Durino- the second week, there was partial recovery of motion m the right arm, but none of sensation. The patient could, by an effort, draw this arm across his breast. CEdema of the left leg appeared, and was treated by bandaging. ' During the third week there was no improvement. ■ , . , . . , DurinS the fourth week, on the suggestion of Dr. A. K. Smith, potassium iodide, and afterward tincture of ergot, were given with perceptible benefit. The mucus diminished in quantity, expectoration became easy, and the patient s appetite increa,se^. During the first part of the fifth week, the improvement was very encouraging. The respiration became more normal (that is, ceased to be diaphragmatic), the bowels acted readily, the appetite remained good, and the bed-sores looked healthy. On November 20, the patient complained of stiff neck, headache [backache], and extreme coldness, and, toward night, had slight fever. On the 21st tlie fever had sub- sided, but he still complained of headache [backache] and coldness, and suppuration was diaixnosticated. On the morning of the 22d he was comatose, with the left pupil dilated, and the right pupil contracted. A blister was applied to the nape of the neck purga- tives, etc., were given, but to no purpose ; he died at 11.15 P. M. Autopsy, 15 hours after death .—The missile had passed from the point of entrance mentioned above, toward TRAUMATIC SPINAL MENINGITIS. 403 the spinal column, crossing the carotid sheath externally, and just missino- it. It appeared to have penetrated the spinal canal through the third intervertebral foramen, but it oould not be found. The membranes of the cord and left hemisphere of the brain were extensively disorganized from inflammation. Plastic lympli, forming a continu- ous layer, was found effused on the inner surface of the theca vertebralis, throughout the entire length of the spinal cord. The subarachnoid space was distended with a pyoid serum, by which the cord was compressed and softened opposite the third and fourth cervical vertebnB. Here the theca vertebralis was ecchymosed and separated from the bone (by the missile). The layer of plastic exudation extended through the foramen magnum, and along the base of the brain as far forward as the optic commis- sure. In the anterior lobe of the left cerebral hemisphere, circumscribed softening- was found, presenting the appearance of an abscess. The gray substance of this lobe was changed in color and consistence, in consequence of the inflammatory process; the medullary substance was injected ; the lateral ventricles were marked by radiatino- bloodvessels ; the corpora striata and optic thalami were injected.' This soldier died very suddenly from traumatic inflammation of the spinal and cranial meninges, the symptoms of which first appeared on ^s'ovember 20, death by coma following on the 22d. The symptoms were rigors, pyrexia, headache, backache, stifihess of the posterior cervical muscles, and €oma, death resulting from compression of the brain as well as from com- pression of the spinal cord, efi:ected by the products of a meningeal inflam- mation wdiich extended over the whole length of the spinal cord, and over the base of the brain up to the optic commissure. It is probable that hyper- iesthesia of the integuments and rachidian tenderness under pressure in the neck were also present at the outset. The anatomical changes wrought by meningeal inflammation are well described. There was a continuous layer of plastic lymph found on the inner surface of the dura mater, extending unbroken from the lower end of the spinal cord up to the optic commissure at the base of the brain. The meshes of the pia mater were also distended by a pyoid serum which lifted up the arachnoid. It is not improbable that this inflammatory attack was directly incited by the autumnal vicissitudes of atmospheric temperature, resulting from what is popularly called " catch- ing cold." But the history of the first four weeks of this man's case is of equal, if not greater, interest to the thoughtful surgeon. The impact of the missile caused ecchymosis of the theca vertebralis, and separated it from the bone. It also bruised the spinal cord, from which lesion a very extensive paraplegia immediately resulted. Moreover, the bruising of the cord was followed by inflammation of the cord-substance, the symptoms of which were exaggerated reflex motion, particularly noted in the partially paralyzed left arm (for it exhibited spasmodic movements whenever he tried to use it), the sensation of cutaneous coldness without any apparent cause, the formation of a large gan- grenous eschar over the sacrum, and the threat of death from sufibcation. JSText, there occurred a most interesting feature of the case, namely, the great benefit which was derived from potassium iodide and ergot. Under these remedies the myelitis rapidly subsided, the respiration ceased to be diaphragmatic, the appetite and digestion improved, the bowels, etc., acted readily, the bed-sores became clean and appeared healthy, and the case began to look quite encour- aging ; the existence of the nerve-lesions was proved, after death, by the soft- ened state of the cord-substance which was found opposite the seat of the original injury. The next abstract presents a brief record of a very instructive case in which hypercesthesia was the most prominent symptom : — 1 Circular No. 3, S. G. 0., August 17, 1871, pp. 23, 24o 404 INJURIES OF THE BACK. A cavalry soldier, aged 28, was accidentally wounded March 26, 1866, by a pistol- shot (conoidal, calibre, 36) which entered his loins near the posterior superior process ^ . of the right ilium, some two inches from the spine, ■p' ggQ passed inward, forward, and upward, struck the spinal column, and finally lodged in the spinal canal opposite the fourth lumbar vertebra (Fig. 880). He instantly fell to the ground ; the lower limbs were paralyzed, and over the entire posterior part of the pelvis there was also complete loss of sensation. On the second day, he complained of much pain across the sacral region and in the thighs ; could not change the position of the lower part of his body, and all attempts by others to move him gave great pain, especially across the lower part of his back ; bowels torpid. He could micturate, but lacked expulsive Showing a pistol-ball lodged in the spinal ^^^^ readily. Afterward, he slowly im- foran^en (canal) of the fourth lumbar ver- P ^ ^^^^ tebra, and causing meningitis. (Spec. 683, piuveu. ^uu / v^^ot l.r.cv.Ual Sect. I, A. M. M.) in an army -wagon, sixty miles, to the post-hospital at Austin, Texas, which he entered on April 18. He then looked emaciated and anxious, and was much exhausted by his journey. He com- plained of pain, especially in the right side of the sacrum, and of severe pam in the pos- terior muscles of his legs, aggravated by pressure. He could not stand without support, and made no attempt to walk. When lying on his side, he was able to slowly flex and extend his legs, but could not separate them ; bowels extremely torpid ; urination frequent and very difficult ; considerable thirst ; but little appetite ; upper extremities not affected. Under dry cupping of the sacral region, enemata and laxatives, tonics, nutrients, and alcoholic stimulants, he improved somewhat, but made no attempt to walk Under the use of strychnia, early in May, his bowels moved spontaneously, and the ability to move his legs was somewhat increased. This medicine, however, was soon discontinued, because it readily exhibited an unduly stimulating action, characterized by the production of diminished sensibility from the haunches downward, with severe pain in the posterior muscles of the legs ; appetite decreasing, and debihty gradually in- creasing Durincx the second week in May and forepart of the third, the patient s general tone diminished'greatly ; sensibility became lost almost entirely below the knees, but limited motor power still remained. The power to urinate was nearly lost ; urine passed in drops, with continued painful desire to pass more (vesical hypersesthesia) ; introducing the catheter gave temporary relief, but he could not retain the instrument longer than a few minutes [in consequence of the urethral hyperaesthesia]. From this symptom, bel- ladonna (<-r. i) would, for a considerable period, give most decided rehef. The patient lay chiefly on his back, with the knees drawn up ; stools passed involuntarily, ihe pain in the le<^s and in the sacral region was increased ; wet cups were applied over the lower part of the spine, daily, for four days, but without any benefit whatever ; he was catheter- ized twice daily, and this was continued until the end. On May 24, he rejected all food. On the 25th, there was active delirium. On the 27th, the delirium still continued ; pulse 120 • respiration 40, and performed almost entirely by the diaphragm ; no sensation in leo-s,'exceptincr under hard pressure, but he kept them flexed upon the thighs, and the thi-hs upon the pelvis; complained of intense pain in the back part of the pelvis, abdo- men, and thorax, extending along the spine upward, making it difficult to rest his neck upon the pillow ; he described the pain as that of lying upon hot embers ; he continued to cry out in pain until a few moments before death, which occurred on the following mornincr (May 28). Autopsy, twenty-one hours after death—The missile had grazed the ricrht tninsverse process of the fifth lumbar vertebra, imbedding some particles of lead therein ; then, glancing upward, had struck the spinous process of the third lumbar ver- tebra (its lower border), and had been deflected through the laminae into the spinal canal. Here it had been deflected downward by the elastic action of the ligamenta subflava to wliich the upper border of the broken laminae remained attaclied, and had lodged (point downward) within the spinal foramen of the fourth lumbar vertebra. The missile rested within the leash of nerves forming the cauda equina, near the left angle of the spinal foramen (canal), its point reaching downward to the lower border of the fourth TRAUMATIC SPINAL MENINGITIS. 405 lumbar vertebra. The spinal membranes surrounding the point of the missile were lacerated, injected, and of" light venous color. The nerve-tissue within the spinal mem- branes was also injured ; it was reduced nearly to a pultaceous consistence ; white soft- ening. The fourth and part of the tiiird lumbar vertebra, with the missile attached, was contributed to the Army Medical Museum. This specimen is represented by the accompanying wood-cut (Fig. 880)/ The intense agony which was engendered by the hyperoesthesia in this case is some- thing too liorrible to be contemplated without emotions of pity. It is worthy of remark that strychnia did harm to this patient, and that its use was suspended for this cause. It is also worthy of remark that the vesical and urethral hyperaisthesia was notably lessened by giving belladonna, and that the application of dry cups was apparently useful on another occasion. The next example occurred in the Crimean war. Intense hypercBSthesia appeared, and fowlroyant symptoms. Death from coma (that is, from com- pression of the brain and spinal cord) resulted in five days. Private S. L., aged 21, was wounded in the trenches, August 23, 1855. A Minie ball passed through his right cheek, fractured the right alveolar processes and ascend- ing ramus of the lower jaw, with comminution, and lodged near the base of the skull. There was not much hemorrhage. The ball could not be discovered, and every attempt to find it caused very acute agony. There was no paralysis. But deglutition was diffi- cult, and every movement of his neck aroused intense pain, so much so as to cause him to scream violently. Delirium, stertor, and coma set in ; death ensued on the 28th, five days after the casualty. Necroscopy showed both jaws to be fractured, and the lower comminuted. The missile had lodged just below the basilar process, having broken off and almost detached a large piece of the atlas, and thus uncovered the spinal mem- branes. They did not appear to have been injured primarily; "but they, as well as the membranes of the brain, showed marks of acute inflammation having been set up."^ On the same page, Staff-Surgeon T. P. Matthew, the surgical historio- grapher of the Crimean War, remarks : " Even where the spinal cord, appa- rently, was not primarily injured, inflammation of it or its membranes was sometimes set up, and quickly proved fatal." The following example of traumatic spinal meningitis and myelitis was characterized by the occurrence of tetanic spasms of the muscles in the extremities : — On the first of August, says Stromeyer, I extracted a bullet, which had entered on the 6th of July, between the laminae of the third and fourth lumbar vertebra?, and there had become fixed. At first there Avere no severe symptoms ; suddenly there occurred violent pains, with cramp in the extremities having similarity to tetanus, and accompanied by delirium. The operation was easily performed by the help of an ele- vator, after dilating the outer wound. On removing the bullet, a finger could be put into the spinal canal. The patient sank rapidly, and the autopsy showed inflammation of the spinal cord and its membranes.^ Tetanic spasms of the muscles were likewise observed in the next instance, which occurred in our civil war : — An artillery soldier, aged 28, was wounded at Gettysburg, July 1, 1863, by a conoidal ball, which entered below the spine of the left scapula, struck the spinous pro- cess of the eighth dorsal vertebra, fractured it, but without displacement, and lodged in the angle between the spinous and transverse processes. He walked to the field hos- pital without assistance, and was able to move about and help himself until the 6th, when tonic spasms of the abdominal muscles and diaphragm set in. They steadily increased in severity ; anaesthetics were administered, and the urine was drawn off by 1 Medical and Sargical History of the War of the Rebellion, First Surgical Volume p. 448. 2 Medical and Surgical History of the British Army in the Crimean War vol. ii. p. 337. 3 Op. cit., p. 38. , . . y. > 406 INJURIES OF THE BACK. a catheter. On the eveninoj of the 7th, he fell into a sleep ; but, upon awakening, the spasms returned and continued until 11 P.M., when death occurred.^ Though the track of the missile was traced in this case, and its place of lodgment discovered by a post-mortem examination, it does not appear that the spinal canal was laid open, and that the spinal meninges and cord were submitted to inspection. Had such an exami- nation been made, the evidences of traumatic spinal meningitis would doubtless have been revealed; for it should be observed that the tetanic spasm first appeared in the muscles (of the abdomen) that were supplied by spinal nerves (the seventh and eighth dorsal) which issued from the spinal column at the place of injury (the eighth dorsal vertebra), and consequently from the focus of traumatic inflammation, whereas true tetanus usually begins with trismus or lock-jaw. There is, then, little room for doubt that the tetanic spasms of the abdominal muscles, etc., which appeared in this case, were merely symptoms or phenomena that resulted from the inflammatory lesions of the spinal membranes and spinal cord. Moreover, tetanic spasms characterized an example presented on page 376, toa;et*her with a wood-cut to illustrate it, that bears a strong resemblance to^Stromeyer's case as briefly related above. In both, a small-arm missile struck the spinal cohmm, and became impacted between the laminae of two lumbar vertebrse. In both instances, severe pain in the spine and tetanic spasms in the muscles of the extremities ensued. In both instances the mis- siles were extracted, and both patients died. The autopsy of Stromeyer's patient revealed traumatic inflammation of the spinal membranes and cord. But the autopsy of the other patient does not appear to have been carried far enough to expose the spinal membranes and spinal cord to view. Never- theless, the symptoms which characterized this case, e. g., the intense rachi- diap pain, the extreme degree of restlessness or general hypersesthesia, and the tetanic spasms, constitute a group of symptoms often seen in cases of epidemic cerebro-spinal meningitis when the spinal symptoms predominate; and, without doubt, these symptoms arose in this instance also from an acute inflammation of the spinal membranes, but having a traumatic, instead of an epidemic origin, just as they did in Stromeyer's case. Epileptiform convulsions, as well as tetanic spasms, are sometimes observed in cases of traumatic spinal meningitis. Charles BelP reports an example in which a subluxation of the last cervical upon the flrst dorsal vertebra was followed, on the eighth day, by general convulsive movements, accompanied by signs of inflammation of the spinal membranes. The patient died twelve days'afterward of exhaustion, not having been completely paraplegic at any time. The autopsy showed a little subarachnoidean eflusion of serum in the cranium, and an abundant deposit of pus within the theca vetebralis, lying between it and the spinal cord. This case has already been mentioned (page 332) ^ Pathological Anatomy of Traumatic Spinal Meningitis.— spinal mem- branes, like the cranial, are not much disposed when injured to exhibit inflammatory changes of a destrucfive character. Still, when their vulnera- tion is attended or followed by influences adverse to healing, they, like the cranial membranes, are liable to take on inflammatory action which may cause death. Having thoroughly discussed the symptoms of traumatic spinal meningitis, it is next in order to consider the structural lesions which it engenders. They consist in the exudation of serum, the formation of plastic lymph and purulent matter, and the perforation, etc., of the membranes them- selves by ulceration. The following abstract and wood-cut (Fig. 881) will serve to illustrate at least some of these lesions. > Medical and Surgical History of the War of the Rebellion, First Surgical Vol., p. 452. * Surgical Observations, p. 145. TRAUMATIC SPINAL 3IENINGITIS. 407 A soldier, aged 37, received a gunshot wound of the back, Fig. 881. at the Wilderness, May 6, 1864 ; the ball entered over the transverse process of a dorsal vertebra, and lodged in the bone. He was sent to Washington ; and, on tlie next day, he was admitted to Mount Pleasant Hospital. On the loth, he was transferred to Jarvis Hospital, Baltimore, where he died on July 20, seventy-five days after the casualty, from spinal meningitis. Necroscopy — It was found that the ball had struck the body, and fractured the transverse process, of a dorsal vertebra. The injured bone was necrosed. The spinal membranes showed ulceration and unequivocal marks of intense inflammation, for two inches above and below the fracture. Tiie spinal cord, opposite, was partially disor- ganized. The inflammatory lesions of the meninges are represented in the adjoining wood-cut (Fig. 881).^ It does not appear that the spinal cord and mem- branes, in this man's case, received any direct injury from the blow struck by the missile upon his spinal column. Subsequently, however, the vitality of the bruised vertebra was destroyed by necrosis, and the inflammatory process spread therefrom to the contig- uous membranes and cord, when the traumatic spinal meningitis, thus excited, caused his death seventy-five days after infliction of the wound. The inflammatory process, when it is excited in the spinal membranes by traumatic causes, may be either diffuse or circumscribed in character. In several in- stances, related above, it was very difl:use, and not only involved the entire extent almost of the spinal membranes, but passed upward through the foramen magnum and attacked those of the cranium. In the last example, however, it was not difl'use, but con- fined to a space extending two inches above and below the place of injury. In the next case the meningeal inflammation was also circumscribed and restricted to comparatively narrow limits : — Capt. Thomas H., 67tl) Regt. Indiana Vols., was wounded by a pistol-ball in the back, November 3, 1863, and entered a general hospital on the 9tli. There was partial paralysis of the left thigh and extremity. The missile had entered about four inches to the right of the fourth dorsal vertebra, but its course could not be traced. The tract of the spinal column, both above and below the wound, was equally sensitive. The paralysis, in the first week, invaded the right leg, tlie bladder, and the rectum ; and, by the end of the tliird week, sensibility and voluntary motion had disappeared (that is, there was complete paraplegia) in all parts below^ the wound. The only noticeable instance of excito-motor action which remained was the peculiarity that tickling the glans penis produced a partial evacuation of the bladder; and this feature continued until the patient's death, which resulted from acute pneumonia on December 19. Necroscopy showed that the ball had passed downward and inward, slightly wounding the costal pleura ; had fractured the right transverse process of the seventh dorsal ver- tebra ; and had lodged in the body thereof, producing a slight exfoliation from the inner side of the body into the spinal canal, which had caused inflammation of the spinal membranes and cord. Pus was found in the theca, that is, in the spinal pia mater. The right lung was far advanced in suppuration.^ This case is strictly analogous to those instances of traumatic meningitis and cerebritis which arise from exfoliations from the inner table of the skull, Showing the efiFects of trau- matic spinal meningitis and myelitis, in the dorsal region. The membranes have been perforated by ulceration, and exhibit other inflammatory changes ; cord partially disor- ganized. (Spec. 3190, Sect. I, A. M. M.) 1 Med. and Surg. Hist, of the War of the Rebellion, First Surg. Vol., p. 439. 2 Ibid., p. 438. 408 INJURIES OF THE BACK. in consequence of cranial Injury, and winch produce subdural or intra- menino-eal abscesses, attended by corresponding palsies of the cerebral func- tions. ''in this officer's case, the pressure exerted by the products of the meningeal inflammation (purulent matter and serum) upon the spinal cord, as well as the inflammatory changes which occurred in the cord-substance itself, caused complete paralysis of all the parts of his body which were situated below the spinal lesion. , , ■ i i • i r A few words should also be said concerning the pathological histology ot traumatic spinal meningitis. This disorder usually consists of acute hyper- 8em.ia and suppurative inflammation of the pia mater. There is a tolerably wxU-marked" congestion of all the vessels in the pia mater, together with purulent infiltration of the subarachnoid lymphatic spaces. The most strik- ing point in connection with it is the strict way in which the purulent for- mation is limited to the parenchyma of the pia mater ; it never transgresses - (when diftuse) the arachnoid lamella which forms its outer boundary. In the first foudroyant example related above, the meshes of the pia mater were seen to be distended by purulent serum which lifted up the arachnoid. The comparison of the arachnoid to a serous sac, formerly so popular, has ceased to be entertainable ever since Luschka's investigations proved that the so- called parietal layer of the arachnoid was merely the epithelium of the dura mater. The very striking deviation from the superficial character of serous inflammations in general, just mentioned, completes the demonstration that the arachnoid is not a serous membrane in the same sense as the pleura or the pericardium. It seems to me," says Rindfleisch, " as though this devia- tion were simply due to the presence of very distensible spaces immediately around the vessels. Here, if any where, we may apply Cohnheim's theory of inflammatory exudation. Even the naked eye can show us that the pus everywhere originates along the course of the vessels. Like a double-streak of a yellowish-white color, narrow at first and growing steadily wider, the pus follows the edges of the vessels, especially of the large and small venous trunks. The longer the process lasts, the nearer do the purulent streaks accompanying the vessels approach one another, till they finally coalesce ; the pia mater swells up as a whole ; it often acquires a peculiar stifthess, owing to the stretching of its fibrous bands, perhaps also to the coagulation of some lymphatic constituents of the exudation."^ It may then be stripped ofl from the compressed and bloodless, rarely softened, surface of the cord, together with the prolongations which it sends into the sulci, forming a solid mould of the rachidian irregularities. The morbid process generally begins with hypersemia (active congestion) of all the inter-meningeal vessels at the place of injury, followed by the appearance of serum and flakes of lymph ; and it terminates, as just stated, in subarachnoid suppuration. rrm^me7?i.-- Traumatic spinal meningitis, whether difl'use or circum- scribed, is an exceedingly dangerous disorder; and, to treat it with success, it is indispensable that vigorous measures should be promptly employed Ihe preventive measures {prophylaxis) consist m removing all foreign bodies from gunshot wounds of the spine, and applying antiseptic dressmgs ; m reducing simple as well as compound dislocations and fractures of the ver- tebra, thereby lessening the meningeal irritation ; in maintaining afterward ' absolute quietude of all the injured parts ; and in promptly abating any in- flammation which may arise in the circumjacent structures. Meningeal congestion should be combated by administering ergot m large doses at short intervals (from 30 to 60 minims of the fluid extract every four 1 Manual of Patliological Histology, vol. ii. p. 309. New Sydenham Society's translation. TRAUMATIC MYELITIS. 409 hours until the indication is fulfilled), and by giving opium or morphia in such doses and at such intervals as will suppress the rachidian pain. The inflammatory process is to be combated by exhibiting one or two purgative doses of calomel at the outset, by abstracting blood locally with leeclies or cups, by applying cold to the overheated back, and by administer- ino- saline drinks of a cooling, laxative, and diuretic nature. At a later statue, potassium iodide in full doses, and counter-irritation by vesicants or by the^ actual cautery should be employed. The remedy, however, which is most efficacious to remove meningeal congestion is ergot, provided it be given in sufficiently large doses ; while that which is most etiectual to pre- vent the exudation of serum and the formation of plastic lymph (and thus to save the spinal cord from undue pressure), is opium, or morphia, also given in adequate doses. attempt should be made to relax the tetanic spasms by administering chloroform or any other anaesthetic ; such medication did no good what- ever in two cases which are mentioned above, and it probably hastened the end in each. But morphia combined with the bromides of calcium, sodium, potassium, or ammonium, and chloral hydrate, may be used for this purpose. In treating the paralysis attending the chronic forms of the disease, the bichloride of mercury, in doses of gr. y'^ every eight hours, often does good. Strychnia is not admissible, and it clearly did harm in one case above related. Traumatic Myelitis. — As cerebriti^ is true inflammation of the hrain-suh- stance, so myelitis is true inflammation of the cord-substance, and as cerebritis presents a marked contrast to cerebral meningitis (or what is popularly known as "inflammation of the brain") in respect to extent, acuity, and phenomena, so true inflammation of the cord-substance difl:ers widely in the same particulars from spinal meningitis (or what is sometimes known as " inflammation of the spinal cord"), which has just been described. Both cerebritis and myelitis are always caused by a wound or an injury in the widest sense of the term — that is, by some local irritation of extra- cerebral or extra-rachidian origin. The skull or the spinal column may have been struck or concussed ; it may have been penetrated by a cut, a stab, or a fracture, which has directly damaged the brain-substance or the cord-sub- stance ; or a focus of inflammation and suppuration, originating in the neighborhood of the brain or the spinal cord, may have been propagated to its tissues at the point of contact ; or, finally, the plugging of a vessel by an embolon, or a thrombus, or the rupture of its coats from atheromatous disease, etc., may have caused a circumscribed, punctiform hemorrhage, followed by inflammation as a secondary consequence. In myelitis, and in cerebritis, the behavior of the parenchyma proper of the spinal cord and brain is the main point to be attended to; this is usually said to undergo purulent liquefaction ; and the statement is so far true that a deposit of pus is usually found to occupy the place of the rachidian or the cerebral substance. "The phenomena of acute myelitis leading to abscess are exactly similar to those of encephalitis [or cerebritis]. The form of the aft'ected part varies with the [nature of the] injury. Fractures of the spine usually crush the cord ; inflammation and suppuration take place around the crushed part, and isolate it from the healthy tissue."^ ^lany examples of traumatic myelitis have already been mentioned in this article. Symptoms. — The acute form of the disease is often ushered in with a dis- 1 Rindfleisch, op. cit.. vol. ii. pp. 324-330. 410 INJURIES OF THE BACK. tinct chill ; pyrexia follows, with thirst and increased frequency of pulse,, and the body temperature may rise to 103° Fahr. The alfected part is generally the seat of a dull pain or ache (quite distinct, however, from the intense pain of meningitis), which is increased by bending and by percussing the diseased part, and by applying a hot sponge over it. The functions of the spinal cord are immediately disturbed, and notable derangements of the cutaneous sensibility at once ensue. They often take the form of "pins and needles," of a sensation as if Vv^ater were trickling over the cutaneous sur- face, as if the limbs Avere asleep, or as if the cutaneous surface were very cold, while in reality it is very hot, and vice versa. It will be remembered that coldness of the surface without any apparent cause was complained of in the first foudroyant case of spinal meningitis above related. But anses- thesia is the general condition of the skin that is most common in this disease. It is, however, attended not unfrequently by cutaneous pain or hypersesthesia ; indeed, spontaneous and severe pains are often felt in the skin, when the cutaneous sensibility is already much impaired. Complete analgesia soon follows. The voluntary motility is destroyed at an early period in this disease. At first the refi.ex excitability may be exaggerated, but it likewise soon disap- pears. Then the sphincter ani and sphincter vesicae entirely cease to act, and the feces and urine fl.ow out into the bed without any restraint whatever. The urine becomes alkaline, and oftentimes is thick Avith mucus.^ Simul- taneously, sacral eschars, or so-called acute bed-sores, are very liable to be formed. These eschars are due less to the patient's position than to the lesion of the spinal cord. In twenty-four hours these bed-sores sometimes appear, and in such cases the febrile movement caused by the myelitis is often mistakenly ascribed to the eschars themselves. In the subacute and circumscribed forms of the disease, the aberrations of sensibility are less strongly marked, and they succeed each other less rapidly on account of the slower progress or the more restricted range of the morbid process. The sensation of a band drawn tightly around the body is generally, but not always, present in such cases, and its seat marks the upper limit of the rachidian inflammation. The destruction of voluntary motility and of reflex excitability usually travels upward, joari passu^ with that of sensibility. The inflammatory process in traumatic myelitis generally exhibits a re- markable tendency to spread upward in the rachidian substance. This pecu- liarity was long ago specially noted by Dupuytren, in cases where inflam- mation of the cord had arisen from dislocation or fracture of the spine. The most frequent mode in which traumatic myelitis destroys life is by par- alyzing the respiratory muscles in consequence of its upward spread, and thus causing fatal asphyxia. The following example illustrates this point, as well as several others in the natural history of the disease : — A cavalry soldier at Fort Gibson, Cherokee Nation, received a shot-wound in the neck, in a brawl, on November 19, 1868, and was taken into hospital shortly afterward. There was complete paralysis of both upper extremities ; respiration gasping and fre- quent ; pulse about 100, of fair volume and strength ; mind clear ; he complained of some pain in the hands. The missile had penetrated the neck, on its left side, at the anterior 1 Dr. C. B. Radcliffe, however, has recorded a case (Lancet, December 3, 1864) in which the urine remained acid throughout. The myelitis was acute and very extensive, and in ten or twelve days death ensued. There were retention of urine and marked priapism. The motor and sensory paralysis extended up to a line drawn round the body four inches below the ensiform cartilage ; reflex movements absent. Autopsy. — Spinal membranes, normal ; substance of cord, yellowish-red in color and softened to the consistence of cream, from its brachial enlargement to its inferior extremity ; it here consisted of tlie debris of its normal structure mixed with blood- oorpuscles, exudation granules, and some pus-corpuscles. TRAUMATIC MYELITIS. 411 border of the trapezius muscle, and about two iiiclies below the mastoid process ; passed downward and to the right; fractured one or more of the vertebrae; and lodged beyond the reach of the bullet-probe. A few loose fragments of bone were removed. He was placed on a water-bed. Anodynes were given to procure sleep and relieve pain. The bladder was relieved by the catheter. The paralysis of the abdominal muscles allowed gases to ccUect in the intestines to such an extent as greatly to augment the pre-existino- difficulty of breathing. Vent was given to these gases, from time to time, by inserting an elastic tube, per anum^ and compressing the belly externally. The paralysis from day tc day became more profound ; the respiration more difficult; asphyxia slowly ap- peared, with delirium followed by coma, and on the 28th deatii ensued, about nine days alter the casualty. The autopsy revealed (1) fracture of the spinous process of the last cervical vertebra; (2) fracture of the lamina? of the first dorsal vertebra at the point where tjiey unite to form the spinous process ; this fracture opened the spinal canal and ruptured the theca vertebralis ; (3) several small fragments of bone, embedded in the substance of the spinal cord, which was softened and bathed in pus. The bullet had also fractured the first rib with the coracoid process of the scapula, and had lodo-ed in the right axilla, where it was found. The lungs were deeply congested, as was the mucous coat of the bronchi ; and the bronchi themselves were filled with a tenacious mucus. ^ The injury of the spinal cord in this case was followed by suppurative inflammation of its substance, which not only involved the whole thickness of the cord, but spread upward also. Simultaneously the paralysis became more profound, and rose to higher points, from day to day, until the man breathed by the diaphragm alone. Then the occurrence of tympanites greatly increased the dyspnoea by opposing the descent of the diaphragm ; tenacious mucus formed in the air passages, and accumulated therein, "because there was no power to expel it by coughing ; mucous rales (bronchial) soon super- vened, and death from suffocation ensued, ere the disintegrating process had ascended the cord high enough to paralyze the phrenic nerves. This man died of ascending myelitis in nine days. But, on page 343, I have presented the case of another soldier who died' of ascending myelitis in about forty- eight hours aftei' sustaining simple fractare of the fourth cervical vertebra, in consequence of falling from a second story. On another pag-e, I have men- tioned the case of a man, aged 40, who died of ascending myelitis on the eleventh day after sustaining simple fracture and dislocation of the eleventh dorsal vertebra, with contusion of the cord. I have likewise referred to many other cases of spinal injury, in 'which ascending myelitis supervened with fatal effect, as was shown by necroscopy. In the next example, the patient died of haemoptysis before the inflammatory process in the spinal cord had reached the stage of suppuration :— A cavalryman, aged 35, entered a general hospital, October 28, 1864, for a wound from a pistol-shot which had penetrated to the left side of the spine, and had fractured the twelfth dorsal vertebra. All below a line drawn from the wound to the pubis was para- plegic. There was much depression ; pulse about 130 ; much pain over abdomen and right side ; constipation ; incontinence of urine from overflow^ of bladder. A catheter was introduced and three pints of very thick, dark-colored urine were withdrawn. Stimulants, tonics, and a cathartic were given, with an anodyne at night. The patient improved and did well until November lo, when a bad cough set in. He died suddenly on the 18th from hasmoptysis. Necroscopy — The spinal canal ^vas laid open posteriorly from the second dorsal vertebra to the sacrum. Upon removing the spinal cord, the theca was found congested and firmly adherent to the vertebra?. The substance of the cord looked very red. The ball had passed between the arches of the twelfth dorsal and first lumbar vertebra?, and then through the body of the twelfth dorsal, outside of the spinal meninges; but its track could not be further traced. The right pleural cavity 1 Circular No. 3, S. G. 0., August, 17, 1871, pp. 21, 22. 412 INJURIES OF THE BACK. contained three pints of dark, bloody, stinking fluid. The muscular tissue in the lumbar reo-ion was very dark and softened, but contained no a-bscesses nor infiltrated pus.^ Death occurred three weeks after the infliction of the wound. The membranes and substance of the spinal eord, in this caise, exhibited the signs of convalescence from in^ammation, and that process must have riin pretty high at one time, for the theca vertebralis had become strongly adherent to the spinal column. The spinal membranes were still congested, and the cord-substance looked very red, when exposed to view at the autopsy. Pathological Anatoiny. — This reddened hue of the rachidian parenchyma is accounted for by the peculiar manner in which the vascular apparatus is involved. The intense hypersemia which ushers in the morbid changes invariably gives rise to a large number of minute ecchymoses ; these, of course, are equally numerous when the hemorrhage is the primary and the inflanmiation the secondary phenomenon. Should the affected part undergo softening and purulent liquefaction, the extravasated blood mingles with the pulp, and imparts to it a more or less intensely red color. Hence, the term red softening is generally applied to parts aftected by encephalitis (cerebritis), or by myelitis r but this term is equally applicable to other cases in which similar effects are produced by very different causes. The presence of pus is characteristic of the inflammatory form of red softening ; so, too, is the pre- sence of an areola, from one to two lines in width, in which the parenchyma is studded wdth numerous bloody points, and swollen by a commencing puru- lent hifiltration. (Rindfleisch.) But purulent softening had not yet appeared in the example just related; or, rather, the hypersemia of the rachidian parenchyma, which was very intense and accompanied by a great multitude of minute extravasations of blood, seems to have been passing away, that is, undergoing resolution or cure, the intensely red hue arising therefrom alone remaining. I have dwelt somewhat upon this case, because it affords sure ground for the hope of obtaining a cure by timely medication in analogous cases of traumatic inflammation of the membranes and substance of the spinal cord. But when, on the other hand, resolution of acute hypersemia of the cord does not occur, either spontaneously or in consequence of treatment, purulent infiltration of the reddened tissue will ensue, and purulent matter will take the place of the rachidian substance. Concerning the manner in which the liquefaction occurs, no unquestionable theory can be advanced in the present anarchical state of our doctrines concerning suppuration. "We can but express suppositions, keeping a firm hold on individual facts of unquestioned certainty to serve as guides. Among these I include," Eindfleisch justly observes, " the passive behavior of the nervous elements in the suppurative process, and the intense activity of the vascular system in every stage of the disease. The nerve-fibres within the affected area are partly suspended m the pus as disconnected fragments, partly protruded from the walls of the cavity in a state of advancing maceration and decay. I have not been able to detect any traces either of fatty or of granular degeneration in them; drops of myelin separate from their surface ; the axis-cylinders grow thmner by degrees, and finally disajjpear. The ganglion-cells of the affected part become darkly granular, and break up into splinters ; I have often recognized well- marked fragments of them in the pulp."^ From what source comes the purulent matter in such cases ? The same indefatigable observer remarks :— " My own investigations have taught me that the pus first collects around those vessels from which extravasation [of blood] has occurred. In trans- 1 Medical and Surgical History of the War of the Rebellion, First Surgical Volume, p. 441. « Op. cit., vol ii. p. 325. TRAUMATIC MYELITIS. 418 verse sections of the encephalitic foci (red softening), hardened in preservative fluids, we find these vessels girdled by a relatively wide areola of pus-cells ; and by dint of careful management, we may even pull vessels coated with pus furnished with regular" sheaths of pus-corpuscles — out of the recent specimen. Finally, we may also see in the transverse sections that the pus has actually juished the extravasated, but still fluid, blood away from the vessels, the blood-corpuscles forming a ring around the pus, instead of a 2:lobular drop. This would lead us to infer that the pus was generated by the adventitia, or furnished by the emigration of leucocytes. Nevertheless, I am loth to refuse the power of generating pus to the neuroglia ; I am quite sure that it is capable of producing corpuscular elements (solitary tubercles, gliomata); and, although I regard the results of my inquiries, just given, as trustworthy so far as they go, yet I do not consider them exhaus- tive." ^ The purulent matter, then, in such cases, (1) arises from the emi- gration of leucocytes; (2) is generated by the adventitia; and (3) is probably produced also by the neurog'lia ; but, whatever be its origin, it destroys and takes the place of the inflamed substance of the cord. Thus suppurative inflammation of its substance may demolish the structure of the spinal cord, not only through and through, but upw^ard as well as downward for a con- siderable distance in its continuity. Thus come to pass the disorganized and liquefied conditions of the spinal cord revealed by necroscopy in cases of vertebral fracture or dislocation, where death has occurred some clays or wxeks after the accident, many examples of which have been mentioned in the foreo;oing pages. To emphasize this important point, a few brief abstracts will here be added: — (1) Zambaco^ mentions the case of a man having fracture and luxation of the third dorsal vertebra. The compression of the spinal cord was not constant ; it could be reHeved by pressure. However, death ensued eighteen days after the injury, through the lungs ; that is, from asphyxia. (Ashhurst.) No doubt, the injury of the cord in this case caused ascending myelitis which disorganized the cord in the upper dorsal and lower cervical regions, paralyzed the respiratory nerves and muscles thereby, and thus completely arrested the resph-atory movements. (2) Luke^ reports the case of a man who had fracture of the seventh dorsal vertebra. The displacement was corrected by making extension, and reduction was accompanied by an audible sound. Death from erysipelas supervened seven days after the accident. On autopsy, the spinal cord was found to be softened and disorganized, and to contain purulent matter. (Ashhurst.) (3) Dupuytren* mentions the case of a man injured by jumping from a third story. There was deformity of the spinal column in the lumbar region, with great mobility ; paralysis, at first partial, but afterwards complete ; and bed-sores. Death resulted. The autopsy revealed fracture of the second dorsal vertebra ; the spinal cord was lique- fied ; and a purulent cyst was found by the tenth dorsal vertebra. (Ashhurst.) (4) Adams ^ relates the case of a woman, aged 28, who fell ten feet, striking the head. " Grating in the neck" was felt ; there was a protuberance in the pharynx and a depression in the back of the neck ; paralysis ; pain ; dyspnoea ; retention of urine; insomnia; involuntary evacuation of the bowels; bed-sores; and convulsions. In twelve days death ensued. The autopsy revealed dislocation of the fifth from the sixth cervical vertebra ; also fracture of the sixth dorsal vertebra. Opposite the latter point the spinal cord was divided, and above it the cord was softened. (Ashhurst.) Here again was shown the remarkable propensity to travel upward, which characterizes trau- matic myelitis. ' Ibid., p. 326. 3 Lancet, 1850. 5 Dublin Med. Journal, vol. vi. « Rec. des Trav. de la Soc. Med. d'Obs., t. i. ^ Diseases and Injuries of Bones. 414 INJURIES OF THE BACK. Moreover, in occasional, perhaps in frequent instances of traumatic myelitis, the inflammatory process does not involve the whole thickness of the cord ; it may be restricted to the central gray matter ; and, possibly, to one of the columns. An instance in point is given by Anstie :— ^ A woman, aged 38, fell thirty feet from a window, and came under Mr. Holt's care. There was a scalp wound, with concussion paralysis and delirium. In eight days death supervened. The autopsy showed fractures of the sixth cervical vertebra and skull ; red softening of the central gray matter of the cord ; antero-lateral columns healthy. (Ashhurst.) Another instance in point is given by Genest : — ^ A woman, aged 40, received a blow on her back. Six weeks afterwards she felt pain starting from the right foot. Gradually the pain extended to various parts of the limb ; and, after a month, it was accompanied by spasmodic contractions, and by diminished voluntary motion. She walked with great difficulty, even with the help of a stick. There was no alteration in the temperature of this limb. The convulsions extended to the other limbs and to the head, and the patient died. Autopsy — Brain normal ; cerebellum a little softened ; no meningitis ; spinal cord healthy, excepting at the swell- ing for the lower limbs, which, for an extent of eighteen lines and a depth of one line, on its posterior aspect, was softened, and looked like cream, somewhat rose-colored. The softening in this case was obviously inflammatory, and was restricted to the poste- rior columns. This circumstance is also instructive as well as interesting, because the morbid action was engendered by concussion (contusion) of the cord substance. To briefly enumerate the morbid appearances which result from traumatic myelitis : they are (1) red softening ; (2) purulent infiltration of the reddened and softened rachidian substance ; (3) collections of purulent matter (abscesses) surrounded by areolae of red softening, one or two lines thick, in the rachidian substance ; (4) more or less complete liquefaction of the cord, but without well-defined margins. The morbid appearances usually extend through the whole thickness of the cord, and some considerable distance in a longitudinal direction, but mostly upward ; occasionally, however, they are restricted to the central gray matter, or to the columns. Etiology. — Traumatic inflammation of the spinal cord may arise from any wound which penetrates the spinal canal. It is often caused by simple frac- tures and dislocations of the spinal column, as well as by those that are com- pound. It is not unfrequently produced by concussions of the spinal cord, especially those that are attended by ecchymosis of the cord-substance ; in such cases, the inflammatory process is apt to be subacute and to pursue a chronic course. Dr. Nairne,^ however, has recorded an acute case occurring in a lad, aged 17, in whom it was caused by severe jolting in a cart. Next day he was unable to walk, from para- lysis ; he rapidly grew worse ; and, after ten days, he died. On autopsy, the spinal veins were found to be greatly congested ; and a portion of the spinal marrow opposite the third and fourth dorsal vertebra?, at least one inch in length, was thoroughly disor- ganized and reduced to a semi-fluid state. Occasionally, traumatic myelitis results from violent strains of the spinal column, although the bones and ligaments are apparently uninjured. Sir W. Gull* relates the case of a man, aged 25, employed as a laborer in the com- mercial dock, who felt a sudden pain in tlje back after lifting some deals, on November 22. He walked to his home (about a mile and a half) ; was apparently well on the ' Trans. Lond. Patlx. Society, vol. x. 2 Brown-Sequard, op. cit., p. 72 ; quoted from Gazette Medicale de Paris, 1831, p. 34. ' Medico-Chirurgical Transactions, vol. xxxiv. p. 37. 4 Guy's Hospital Reports, 18r)8, pp. 189, 190. TRAUMATIC iMYELITlS. 415 following day. Next morning (November 24), on waking, the legs were paralyzed. On the 26th, he entered the hospital. There was complete paraplegia, a bed-sore had already begun to form over the sacrum, and ammoniacal urine dribbled from the blad- der. He died exhausted, on January 2, forty-one days after the strain. Autopsy. — A large bed-sore exposed the sacrum in its whole length. The bones and ligaments of the spine exhibited no trace of injury. The cord was softened, oi)posite the fifth and sixth dorsal vertebrae, through all its columns, into a thick, greenish, muco- puritbrm Huid, with a brown tinge. Lumbar and cervical portions of tlie cord normal. Commencing suppuration in the cortical substance of the kidneys. Mucous membrane of tlie pelves greenish, with patches of greenish fibrinous exudation. Mucous membrane of the ureters and bladder in the same condition ; the bladder contained a quantity of muco-purulent fluid. The microscope showed the softened part of the cord to consist of disintegrated nerve-tissue, with a few irregular collections of granules. Prognosis. — The outlook in cases of traumatic myelitis is always gloomy. From inflammatory disintegration of the spinal cord, gangrenous bed-sores often arise ; and they prove fatal, not unfrequently, by inducing septicaemia or pygemia, as happened in the following instance : — A soldier was wounded at Antietam, September 17, 1862, in the lumbar spine, and lay on the field until the 20th, when he was taken to general hospital. At that time he could walk, but paralysis soon supervened. Retention of urine lasted two days ; no difficulty afterw^ard ; no derangement of the alimentary canal ; pulse small and weak ; face flushed. The patient suffered greatly from bed-sores. On October 6 he suf- fered great pain in the legs ; they were without feeling, but warm. On the 10th, pro- fuse sweats occurred; he sank rapidly, and died on the 11th, apparently of septicaemia arising from the bed-sores. A conoidal ball was found to have passed through the spinal column and cauda equina at the third lumbar vertebra, and to have lodged at the left intervertebral foramen ; condition of cord and membranes not reported.^ Again, traumatic myelitis may destroy life by causing vesical and renal inflammation, as well as an alkaline state of the urine. But the discussion of this point is reserved for the section on Disorders of the Urinary Ora;ans arising from Lesions of the Spinal Cord. Most frequently, however, traumatic myelitis ends in death by asce*nding the spinal cord until it involves the origins of the spinal nerves upon which the respiratory movements depend, when paralysis of the respiratory muscles and death from asphyxia (apnoea) ensue. Stromeyer mentions a case in which the posterior parts of the fifth and sixth cervical vertebrae were torn away by a bullet, and which ended fatally on the fifth day from this cause. Paralysis of the lower extremities occurred on the first day ; afterward, complete paralysis of the arms, etc., was superadded.^ I have already presented many examples in Avhich death resulted in the same way, that is, by paralysis of the respira- tory muscles in consequence of ascending myelitis. In the following example, where the cauda equina was injured, death appears to have been caused in the same manner : — A corporal, aged 26, was wounded by a conoidal musket-ball, July 9, 1864, in the lumbar region, and on the next day entered general hospital. Three days after that, incomplete paraplegia set in. He suffered at times from excruciating pains at the seat of the wound and in the lower extremities. Anodynes were freely given. Sphincter ani muscle paralyzed ; patient delirious at times ; pulse slightly accelerated. Death resulted on the 18th. Necroscopy — The missile had entered at a point midway be- tween the anterior and posterior spinous processes (upper) of the ilium, one inch below the crest, passed inward and backward, chipped the sacrum at its posterior superior angle, fractured the fourth lumbar vertebra, and lodged in the spinal canal ; condition of the Cauda equina and membranes not reported.^ The symptoms clearly indicate 1 Medical and Surgical Historj of the War of the Rebellion, First Suro-ical Vol. p. 446. 2 Op. cit., p. 37. 3 Med. and Surg. History of the War of the Rebellion, First Surgical Vol., p. 447. 416 INJURIES OF THE BACK. that this also was a case of ascending myelitis. Paraplegia beginning some days after the injury was inflicted, and then gradually extending upward, with incontinence of feces and urine, delirium, and diaphragmatic breathing, are signs quite characteristic of this affection when it spreads from the lumbar, upward to the cervical region. In respect to disordered sensations, it should be observed that the excru- ciating pains in the wound and lower extremities which this patient endured, arose from the sphial meningitis which attended the inflammation of the cord-substance. But patients having acute traumatic myelitis often make no complaint of pain whatever during the whole course of the disease. A case in point is related on page 371, in which the cord was severed by the missile (Fig. 870) ; and although the upper portion of the cord was much softened by the inflammatory process, there was i^o complaint of pain. Sir W. Gull's case of acute myelitis, arising from a strain of the back (related above), like- wise shows that the spinal cord may be completely destroyed for a consider- able distance by the inflammatory process without causing much if any pain ; for, in that case, no pain wbg^tever was complained of, excepting the pain which attended the strain itself. Among the symptoms which are particularly bad as prognostics in cases of traumatic myelitis, we may mention gangrenous eschars over the sacrum that are rapidly enlarging, inflammations of the kidneys or bladder that are rapidly extending, ascending paraplegia— paralysis of the upper extremities appearing some days after that of the lower extremities, etc., has occurred — and diaphragmatic breathing, especially when the latter is attended by dys- pnoea and bronchial rales, for then the end may be quite near. But, although the prognosis of traumatic myelitis is generally unfavorable, we are still not entirely without hope during the first stage of the disease ; for, in the case of the cavalryman, aged 35, whose death suddenly resulted from hseraoptysis the case is related on page 411), the disease was shown by the necroscopy to be undergoing resolution ; and in the foudroyant case of traumatic spinal meningitis related on page 402, potassium iodide and ergot were •ad ministered with a notably good eflect upon the inflammation (acute hypenemia) which attended the injury of the cord-substance, and preceded the inflammation of the spinal membranes. Treatment— ^trome J er says: "In a case where a bullet, entering laterally, bruised the third and fourth cervical vertebrae severely, and was not extracted, death resulted from the advance of inflammation of the spinal cord and brain; there was at first paralysis of the arm belonging to the injured side ; it was followed by incomplete paralysis of all the limbs, ending in coma. Anti- phlogistic treatment had been entirely neglected." ^ The patient afflicted with acute traumatic myelitis should always be placed on a water bed. In other respects the prophylaxis and treatment of this disease are the same as for traumatic spinal meningitis (see page 408). For an account of the prophylaxis and treatment of sacral eschars (so- called bed-sores), and of vesical and renal inflammations which result from myelitis, the reader should consult the sections specially devoted to those topics. . In regard to the treatment of chronic myelitis with paraplegia, I will briefly mention a case which was successfully managed by Dr. C. Taylor.^ The disease had lasted eleven months before the treatment was comnaenced. This consisted in the administration of ergot and belladonna, potassium iodide, and cod-liver oil, with alternated cold and hot flapping of the back, twice daily, and a cold douche followed by violent rubbing with niustard every morning. Complete recovery, excepting some slight want of ability to guide 1 Op. cit., p. 38. ^ British Med. Journal, May 24, 1862. SACRO-GLUTEAL ESCHAKS. 417 the legs, was obtained The symptoms were very well marked; the treat- ment was, therefore founded on an accurate diagnosis. It will also be remembered that belladonna (per orem) gave notafie relief to vesical and urethral hypersesthesia m one of the cases related above. In at least three mstmices belonging to the same category as Dr. Taylor's patient, I have seen much benefit derived from the fluid extract of ergot and potassium iodkle In one case where there probably was constitutional (tertiar\ ) sv)>hilis cor rosive sublimate (gr. ^ thrice daily) did good. Concerning bellidouna, E row, : Sequard justly remarks that no other medicine known has so much l ower to diminish the reflex faculty of the spinal cord.' Ifux vomica and strychnia are never admissible in the treatment of this disease, because they increase the amount of blood in the cord. •'^ "iciedse Sacro-Gluteal Eschars, and other so-called Bed-Sores, arising from Lesions of the Spinal Cord and Spinal Nerves. These affections so often present themselves in cases of spinal iniury t to'™ {f'"' f *° both surgeons and attendants, as''weli as to patients whenever they do appear; and finally, they prove so fre^ quently to be the proximate cause of death in fatal cls'es of sS injury that a special consideration of them is demanded in this place There are two important varieties of these eschars or sores which are met with iii cases where the spine is injured ; and they differ very widely in respec to thei? causation, the gravity of the r prognosis, and the remedial measure that a^e necessary _ These distinct kinds or varieties of bed-sores are : (1) the cammn or that which IB often met with in cases where there is no spinil fnjury nor spinal disease as well as in cases where the spinal column is injured ■ IId7>) he neurotroplue ov neMropathie or that which arises from somi morbid exci^ tation or disease of the spinal cord or spinal nerves. The former has hnl been known ; the latter w-as first describid by M. Brown-Sequaixl! = (1) The common kind of bed-sore is liable to occur in all injuries or dis- eases which are attended with inability on the part of patients lo move themselves or change their positions in bed ; for instance, in cei ta n fLTurls of the femur and in certain forms of disease or injury of the hip oi^in etc as well as m fractures and dislocations of the spind c^olun n Siuch cases the patients, unless properly cared for by others, ^vill continue to lie in one set led or unchanged position all day, and all nic^ht, perhaps for several davs and nights together. Hence, the whole weight °of heir h 4 will press Sh concentrated energy upon the integuments which cover thf^ Cjecti^^ points of their pelves The skin and fascia overlying the Zerhml co f vex, and irregular surface of the sacrum sustain the priifciml pS'e That" compression interrupts the circulation; the blood which^oui t to ^^^te^^ he compressed tissues is prevented from doino- so • the blood nWn.l,, +i • squeezed out; the vessels are tenantless. An add tlndevif rrnvfin, almost impossible, with even the o-reatest care to nrevp^^^^^^ lemains; it is but ver^^ little, from trickling intS ^^H^^^Zj^Z^^l^:^^ rurthermore in spite of every attention, the fecal discharge lodge d oi the ment's of^r ■ T '^'i!"'' '^"'^ ^ets mixed with the i^rine. " t1^ integu- ments of the nates may become macerated in tliis stinkino- mixture and then Its liquid portion will act on the sodden tissues like ahs?harot?c' sub stance. It is, therefore, not surprising that the intec^uments coveri^r he sacrum, etc., when subjected to the destructive influenc% Jpres ure"oTcon! » Op. cit., pp. 175, 176. VOL. IV. — 27 418 INJURIES OF THE BACK. stant or long continued, combined with that of decomposing urine and feces, should soon become converted into an eschar, a slough, or a bed-sore, .bor a further account of the common variety of bed-sore— of its symptoms and treatment— the reader is referred to Prof. Moore's Article m the J^irst Vol- ume of this Work, pp. 800-802. (2) The neurotrophic or neuropathic variety of bed-sore appears to have been clearly understood for the first time by M. Brown-Sequard, as already intimated, for he first demonstrated by experiments on animals the peculiar nature, as well as the causal relations and causal indications for treatment, of this important lesion. The celebrated Dr. Bright, however, had already been so much struck by its chief clinical features that he caused drawings and models in wax illustrating them to be prepared ; and he, likewise, related four examples in point in his " Reports of Medical Cases."^ But M. Brown- Sequard, after prolonged research and reflection, and after making numerous experiments on animals, to elucidate this lesion, remarked concerning it, in 1858, as follows : — . V ^ "The production of sloughs on the sacrum cannot be considered as an eftect of prolonged pressure [from the decubitus] upon the parts of the skin where they appear, [inasmuch] as they sometimes are produced m a few days and even in a few hours after the fracture. They result from a morbid excita- tion of the spinal cord, and not from the loss of action [paralysis] of that nervous centre owing to its partial or complete section, as I have proved by experiments [on animals] showing that they never occur after [simple] section of the cord. The proof that pressure upon the sacrum has but a slight influence in their production, is clearly given in the case of animals on which, after fractures of the spine, I have seen sloughs occurring m parts that were not subjected to pressure. Besides, it is known that men who are confined to bed by other causes than a nervous complaint, may bear pressure upon the same part of the body for a long time without producing sloughs. Pressure upon the sacrum is, therefore, only an additional cause of sloughs, i or the mode of action of the nervous system in producing alterations of nutrition, I will refer to my lecture on the influence of the nervous system upon nutri- tion,2 and I will only say here that an irritation, and not a paralysis, is the cause of these morbid changes."^ , . ^ n Among the points established in the lecture to which he refers, are the following: — . ^ ^ , (1) The phenomena of reflex action, that is, pains and muscular contrac- tions in the peripheral parts, can also be produced by directly irritating either the spinal cord as a compound nervous centre (that is, a series ot nervous centres arranged one above another), or the spinal nerves which issue trom it. (2) " The phenomena of this direct irritation have very often been mistaken for consequences of the absence of action in the nervous centres. I will merely point out here the rapid sloughs that are observed after fractures or luxations of the vertebral column, and the rapid change of the urinary secre- tion in similar cases."* ^.i • i (3) " I will only add, as reo;ards the influence of the pressure on the spinal cord producing sloughs on the nates and other morbid changes, that it is 1 Op. cit., vol. ii. pp. 383, 423, Diseases of the Brain and Nervous System. London, 1831. 2 For more details on the capital point that it is chiefly owing to a morbid ^f^^^^^he nervous system that alterations of nutrition take place in diseases of that system, and not, genera ^ supposed, to a paralysis, that is, to a cessation of the action ot that system, see Journal de Physi- "^'3^ Brown^FquaM's Lectures on the Physiology and Pathology of the Central Nervous System, etc., pp. 248, 249. 4 Ibid., p. 176. SACRO-GLUTEAL ESCHARS. 419 chiefly in exciting a persistent contraction of the bloodvessels in the parts where nutrition or secretion is morbidly altered, that the pressure on the cord acts. As it often happens that death, after a fracture or a luxation of the spine, is due to the slough formed on the nates, I think I must remark that ^ a very good means of dilating the bloodvessels consists in exhaustino- their irritability by applications of powerful galvanic currents."^ ^ " To complete the demonstration of the proposition that death after frac- ture of the spine is usually due to the effects of the excitation of the spinal cord by pieces of broken bone [by ecchymosis from contusion of its sub- stance, and by inflammation of its substance], and not to the results [merely] of a partial or complete section of this nervous centre, we will only say that there are many cases on record showing that a section or even a crushins; of the spinal cord has not proved fatal [in man], and that in animals death is rarely caused by a partial or complete section of the cord in the dorsal region while they die as quickly and as often as men after a fracture of the spine, if .the broken pieces be not removed [and if myelitis, etc., be not prevented].'"^ There is no doubt, then, that the eschars in question result not from mere division of the cord-substance, whether partial or complete, but from morbid excitation of that substance arising either from the irritation that is caused by the contact of foreign bodies, e. g., splinters of bone and extravasations of blood, or from the inflammatory process acting upon its histological ele- ments, when it is aroused by the injury. This remarkable affection of the parts situated at the peripheral extremi- ties of the spinal nerves, which results mainly from central causes, Samuel has proposed to characterize by naming it Decubitus Acutus, and Charcot has accepted the appellation. ^ ^Nevertheless, this term is far from being satis- tactory, first, because the term ''decubitus" is commonly applied to the pos- ture ot the patient in bed, which has generally but a small share in the production ot the disease ; and, secondly, because in some strondy marked exan]ples on record, the " decubitus" has had nothing whatever to do in causino- the peripheral gangrene, as, for instance, in the following highly instructive case, which has already been several times referred to :— The late Dr D. S. Conant^ presented to the New York Pathological Society, together with the osteological specimen, an account of an interesting case, in which the last dorsal and the first lumbar vertebra were fractured, and the spinal cord severed by an osseous splinter from the laminae of the first lumbar. Within six days after the casu- alty, an immense, gangrenous blister formed on the inner side of each thio-h without any apparent cause. ° A stout man aged 55, was blown off from the rigging of a ship on which he was at work, by a high wmd on a certain Monday. He hit something in his descent and turned over, but finally struck heavily upon his shoulders. When taken up by his comiacks, he was completely paralyzed in both lower extremities. Three days after- ward Dr. Conant saw him in consultation, and found that there was complete loss of sensibility and moUon below a certain well-defined line extending around his body Ihere was also noticed a posterior angular deformity of the spine at the dorso-lumbar junction and Dr. Conant diagnosticated fracture with crushing of the body of the Uvelfth dorsal vertebra, and with fragments of bone impinging upon the spinal cord. The patient went on very well until the Saturday following the injury his mind remaining perfectly clear. On Sunday morning his physician noticed a large blister on he inner side of each thigh, and extending nearly tlie whole length thereof, uncon- nected with any previous local irritation. At four o'clock he had a chill, his mind till then having remained clear. But soon after be became delirious, and quietly died ! Ibid. p Ibid., p. 250. Philarelph7a,T879^' translated by Dr. G. Sigerson, p. 57. * American Medical Times, June 1, 1861, pp. 359, 360. 420 INJURIES OF THE BACK. , without any convulsions at seven o'clock the same evening, six days and some hours after the accident, apparently in consequence of septicaemia. , . -, p Autopsy There was a considerable quantity of extravasated blood on each side ot the spinal column, in the vicinity of the last rib. The body of the last dorsal vertebra was found crushed, and a little piece of bone from the laminae of the first lumbar ver- tebra had cut the spinal cord entirely off. The blisters on the inner sides of the thighs were found to be the results of mortification. The internal organs were all healthy. No statement is reported as to the presence of a sacro-gluteal eschar, but without doubt there was a large one formed by Saturday, when it was noted that the patient was not doing so well. It is mentioned that there was but little disturbance of the pulse, notwithstanding that mortification was occurring in the lower extremities. The textural condition of the spinal cord, aside from its complete division by a fracture- splinter, is not described. The gangrenous inflammation 'of the thighs was thought to be due to " injury of the sympathetic ganglia situated at the angles of the last two ribs." But, inasmuch as in other cases belonging to the same category, similar eschars have appeared when vaso-motor paralysis has been completely wanting, it is only fair to infer that in this case the gangrenous lesions of the thighs arose from morbid excita- tion of the spinal cord, which is merely another name for traumatic myelitis, at least in this particular instance. Again, in the following example of chronic myelitis arising from concussion of the spinal corcl, at the lower part thoreof, where the resultant paraplegia was very far short of being complete, an ulcer or slough of large size pre- sented itself in the integuments over the sacrum, although there had been no absolute confinement to bed at any time Professor Wm. A. Hammond ^ relates the case of an originally healthy married wo- man, ao-ed 22, admitted into the Baltimore Infirmary, on March 14, with chronic myelitis, the result of an injury. She was a sober, intelligent young woman, by occu- pation a weaver, four years married, and the mother of a child then three years old. She had always been healthy until her present illness, excepting that in girlhood she had been affected to some extent with rheumatism and occasional epistaxis. Eleven months before admission, whilst in a somnambulistic state, she fell from a second-story window, and struck the hand-rail of a porch in her descent, injuring her back about the junction of the lumbar vertebrae with the sacrum. The immediate consequences were pain in that region, soreness across the abdomen, and the passage of bloody urine. For seven months catheterization was necessary, after which time the bladder in a measure recovered its contractility, but soon lost it again, the sphinc- ter also becoming paralyzed. Severe cough likewise ensued; and the catamenia, heretofore quite regular, entirely ceased. There was slight paralysis of the lower ex- tremities from the time of the accident, which gradually increased until considerable difficulty was experienced in walking, or even in standing. There was also deficient sensibility in both lower extremities, and likewise over the sacral region. Soon after the accident, the sphincter ani lost its power. From the first, she experienced more or less numbness and spasm in her lower extremities. She had been treated by cupping the lumbar and sacral regions, and by strychnia. At the time of admission, there was complete paralysis of the sphincters ot the bladder and rectum. Her urine was constantly flowing from her, and the moment her feces entered the rectum it was evacuated. Upon introducing a finger into the bowel, it was found to be entirely relaxed ; and, in fact, three or four fingers could be inserted with ease. Her lower extremities were partially paralyzed. Although she could still walk, she did so with difficulty. Frequent cramps and almost constant formication were present, and there were occasional startings of the limbs without her being aware of them. There was a good deal of pain in the sacral region ; and, as is usual in such cases, a large ulcer existed in the same locality. On applying the sesthesiometer to the anterior surface of her legs and thighs, to those parts which are supplied by branches of the lumbar plexus of nerves, there was no diminution of sensibility found. She appreciated the two points when separated only 1 American Medical Times, June 15, 1861, pp. 379-381. SACRO-GLUTEAL ESCHARS. 421 to .the extent of half an inch. But, on applying tlie instrument to the posterior surface of her legs and thighs, to the parts which are supplied by the sacral plexus, sl)e was conscious o but one impression. Even when the points were separated to the extent ot five inches, but one impression was perceived ; and, over the gluteal and sacral . regions, she could not feel them ^it all. It was therefore evident that the disease affected the portion of the spinal cord from which the sacral plexus arose— namely the lower portion. In addition, it was found tiiat the sphincters of the bladder and rectum, which likewise derive their nerve-filaments from the same plexus, had lost their contracti e power. Tliere was a sense of constriction also present, and the urine was strongly alkaline. The diagnosis of chronic myelitis was founded on the fact that for a Ion- time the i>a. tient had experienced constant pain at the point where the healthy and diseased portions of the cord united ; that there was a sense of constriction also present there ; that there was a feeling of numbness almost constantly present in the paralyzed portions of her body • and, frequently, other morbid sensations, such as coldness, burning, formication, etc ' that there were oftentimes reflex-motor spasms in the lower extremities ; that there was well-marked anaesthesia in the portions of cutaneous surface supplied by nerves issuin- from the diseased part of the spinal cord ; that the sphincters of the anus and bladder were paralyzed ; that the normal movements of the lower extremities were consider- ably impaired ; that there was a large slough over the sacrum ; and that the urine was strongly alkaline. The treatme7it consisted in administering ergot in moderate doses by the mouth, and belladonna by the skm, by applying thereto a large plaster made of that remedy ; fresh air, moderate exercise, and a good, nutritious, diet were also enjoined. The sacral slough was treated by the method recommended by M. Brown-S^quard (which will presently be described), and by applying galvanism. May 16. The patient has recovered full control over the bladder, the rectum, and the extremities ; her ability to walk is also very much improved. The slouo-h over the sacrum has been entirely cured. The pain has almost entirely departed from the cord and she IS no longer troubled with cramps or numbness in the lower extremities. This highly beneficial plan of treatment is to be continued until the cure is comolete I he history of this exceedingly instructive case I have presented as brieflV as seemed consistent with elucidating in a satisfactory manner the symptoms, the diagnosis, and the therapeusis of this sometimes obscure and often very troublesome disorder of the spinal cord ; and by so doing I have really saved the use of many words and even para- graphs in the way of abstract description, which ultimately would have been required. T ^ ^^^'^ presented two important examples in which the patient's " decu- bitii. had no part whatever in the production of the eschars in question, and mthQ latter ot them the eschar was not even " acute." It is, therefore ouite evident that the term " decubitus acutus" is not at all appropriate for such mstances, as well as not particularly appropriate for any instance of the lesion under consideration ; and with a view to indicate at the fii-st o-lance the ner- vous origin ot the^e sloughs, I have ventured to call them imiropaihic eschars, that IS, eschars which arise mainlv in consequence of morbid excitation or disease of the spinal cord itself, or of the spinal nerves that supply the parts on which the eschars are formed. ^ Symptoms of Neitropathic Eschar s.~ThQ)^v^t sign of this disorder is an ery- thematous patch on which vesiculc^ and bullae are rapidly developed; morti- '^wf" ^,y^i^,.P^^t^,^^ ^lie skm and subjacent tissues very often ensues. VVlien this disorder appears in consequence of a lesion of the spinal cord It usually presents itself in the sacral region. Here it is bisected vertically by the median line ; and it extends itself symmetrically, on either side, into the adjacent integuments. (Fig. 882.) But it may likewise appear on almost any part of the truidv or the members that may be subjected, by posture, to a somewhat continuous pressure. In certain cases, a very slight and a very short pressure suffices to determine its appearance. Finally, there are some 422 INJURIES OF THE BACK. Fig. 882. cases, the number of which is probably not very great, wherein it seems to be produced without the intervention even of the least degree of pressure, or of any other cause of a similar kind. I have just presented two very instruc- tive examples belonging to this cate- gory. This disorder is quite distinct from the various cutaneous eruptions which are seen not unfrequently in the sacral region of patients condemned by dif- ferent aifections to long maintain a recumbent posture in bed. These eruptions, which sometimes are ery- thematous and lichenoid, sometimes pustular and ulcerous, sometimes pap- ular, and having a deceptive resem- blance to syphilitic sores [plaques mu- qiieuses), are generally caused by re- peated and prolonged contact with irritating substances, such as decom- posing urine and fecal matter. They, as well as the neuropathic erythema and blebs, may become the starting points of genuine eschars, as already stated above. But the neuropathic eschar is often distinguishable, clinic- ally , from that of the former, by certain important characteristics, namely : (1) By appearing shortly after the pri- mary disorder of the nerve-tissue, or by following upon a sudden exacerbation of that disorder ; and (2) By exhibiting a very rapid evolution. (Charcot.) Some days, or, it may be, onl}^ some hours, after the causative affection of the spinal cord has manifested itself in such cases, there appear on certain portions of the skin, already mentioned, one or several erythematous patches, variable in extent and irregular in shape. The skin hei^e has a rosy hue ; sometimes, however, it is dark-red, and even violet, but still the color disappears mo- mentarily on making pressure with a finger. M. Charcot has ascertained that in such cases the derma is, anatomically, infiltrated with leucocytes, as happens in erysipelas.^ Occasionally, but, for the most part, in examples of myelitis, there-appears besides an apparently phlegmonous tumefaction, involv- ing the derma and subjacent tissues, which may be attended by acute pain^ if the affected part have not been previously stricken with anaesthesia. In a day or two, but sometimes sooner, vesicles or bullae make their ap- j)earance about the middle of the erythematous patch ; they contain a liquid substance or serosity, which is sometimes colorless and perfectly transparent^ and sometimes more or less opaque, reddish, or of a brownish hue. If the causative affections of the spinal cord or spinal nerves now abate, the vesicles and blebs soon wither, dry up, and disappear. Sometimes, how- ever, the blistered epidermis becomes torn, drops off* in pieces, and lays bare a bright-red surface strewn with violet points or patches, corresponding with a sanguinolent infiltration of the cutis vera. In such cases, the subcutaneous connective tissue, and sometimes even the subjacent muscles, are likewise invaded by the sanguinolent infiltration. This fact M. Charcot has repeat- edly verified by post-mortem examination.^ Showing a sacro-gluteal eschar of neuropathic origin, which was formed in a case of myelitis involying the dorsal portion of the spinal cord: 1. The mortified part 2. The erythematous zone. (Charcot.) Op. cit., p. TjS, foot-note. 2 Ibid. 58. SACR0-13LUTEAL ESCHARS,. 423 These violet-colored points or patches of saiiguinoleiit infiltration rapidly widen, and soon their edges run together or coalesce. Thus, in a short time, there supervenes in the affected part a mortification of the cutis vera, which is at first superficial, but soon becomes profound, and may involve not only ^ the subcutaneous connective tissue, but likewise the subjacent muscles, and even the subjacent bones. Thus the eschar is constituted in the neuropathic cases under consideration. If there be some chance for a favorable issue still remaining, the work of reaction against, and elimination of, the mortified tis- sues at once begins ; and, should the prospect become more favorable, a period of reparation w^ill follow, which, however, is liable to exhibit many fluctua- tions in its course. It should have been stated that in cases of typhus and typhoid fever, a cuta- neous afi^ection of the sacro-gluteal region, etc., not unfrequently occurs, which bears a strong resemblance to the neuropathic bed-sore now under considera- tion, and which, perhaps, arises in part from analogous conditions. This cuta- neous afi:ection of the buttocks, in typhus and typhoid fevers, has been minutely described by Piorry, in France, and by Pfeiifer, in Germany. In the production of neuropathic bed-sores, the patient's posture in bed often plays an important part. For instance, it is not unusual in cases where the patient is so placed as to repose on his side, during part of the day, to find, in addition to the sacral eschar, large necrotic ulcerations occurring over the great trochanters. It is also quite common to see in cases of spinal injury attended with paralysis, that the difi:erent parts of the paralyzed limbs which are exposed to only slight and brief pressure, such as the ankles, heels, and inner surfaces of the knees, present lesions characteristic of neuropathic bed- sores. On page 269 [supra)^ I have presented, with a wood-cut (Fig. 852), an abstract of the case of a soldier whose spinal cord was severed by a knife opposite the fifth cervical vertebra ; neuropathic sjDhacelus soon followed, attacking all the projecting points on the lower part of his body, and pro- ceeding rapidly until it almost bared the sacrum. In some rare instances, I have also seen neuropathic eschars present themselves over the scapulae and over the olecranon process. Clinical Relations. — In the foregoing pages I have mentioned or referred to a great many cases in which neuropathic eschars appeared in connection with fractures or dislocations of the vertebrae, and consequent injury of the spinal cord. In regard to the time wdien the symptoms of neuropathic eschars are most likely to present themselves in cases where the spinal column is injured, Dr. E. Grurlt, whose opinion on this subject is based on the study of a very large number of cases, holds that the first symptoms of this afi:ection usually appear from the fourth to the fifth day after the accident. But the initial erythema and bullee may appear very much earlier than that ; for, on page 315 {supra)^ I have presented, with a wood-cut (Fig. 859) illustrating the ver- tebral lesion, the case of a soldier who dislocated the fourth cervical ver- tebra with much displacement and much damage to the spinal cord, in a vain attempt to turn a somersault, and who survived the accident only forty- four hours ; nevertheless, it was found at the autopsy that " ulceration over the sacrum had already commenced ;" that is, a w^ell-marked bed-sore was already formed. In this case, then, the initial erythema and vesicles or blebs must have presented themselves within a few hours after the accident. The initial symptoms of a neuropathic eschar on the breech appeared in less than thirty-six hours after the injury, in a case under the late Dr. James E. Wood's care, at Bellevue Hospital : — The patient was a stableman, aged 30, who fractured the seventh cervical vertebra by falling down stairs, at 7 P. M., on June 13. He was insensible for the moment. 424 INJURIES OF THE BACK. On the 14th, at 6 P. M., he was admitted to the hospital, with complete motor and sensory paralysis of the entire body, below the third rib in front and the fourth rib behind. The decubitus was dorsal, with head and neck thrust forward. The respira- tion was purely abdominal (diaphragmatic). The penis was strongly erected. Neither urine nor feces had been passed since the accident. On the 15th, A. M., a red spot, nearly two hands' size, was observed upon the left nates, and vesication in the fissure near the extremity of the coccyx. In the evening, marked increase of temperature all over the surface of the body was found, and a pur- plish spot, the commencement of a slough, low down in the cleft of the nates. On the 16th, A. M. A purple spot commencing over the third or fourth lumbar vertebra ; some haematuria ; and conside^-able tympanites. 7^ P. M. Great dyspnoea ; bronchial tubes and trachea filled with secretion. On the 17th. The incipient bed-sores no further developed ; patient delirious at times through the day. 7 P. M. Entire anaesthesia and paralysis of both arms — they were not paralyzed early in the afternoon ; great tympanites ; urine high-colored ; priapism always induced by passing the catheter ; was conscious and sane. 9 P. M. Comatose and insensible ; eyes suffused ; convulsive movement of lower jaw ; body still hot ; pulse full and strong. 11| P. M. Died quietly, comatose, and without general convulsions, four days plus four and three-fourth hours after the accident. Autopsy Body of seventh cervical vertebra fractured transversely and completely ; ligamenta subflava completely disrupted ; the vertebra dislocated ; spinal cord not lacerated ; brain moderately con- gested. Pathological condition of the cord not described.^ The ascending and deep- ening character of the paralysis, however, denotes, under the circumstances, that there was ascending myelitis. In a case related on page 390 (supra) the initial symptoms of neuropathic sphacelus simultaneously occurred at several different points in the lower extremities, in less than twenty-four hours after the spinal lesion : — The patient was a derrick-man, aged 41, admitted to Bellevue Hospital, in Dr. Stephen Smith's service, two hours after he had sustained a fracture of the tenth dorsal vertebra, with complete paraplegia, in consequence of being thrown from a cart and striking his back upon the stony street. Next .morning it was observed that sloughs had commenced to form upon the heel and upon the ball of the great toe of his left foot, and over the external malleolus of his right ankle, without any apparent cause ; several hours afterwards, death ensued in consequence of compression of the spinal cord by extravasated blood. In a case recorded by Dr. L. Buchner, of Darmstadt, in which a man, aged 46, liad sustained complete diastasis of the sixth and seventh cervical vertebra by falling from a height, and in which death supervened sixty hours after the accident, a well-marked bed-sore of spinal origin was already visible. (Gurlt.) It has been claimed by many that ancesthesia is an essential factor in the causation of bed-sores having a spinal origin. This view, however, is nega- tived by the case of a young woman, aged 22, related by Professor Hammond, which I have presented on page 420 ; for, in that case, a large sacral eschar appeared, although the patient had never been confined wholly to bed, and had never been entirely unable to walk ; and, therefore, of course, had never had complete paraplegia, nor anything like profound ansesthesia. This view is also negatived by an example of vertebral fracture reported by Jeffreys : — ^ The patient was a man, who was injured by a fall of twenty-five feet from a ladder. There was much shock, with a cold skin, and a barely perceptible pulse. All the parts below the fracture were deprived of sensibility and voluntary motion. Next day there was persistent priapism ; " then supervened phlyctenae in the region of the sacrum and, on the same day, " the patient recovered his sensibility." Death, however, ' New York Journal of Medicine, January, 1859, pp. 85-87. 2 London Medical Journal, July, 1826. SACRO-GLUTEAL ESCHARS. 425 ensued ; and, on post-mortem examination, it was found that the bodies of the seventli and eighth dorsal vertebrae were broken into several pieces, which were much displaced. In a case where neuropathic eschars appear, priapism, strong alkalinity of the urine, hsematuria, inllamniation of the urinary bladder or kidneys, hyper- ^ sesthesia, vaso-motor exaltations or depressions of the body-heat, clonic con- vulsions of the paralyzed members, tonic (that is, tetanoid) spasms occurring in paroxysms, in brief, all those symptoms which usually reveal an excited state of the spinal cord and spinal membranes, often precede, accompany, or closely follow the formation of these eschars. When the injuries (traumatisms) or the secondary lesions which excite the spinal cord in cases where neuropathic eschars ensue, afiect the cord symme- trically, the eschars themselves, as a rule, are symmetrically developed, as shown by Fig. 882 ; as also happened in Dr. Conant's case, where a laro;e gangrenous eschar, of an equal size, presented itself on the inner side of each thigh ; and^ as in Dr. Stephen Smitli's case, referred to above, where sloughs of similar size and appearance simultaneously formed on each foot and ankle, in consequence of spinal injury. But, when the traumatism affects one f^ide only of the spinal cord, then the neuropathic eschars which arise therefrom are not symmetrically developed ; they are found only on the side of the i)ody opposite the side of the cord which is injured or diseased. For ex- ample, in the case of a man admitted into Professor ^^'elaton's ward at the St. Louis Hospital, for a sword-wound of the back dividing the left half of the spinal cord (I have already presented a pretty full account of this case on page 394), ''a slough formed on the right side of the sacrum, although the patient had not felt anything there.'' The man, however, recovered. The same peculiarity has been observed in several analogous cases ; and, accord- ins^ to M. Brown-Sequard's experiments, it is a constant fact in the case of animals. The information derived from M. Brown-Sequard's experiments in this regard, is capable of giving so ninch practical aid or useful help to surgeons m diagnosticating spinal lesions and spinal disorders, that I will briefly refer to them in this place. We learn first from these experiments, that after wounds dividing one lateral half of the spinal cord, there supervenes in animals motor paralysis of the lower extremity on the same side as the lesion of the cord. This limb also presents exaltation of tactile sensibility (hyper^es- thesia) in a more or less marked degree, and it likewise exhibits a notable elevation of temperature correlated with vaso-motor paralysis. But the opposite limb, on the contrary, retains the normal temperature and the normal power of motion, whilst its tactile sensibility is much lessened, or may even be extinct ; that is, it exhibits ansesthesia and sensory paralysis. All these phenomena or symptoms are exactly reproduced in man under analoo-ous circumstances. In his case, as in that of animals, we may also find various trophic derangements rapidly supervening in the peripheral parts of the body, which manifestly arise from the sq^inal lesion. Among the conse- quences of these trophic derangements I have already mentioned bed-sores, occurring not on the injured side, where the voluntary motor and vaso-motor paralysis is to be found, together with exaltation of temperature and hyper- pesthesia, but on the opposite side of the body, particularly on the opposite side of the sacral region, that is, on the side where the motor functions, both voluntary and vasal, are unimpaired, and where there exists only a deadening of the sensibility, or aneesthesia. This circumstance clearly shows that neuro- pathic bed-sores do not arise from vaso-motor paralysis, as some persons have vainly imagined. In man, other nutritive lesions of a similar character have been observed. 426 INJURIES OF THE BACK. I shall here take space to mention only two of them, namely : (1) Rapid diminution of the faradic contractility of the muscles, soon followed by an equably rapid atrophy of the muscles themselves, or acute muscular atrophy ; and (2) A peculiar form of joint-disease inflammatory in character, or spinal arthropathy. It is, however, a remarkable fact, that while the spinal or neu- ropathic eschar, in cases where the cord is partly divided, appears on the side of the sacrum opposite the spinal injury, the arthropathy and the muscular atrophy are to be found in the limb belonging to the same side as the spinal injury. For example, in the case of a man who was admitted into Professor Nelaton's ward with a sword-wound dividing the left half of the spinal cord (already twice mentioned), the symptoms showed rapid improvement up to the twelfth day after the casualty ; on that day it was remarked that,- without apparent cause, the leftleg^ still more sensitive than normal, had increased in volume, and that a quantity of fluid had accumulated in the left knee-joint sufficient to float the patella half an inch above the condyles. Two or three days subsequently, an eschar was observed occupying the right lateral part of the sacrum and the right gluteal region.^ Another very instructive example, which occurred in one of Dr. Cusco's patients, is related by M. Charcot, and I will present a brief abstract of it : — A man, aged 40, was stabbed with a poniard, in the night of February 15-16, 1871, at the third dorsal vertebra, and on the left side thereof. The weapon penetrated downward and toward the right, and divided the left half of the spinal cord. The left leg was immediately stricken with motor paralysis, while the right was not. He was at once brought to hospital. In the morning the following note was made : Left lower extremity, complete motor paralysis ; limb perfectly flaccid ; no trace of contraction, nor of rigidity ; no spasmodic movements, nor subsultus. But its sensibility is greatly exaggerated ; the least touch of the skin, especially near the foot, causes pain ; pressure has the same effect ; a sHght pinch or a tickle is followed by very painful sensations ; the appHcation of a cold body produces painful sensations which the patient compares to prickings. JRight lower extremity, the voluntary motions are all perfectly normal, but the sensibility is almost completely destroyed ; complete analgesia ; sensitiveness to touch almost null ; the contact of a cold body causes an obscure, dull, prickUng sensa- tion. The insensibiUty is not restricted to the lower limb ; it ascends to a level with the right nipple. The urine and feces passed involuntarily. On the 24th, it was noted that the left (motor-paralyzed) hmb was warmer than the right ; and that the patient complained of feeling constricted or compressed at the base of the thorax. On March 5th (seventeenth day), the patient complained of troubled sight : left pupil contracted more than right pupil ; the vessels of left eye more numerous and volumi- nous than those of right eye. The evacuations, for the last two days, had again been voluntary. The state of the lower extremities remained unchanged. On the 13th (twenty -fifth day), the right buttock, since the day before, had been the seat of livid redness, and the epidermis had already fallen off from a part of the erythe- matous patch. On the 14th, the integuments on the right buttock, near the sacrum, were denuded to the extent of a crown-piece, and ecchymosed — that is, there was a spinal bed-sore. The left knee-joint was red and swollen, and hkewise the seat of spontaneous pains, which were increased by moving the joint — that is, there was spinal arthropathy. On the 24th, an ulceration had occurred on the right buttock, on a level with the ecchymosed patch, which now was covered with granulations. The left knee was almost free from redness and swelling, as well as from pain.' The following very instructive example of acute muscular atrophy, taken from Dr. W. Miiller, is likewise presented by M. Charcot : — ^ 1 Brown-Sequard, Journal de la Physiologie, t. iii. p. 130. 2 Op. cit., p. 70. ^ Ibid., pp. 70, 71. SACRO-GLUTEAL ESCHARS. 427 The patient was a woman, aged 21, who was stabbed with a knife in the back, at the fourth dorsal vertebra; the weapon, as the autopsy afterwards demonstrated, divided the left lateral half of the spinal cord, two millimetres above the third pair of dorsal nerves. On the first day, complete paralysis of motion and hyperaisthesia were observed in the left lower extremity ; tiie opposite limb was anaesthetic, but not paralyzed. On ^ the second day it was found that the muscles of tiie paralyzed member, and of the lower part of the abdomen, gave no reaction under faradic stimulation, whilst, in the corre- sponding parts of the opposite side, the electrical contractility continued normal. On the eleventh day, a neuropathic or spinal eschar was formed, which occupied tiie right sacro-gluteal region, and extended to the right gluteal eminence. It was also remarked, on this day, thaj the paralyzed limb had notably wasted away, and measured about two inches less in circumference than the anaesthetic member. On the thirteenth day, death occurred. At the autopsy, the borders of the spinal wound appeared tumefied, and of a reddish-brown color ; a thin purulent layer covered it. Below the wound, the left lateral column presented the anatomical characteristics of descending myelitis, throuo-h- out its whole length. ° Thus, we find that when the neuropathic or spinal bed-sore appears on but one side of the sacrum, or on one buttock only, in consequence of injury or division of the lateral column belonging to the opposite side of the spinal cord, the eschar is liable to be accompanied by a peculiar joint-disease of spi- nal origin, or by an acute muscular atrophy, also of spinal origin, which affec- tions, however, both occur on the side opposite the neuropathic eschar— tliat is, in the lower extremity belonging to the same side as the spinal lesion. These clinical facts, and the intimate clinical connection which exists amono- these disorders when they are developed under the circumstances just met? tioned, should be known to all surgeons.^ Continuing our inquiry into the" clinical relations of neurotrophic or neu- ropathic eschars, we shall next find that they may arise from those forms of traumatic myelitis which are not attended by wounds of the spinal cord, nor by fractures, nor by dislocations of the spinal column. We shall likewise find that they may arise from this cause quite as rapidly as they would if the spinal column were also fractured. A case reported by Sir W. Gull, which I have already presented on page 414 {supra), clinically illustrates in a useful manner this mode of causation : — The patient was a laborer, aged 25, who felt a sudden pain in his back, after lifting a heavy weight. On the morning of the second day afterward, his lower extremities were completely paralyzed. Two days later he entered hospital. A bed-sore had already began to form near the sacrum, and ammoniacal urine dribbled from the blad- der." Death occurred forty-one days after the strain. Autopsy A large bed-sore had bared the sacrum in its whole length. The bones and ligaments of the spine exhibited no trace of injury. The spinal cord was disorganized by myelitis opposite the fifth and sixth dorsal vertebrae. In this example of acute myelitis resultino^ from a strain of the back, the bed-sore began to appear within four days "after the injurv, and two davs after the symptoms of myelitis had declared themselves. 1 have also pre- sented on page 420, as will be remembered, the case of a woman, ao-ed 22, reported by Professor Hammond, in which myelitis arising from concussion of the spmal cord, the result of a fall, was attended with the formation of a large sacral eschar. > There are, however, unilateral bed-sores also of cerebral origin— that is, bed-sores which arise from diseases of the brain, such as cerebral hemorrhage, cerebral embolism, cerehral soft- ening, etc —which appear on one cheek only of the nates, but they do not come within the scope of this article. I will merely remark here : (1) that the acute hed-sore which arises from cerebral diseases does not essentially differ from that wliich arises from spinal lesions (Charcot)- (2) that the cerebral bed-sore can usually be distinguished with ease from that which is of spi- nal origin ; and (3) that a full account of the genesis of cerebral bed-sores, illustrated with a wood-cut, IS to be found m Charcot's Lectures on the Diseases of the Nervous System p 63 428" INJURIES OF THE BACK. But sjyontcmeoiis acute myelitis, as well as traumatic acute myelitis, very often determines the precocious formation of sacral eschars, especially when it sets in suddenly and its evolution is rapid. Manj' instances belonging to this category have been placed on record by Gull, Duckworth, Joffroy, Engelken, Voisin, and Cornil, as well as by other observers. We may also see a sacral eschar rapidly form in cases of spinal disease where the evolution is slow, should a new irritation of an active character suddenly intervene, or should an acute inflammatoiy process be suddenly superadded to the preexisting lesion, ^ot only the exacerbations of partial sclerotic myelitis, but also the sudden invasion of the rachidian cavity by purulent matter emanating from an abscess, in the case of patients sufiering from vertebral disease, may cause the rapid formation of sacral eschars. Should a tumor occupying the central part of the cord provoke the develop- ment of acute myelitis by its presence, the same result will follow. Several examples of this kind are on record. (Charcot.) ^Neuropathic sphacelus of the integuments on the sacrum and nates may be causecl by trawaaiism of the cauda equina^ as well as by morbid excitation of the spinal cord itself. This important fact is proved by a case reported by M. Couyba,^ and mentioned by M. Charcot: — ^ A young soldier received a shot-wound at the outpost of Clamart. The missile entered his left side* near the anterior extremity of the tenth rib, and emerged on the right side of the spinal column, about three inches from the spinous process, and on a level with the second lumbar vertebra. Paresis, with acute hyperaesthesia, of the lower extremities ensued. On the fifth day after the casualty, a bulla appeared on the right gluteal eminence, and quickly gave place to an eschar, which progressively extended so as at last to wholly cover the sacro-gluteal region. On the nineteenth day, death resulted. Autopsy A layer of purulent matter covered the spinal cord, both anteriorly and posteriorly, from the cauda equina up to the cervical region. The cord itself, when examined, first in the fresh state, next in numerous hardened sections, did not exhibit any alterations. But a certain number of nerve-tubes in the nervous cords which form the cauda equina, presented the anatomical characteristics of fatty granular degene- ration. Thus, the demonstration that a morbid excitation of the cauda equina had existed during life, was made complete. Additional examples of the same sort might be cited. Finally, the morbid excitation of any peripheral nerve may be attended with the rapid formation of eschars in the integument belonging to its area. For example, M. Charcot^ relates the case of a woman at La Salpetriere, who had an enormous fibroid tumor on the left side, which compressed, in the pelvis, the roots of the crural and ischiatic nerves of the same side. There had resulted a paretic state of the corresponding member, accompanied by acute pains running along the track of the principal nerve-trunks. One morning, shortly after the appearance of the first symp- toms of compression, it was remarked that an eschar had rapidly formed on the left of and near to the sacral region. Likewise, on the left knee's inner surface some pemphi- goid bullae were found, in a spot which had been pressed upon by the right knee for a considerable time during the night, in consequence of the patient's attitude while asleep ; these pemphigoid bullae were filled with a brownish liquid, and soon gave place to an eschar. Nothing of the kind was developed on the right knee. The fact that eschars of the integument may quickly form in consequence of morbid excitation of the spinarnerves which supply the peripheral areas w^here the eschars themselves appear, as occurred in the case just related, aftbrds another good reason why the terminology of such eschars should be I Th6se de Pans, 1871, p. 53, Obs. xiii. 2 Op. cit., p. 75. » Ibid. SACRO-GLUTEAL ESCHARS. 429 characterized by a name which distinctly recognizes their neurotrophic or neuropathic origin. Course and Consequences of Neuropathic Sphacelus or Eschars. — Should the disease spontaneously abate, or should the treatment prove successful, it may happen: (1) that the initial vesicles or blebs will wither, dry up, and leave a healthy surface ; or (2) that the erosions, being superficial, will take on healthy action, granulate, and cicatrize ; or (3) that the slough, although extending deeply, will become surrounded by a line of inflammatory demarcation sepa- rating the dead from the living tissues ; that purulent matter will form throucrh- out this line of demarcation, whereby the slough will become detached from the living tissues, so that it can be readily taken away by the surgeon ; that the cavity thus formed will fill up by the granulating process; and, Anally, that the space occupied by the slough, whether large or small, will become covered with new integument in the form of a cicatrix. But not always, nor even in a majority of instances, is this fortunate issue obtained in cases of neuropathic sphacelus. On the contrary, this dis- order often proves fatal, and that, too, in certain determinate ways, which I will now proceed to point out : — (1) Occasionally, this disorder directly destroys life by causing acute septi- ccemia. That is, it sometimes happens in cases of neuropathic sphacelus that the eschars are very large, and at the same time do not become environed by any lines of inflammatory demarcation which plug with coagula the veins passing from the dead into the living tissues ; wherefore these vessels remain open, and directly convey the decomposing blood, and putrid juices and putrid gases from the dead parts, into the general current of the circulation. Thus, septic poisoning of the blood, or septicemia in its most acute form, sometimes occurs in cases of neuropathic sphacelus, and quickly destroys life. Without doubt this happened in the case reported by Dr. Conant, and already presented on p. 419, where a man had sustained vertebral fracture at the dorso-lumbar junction by being blown off from the riggino; of a vessel while at work ; for, on the morning of the following Sunday, a'large blister of mortiflcation was noticed on the inner side of each thigh, which extended nearly the whole length thereof; at 4 P. M. he had a violent chill, and became delirious ; he sank rapidly, and died quietly at 7 o'clock on the same evening ; and the autopsy revealed no cause for his sudden death, excepting the neuropathic gangi-ene and the consequent septicaemia. A case of simple fracture of .the first lumbar vertebra, with a wood-cut to dlustrate it (Fig. 862), was presented on page 351, in which it is not improb- able that septicemia arising from a neuropathic eschar was likewise the immediate cause of death ; for " the parts in the region of the sacrum were gangrenous," and smelled so badly that it was necessary to apply strong disin- fectants (chlorides), in order to suppress the stench. (2) ^sTeuropathic bed-sores not unfrequently destroy life by inducing puru- lent infection, or pyxmia, attended with the production of metastatic abscesses in the viscera. I have already mentioned a considerable number of cases in which this accident occurred, and here is another example:— J. H. Gray^ relates the case of a boy, aged 13, who fell thirty-five or forty feet, striking his back, and was stunned. Projection of tlie sixth or seventh dorsal vertebra was noted ; also delirium ; paralysis ; priapism ; incontinence of urine and feces ; ab- normal heat ; excoriation ; on ninth day cystitis ; bed-sores. He did well for three weeks, but then rigors occurred, and were foUowed by death twenty-eight days after the accident. Necroscopy revealed fracture and displacement forward of the sixth dorsal ' London Hospital Reports, vol. i. 430 INJURIES OF THE BACK. vertebra ; cord crushed, but not compressed ; metastatic deposits (abscesses) in several viscera. (Ashhurst.) M. Charcot thinks that this sequel of spinal bed-sores is seldom met with. But experience, especially that gathered in old or perhaps infected hospitals, proves the contrary. (3) Sphacelus of neuropathic origin not unfrequently proves fatal in conse- quence of the formation of gangrenous emboli^ or the occurrence of gangrenous embolism. " In this variety," says M. Charcot, " thrombi impregnated with gangrenous ichor are transported to a distance, and give rise to gangrenous metastases, which are principally observed in the lungs. This is a point upon which Dr. Ball and myself have insisted in a work published in 1857.^ But long before us, and even long before the theory of embolism had been Germanized, M. Foville^ had expressed his opinion that a considerable number of cases of pulmonary gangrene, observed in the insane, and in dif- ferent diseases of the nervous centres, are caused by ' the transport into the lungs of a part of the fluid which bathes the eschars of the breech.' I give the preceding quotations from MM. Foville and Charcot, in order to show- not only that gangrenous eschars of the sacrum may cause pulmonary gangrene through the agency of pulmonary embolism and pulmonary infarction, but also that French observers have had some share of importance in developing the theory of embolism itself. (4) ^Neuropathic eschars prove fatal most frequently of all, perhaps, in con- sequence of exhaustion — that is, the sufi:erers die worn out by the discharge and irritation, combined with a certain degree of septicaemia which is almost always present in such cases. The process of mortification tends gradually to invade the deeper tissues, as well as to spread more widely on the surface. In this way, the trochanteric synovial bursse may be laid open, the trochanter itself denuded of periosteum, the gluteal muscles, the nerve-trunks, and the )loodvessels of a certain calibre laid bare. But I can best describe the phe- nomena of sacral eschars ending in death from exhaustion, by briefly relating an example : — A female domestic, aged 30, moderately temperate, and of good constitution, was admitted into Bellevue Hospital, on the afternoon of August 30, on account of frac- ture and luxation of the first lumbar vertebra, with the following history. About 9 or 10 o'clock on the previous evening, while in a somnambulistic state, she walked out of a third-floor window, and, falling two floors, struck upon the slated roof of a shed. She was not rendered insensible, even for a moment, but could give no account of the direc- tion in which the blow was received, excepting that she struck upon her left side. No paralysis nor anaesthesia followed the accident, and no pain except upon motion. The left leg, however, had felt " numb" ever since. No urine nor feces had been passed since the accident. Upon examination, slight deformity, a slight displacement of a vertebra backward, was detected at the position of the last dorsal or first lumbar vertebra, and very slight tenderness a trifle lower down ; but no redness nor ecchymosis, nor any other external mark of injury. The respiration was natural in character and frequency; the pulse rather frequent, but of moderate strength. The urine was withdrawn by catheter for a few days, and after that was passed invol- untarily until death. The bowels acted regularly. In the course of eight or ten days after admission, the vertebral prominence increased so much as to make easy a diagnosis )f luxation backward of the first lumbar vertebra. No motor paralysis nor anaesthesia of the limbs or body appeared in the case. The very intense pain occurring upon the slightest attempt at motion, which originally characterized her condition, gradually diminished, and at length in considerable measure disappeared. * De la coincidence des gangrenes viscerales et des affections gangrdneuses exterieures. L'Union Medicale, 26 et 28 Janvier, 1860. 2 Dictionnaire de M6d. et de Chirurg. Prat., t. i. p. 556. ^ Charcot, op. cit., p. 60. SACRO-GLUTEAL ESCHARS. 431 Fig. 883. A bed-sore early formed over the sacrum, and slowly proceeded inward or deepened until exposure of the bone was effected. Subsequently, diarrhoea supervened. She sank from exhaustion ; and, or October 6, she died, thirty-eight days after the accident. Autopsy Crushing of the body of the first lumbar vertebra, with displacement of the entire vertebra backward, was revealed. Firm union in the fractured vertebra had taken place. ^ It is worthy of particular mention that a sacral eschar attacked this Avornan although she had no sensory nor motor paralysis whatever, that the eschar soon followed the accident, that it steadily deepened until it laid bare the vsacrum, and that it caused death by producing exhaustion. The sacrum itself was probably necrosed, for it has often been found necrosed in analo- gous cases. (5) Finally, sacral eschars of neuropathic origin pretty often prove fatal by destroying the sacro-coccygeal ligament and thus opening the sacral canal, or by penetrating this canal in some other manner ; whereupon there quickly: supervenes either a simple^ imrulent^ ascending meningitis^ or a sort of ichorous, ascending meningitis. I have already mentioned a number of instances in which the sacral canal was opened by bed-sores with fatal effect. Mr. Hilton states that he has " several times seen fatal mischief result from a bed-sore extending to the interior of the vertebral canal, and causing inflammation of the spinal cord and its membranes. He likewise presents an accurate draw- ing made from a preparation illustrating this important pathological condition, of which the accompanying wood-cut (Fig. 883) is a copy. This cut will remind surgeons of the close proximity of the spinal dura mater and the posterior wall of the sacral canal to bed-sores, a, a, a. A ver- tical section of the third, fourth, and fifth lumbar vertebrae. 6, b. A vertical section of the sa(!rum. d. A portion of the sacral arch turned backward, e. Short, delicate, and elastic ligaments, seen proceeding from the lower part of the spinal dura mater to the sacrum, c. Dura mater, containing the cauda equina, spinal pia mater, and spinal arachnoid extending to a point opposite the second bone of the sacrum. Numer- ous strong ligaments are shown afiixing the dura mater to the posterior ligament of the spinal column, oppo- site the second portion of the sacrum. Three distinct, slender ligaments proceed to the third, fourth, and fifth pieces of the sacrum. (Hilton.) The fact that the spinal membranes extend downward as far as the second piece of the sacrum, is well shown in the cut (Fig. 883). In one of Mr. Hilton's cases death re- sulted from pyaemia (pyaemic pneumonia), although the bed-sore had reached the interior of the vertebral canal, and involved the membranes of the spinal mar- row.3 Of the ichorous form of ascending meningitis, MM. Lisfranc and Baillarger have reported many remark- a])le examples. In this afiection, it is found that a puriform, grayish, acrid, and fetid liquid steeps the spinal meninges and the cord itself ; sometimes only the lower part, some- times the whole cord is bathed in this liquid, Avhich, occasionally, is also found To illustrate the penetration, of tlie sacral canal hy bed-soros, and the occurrence of latal spinal meningitis therefrom. (Hilton.) ' New York Journal of Medicine, March, 1859. pp. 244, 245. 2 Op. cit., pp. 213, 214. 3' Op cit., p. 43. 432 INJURIES OF THE B^\CK. at the base of the encephalon, as likewise in the fourth ventricle, in the aque- duct of Sylvius, and even in the lateral ventricles. At all these points in such cases, the cerebral substance is discolored on its surface and to a certain, depth, acquiring a slaty-bluish tint, which is a product of imbibition, mace- ration, and dyeing. (Charcot.) When ichorous cerebral meningitis has a sacral bed-sore for its startuig-point, the slaty hue, but more pronounced, is found over the whole extent of the spinal cord, and it grows more strongly marked as one approaches the bed-sore which has opened the sacral canal. Simple, purulent, ascending meningitis, however, is not attended with this peculiar discoloration ; but it is unnecessary to dwell longer on this point, although it is by no means an unimportant one. Pathogeny. — From the foregoing exposition of whatever facts are known concerning the variety of sphacelus in question (that is, concerning the acute sacral eschar, etc.), it' is evident that the patient's position, or pressure, is never the chief cause of its production, and that in some cases pressure does not assist at all in originating it. It also appears that its causation in no way depends upon paralysis of sensation and voluntary motion ; for, in a case where the first lumbar ver- tebra was fractured (it is related on page 430), a sacral eschar appeared early and progressed steadily until it produced fatal exhaustion, although there was no paralysis whatever of sensation and voluntary motion. Other exam- ples of similar import have likewise been mentioned in the foregoing pages. Furthermore, it appears that the acute bed-sore does not arise from vaso- motor paralysis (that is, from paralysis of the bloodvessels) ; for, in the hemi- paraplegia which ensues when one lateral half of the spinal cord is divided, the eschar never appears on the side of the sacrum, or in the lower extre- mity, where the vaso-motor paralysis is to be found, but on the side cf the sacrum, or in the lower extremity, where vaso-motor paralysis does not exist. The inference is, of course, conclusive. Finally, the kind of sphacelus in question does not result from the mere absence of nerve-action ; for, in several cases of shot and other fractures of the vertebrae (related above), in which the spinal cord was partially or com- pletely divided, no bed-sores appeared, although the patients survived their injuries several, and, in some instances, many days. The soldier whose verte- bral fracture is represented by Fig. 871 (p. 371), survived a complete division of the spinal cord for twenty-nine days, and yet no bed-sore presented itself. Hutin's patient lived fourteen years — although the right half of the cauda equina had been divided by a small-arm missile near its commencement, the left half displaced by it, -and its substance much disorganized — and ultimately died of Bright's disease. But examples almost without number can readily be adduced to show that the spinal cord may be divided, either partially or completely, without the supervention of bed-sores, however long the survival be protracted. On the other hand, m perusing the cases of spinal injury where acute bed- sores, or analogous sphacelations, did appear, and where the condition of the cord revealed by post-mortem examination is described with sufficient minute- ness, we generally find it distinctly stated, either that the cord \\^as sufifering from active mechanical irritation eftected by the displaced and fractured ver- tebrae, or by the extravasation of blood, or that the cord-substance had under- gone certain changes which we know result from the inflammatory process, or that the spinal membranes were inflamed. Thus, in the case of shot-fracture of the spinal column, represented by Fig. 870 (p. 371), hi which the missile divided the spinal cord and lodged in the spinal canal opposite the fifth dorsal vertebra, a sacral eschar appeared ; two weeks afterwards " sloughing of the SACRO-GLUTEAL ESCHARS. 43a lower extremities" was noted ; after another month, " sloughing extending" was- part of the record made ; and six weeks after that, death from exhaustion ensued. At the autopsy it was found, not only that the spinal cord was severed, and that the missile lay in the spinal canal, hut also that the upper section of the spinal cord was much softened," that is, exhibited a change which, under the circumstances, was doubtless inflammatory. Most of these particulars are taken from the Medical and Surgical History of the War of the llebellion. First Surgical Volume, p. 440, where the case is fully reported. Many similar instances "have been mentioned in the foregoing pages, where acute sacral eschars or other sphacelations of an analogous character were attended with either an active mechanical irritation or a positive inflammation of the cord- substance, as w^as proved by post-mortem examination. On the whole, then, the dominant and ever-present fact in such cases is the active irritation of a more or less extensive region of the spinal cord, which mostly shows itself, anatomically, by the changes that characterize inflammation of the cord-sub- stance (myelitis), and, clinically, by the outward phenomena or symptoms that arise from this lesion. Moreover, this conclusion is in strict conformity with the results of experiments on animals, which show that in them the develop- ment of gangrenous ulcerations over the sacrum does not supervene on ordinary sections of the cord, but only in cases where inflammation occurs in the cord- substance or membranes around the traumatic lesion. So much concerning the pathogeny of this most troublesome and destructive disorder appears certain. But it is not probable that all the constituent parts of the spinal cord are equally liable, w^hen excited by irritation or inflammation, to provoke the development of acute bed-sores. The great frequency of this accident in eases of h?ematomyelia, and of acute central m3^elitis, where the lesion occu- pies chiefly the central region of the spinal cord, seems to designate the gray substance as playing a predominant .part in this respect. (Charcot.) This power is doubtless shared also by the posterior wdiite fasciculi, for M. Char- cot has shown that irritation of certain parts of these fasciculi has the effect of determining the production, not only of various cutaneous eruptions, but likewise of dermal necrosis with deep ulceration.^ Furthermore, it is perfectly established that traumatism of the cauda equina, and other irritative lesions of the peripheral nerves, may give rise to an acute bed-sore, on the one hand, or to sphacelation of the integuments in their terminal areas, on the other hand. The illustrative examples presented above make this point quite clear; and there are many other examples on record. Perhaps, irritative lesions of the spinal ganglia of the nervi sympa- thici, too, may sometimes determine the rapid formation of eschars. But on this point we need more light to be thrown by clinical and pathological observations, as well as b}- experiments on animals. Finally, in regard^ to the essential lesion of the spinal cord, of the cauda equina, or of the peripheral nerves in general, which determines the develop- ment of acute bed-sores and of other analogous sphacelations of the integu- ment, we are still in the dark, at least as far as any positive knowledge of the subject is concerned. But, after all, it may in time yet be demonstrated that there really are trophic nerves, as Samuel has supposed, and that the pathological excitation of these nerve-fllaments, whether it be effected in the spinal cord, or in the cauda equina, or in the trunks of other peripheral nerves, is attended by the formation of tegumentary eschars in the areas where the disordered nerve-filaments terminate, and over w^hose nutrition they preside. VOL. IV. — 28 1 Op. cit., pp. 52, 73, 74. 434 INJURIES OF THE BACK. Prognosis. — ^Neuropathic bed-sores, and neuropathic sphacelations in gen- eral, never bode any good. Still, they portend more of evil when they appear in the course of some affections, than they do when they appear in the course of others. For instance, a sacral eschar very seldom presents itself in a case of injury or disease of the brain which is to have a favorable termination ; its appearance in such cases, therefore, constitutes a most inauspicious sign. "We mioiit in fact call it sphacelus ominosus, the ominous bed-sore, by way of distinction. (Charcot.^) This accident, I repeat, rarely proves deceptive in cerebral injuries and diseases ; and inasmuch as its existence may be discerned from its very incipiency, it becomes of great value, especially in doubtful cases. The only prognostic sign that can at all rival it in cases of sudden hemiplegia, according to M. Charcot, is a very marked fall of the central temperature below the normal, occurring at the outset of an attack. Thus, the vesicul^e and bullse which are the precursors of neuropathic sphacelus will, from their first ax)pearance on the scene, enable us to form a prognosis with certainty in such instances. But, in spinal injuries and diseases, recovery may yet take place after neu- ropathic bed-sores have appeared. Many such examples are on record, and almost every experienced surgeon has witnessed several. There are, how- ever, certain phenomena which portend an unfavorable issue for the neuro- t pathic sphacelations which result from spinal injury. These signs of impend- ing evil are the following : (1) An early appearance of such sphacelations — that is, their occurrence before the pressure resulting from the patient's pos- ture in bed has had sufficient time to share in tl^eir causation ; (2) Their appearance in parts where pressure has had very little, or even no share at all, in their causation, as, for example, on the ankles, legs, inner surface of the thighs, etc. ; (3) Their simultaneous appearance at several different points on both lower extremities ; (4) Their very rapid enlargement on the one hand, or their steady enlargement in spite* of treatment on the other ; (5) The appearance of symptoms denoting that septicaemia, pysemia, or ascending sup- purative meningitis from penetration of the spinal canal, has occurred — a sign which usually denotes that the end is not far ofl^ In a case reported by Mr. Hilton,^ where a sacral eschar reached the interior of the vertebral canal and involved the membranes of the spinal marrow, x)y?emia also supervened, and caused death in nine days. On autoi:)sy the whole right lung was found pneu- monic, with numerous, well-defined, small collections of pus in difterent parts of it. Treatment. The causal indications should be sought for and fulfilled as far as possible. To this end, in simple fractures and dislocations of the spinal column, reduction should be effected, for thus the risk of mechanical irritation of the spinal cord or its membranes, by the displaced vertebrae, will be more or less considerably lessened. In gunshot and other compound fractures of the spinal column, all foreign bodies should be removed from the wounds. In cases where spinal meningitis or myelitis is present and acting as the efficient cause of the bed-sores or sphacelations (and these cases form a numerous class), potassium iodide, ten grains three times a day, and fluid extract of ergot, one drachm three times a day, should be administered. When ergot has lost its effect, belladonna in rather large doses has sometnnes been exhibited with benefit in cases of myelitis. But the chief internal remedies against spinal con2:estion, spinal menhigitis, and spinal myelitis, are potassium iodide and ergot, and both drugs must, as a rule, be given in full or even excessive doses, to secure their good efiects in these disorders. I advocate the trial of these [« Charcot uses the term decubitus oininosus.'] 2 Op. cit., p. 213. SACRO-GLUTEAL ESCHARS. 435 remedies in bed-sores and other sphacelations of spinal origin, not only on general principles, but also because, in several instances related in the fore- going pages, the good etiects of these remedies were conspicuous in the rapid healing 6f the ulcers, and in the disappearance of the other spinal symptoms. Although the pressure resulting from the patient's posture in bed is never the chief cause of neuropathic bed-sores, v^e should always endeavor to pre- vent its occurrence, or mitigate its effects, by placing the patient upon a water- bed, or by employing the various expedients which were mentioned in \^ol. I. (p. 801) ; but, if possible, a water-bed should be obtained for such cases, because no expedient or combination of expedients will answer the purpose nearly as well. The integuments on the sacrum and nates should be kept dry and clean, that is, unsoiled with decomposing urine and feces ; and these parts, in bed-ridden people, should be sponged over at least once a day with diluted alcohol or rectified spirit. But when the eschar or sphacelus appears notwithstanding these measures, what more is to be done ? The indication then is to limit the extent of the slough, as much as possible, by restoring or invigorating the circulation of blood in the affected parts. There are two procedures for fulfilling this indi- €ation, both of which possess great value. One of them was devised by M. Brown-Sequard, and I shall proceed to describe it in his own words : — " I have tried," he says, " to prevent or cure those sloughs which are an evident result of the disturbance of nutrition due to an irritation of the nerves of bloodvessels, by acting upon the bloodvessels of the part where the sloughs exist. I have made experiments upon animals, showing that applying alternately two poultices, one of pounded ice, the other a very warm, bread or linseed poultice, there is a very rapid cure of the sloughs [when] due to a nervous irritation. Several medical men have already obtained the same results in man that I have obtained in animals, by follow- ing the plan of treatment that I have proposed. The pounded ice, kept in a bladder, is to be applied for eight or ten minutes, and the warm poultice for an hour or two, or even a longer period. ... I think I can safely say that, in cases where a slough is begintiing, its progress will always be stopped by the means I propose."* The other method is that of galvanism, which was first suggested and employed by Dr. Crussel, of St. Petersburg, and is as follows : A thin silver plate, no thicker than a sheet of paper, is to be cut so as to fit the exact size and shape of the bed-sore. A zinc plate of about the same size is connected with the silver plate by a fine silver or copper wire, six or eight inches in length. The silver plate is then placed in immediate contact with the bed-sore, and the zinc plate on some part of the skin above it— a piece of chamois-leather, soaked in vinegar, intervening, which, however, must be kept moist, or thei-e will be little or no action of the battery. Within a few hours the beneficial effect becomes perceptible ; and, iu a day or two, the cure is in most cases complete. In a few instances a longer time is required. I have frequently seen," Professor Wm. A. Hammond says,^ " bed-sores three or four inches in diameter, and half an inch deep, heal entirely over in forty-eight hours." Mr. Spencer Wells states that he has often witnessed large ulcers covered by granulations within twenty-four hours, and completely filled up and cicatrization begun in forty-eight hours, under this treatment ; and that it is the best ot^all methods for treating ulcers of indolent character, and bed-sores. Professor Hammond further states : " During the last twelve years I have employed it to a great extent in the treatment of bed-sores caused by disease of the spinal ^ Lectures on the Physiplogy and Pathology of the Central Nervons System, etc., pp. 2&0, 261. 2 Diseases of the Nervous System, 1881, p. 453. 436 INJURIES OF THE BACK. cord, and with scarcely a failure— indeed, I may say without any failure except in two cases where deep sinuses had formed which could not be reached by the apparatus."^ If this plan of treatment should prove equally successful in other hands, a large share of the mortality which arises from spinal injuries may be avoided. In the absence of ice, M. Brow n-Sequard's method may be employed by alternately applying to the bed-sores sponges, one of which is saturated with hot water and the other with cold water. This should be done several times every day, for five or ten minutes at a time; the eftect is to increase the vascular activity of the part, and to promote granulation. Disorders of the Urinary Organs arising from Lesions of the Spinal Cord. Disorders of the urinary bladder, the ureters, and the kidneys, result from lesions of the spinal cord — from the so-called idiopathic, as well as from the traumatic afiections of that organ— with even greater frequence than the bed- sores and other neuropathic sphacelations which have just been described ; for, while the tegumentary eschars that arise from spinal lesions are always attended by more or less important disorders of the urinary organs, the latter not unfrequently present themselves in cases where the spinal cord is injured or diseased, without the fellowship of the former. Moreover, these urinary affections very often aid materially in producing death, and, not unfrequently, are the chief or even the sole proximate cause of a fatal issue, in such cases. These disorders, therefore, possess a degree of importance which is scarcely inferior to that of the neuropathic lesions of the integuments which have just been discussed ; and they likewise should be attentively considered in this place. . The urinary affections that result from lesions of the spinal marrow are quite diversified, but may all be embraced and arranged under the following heads : (1) Paralysis of the bladder ; (2) Alterations of the urinary secretion ; (3) Inflammation of the kidneys, of the ureters, and of the bladder. Paralysis of the Bladder. — Inasmuch as the muscular apparatus belong- ing to the urinary bladder consists of two distinct parts, namely, (1) that which is employed to retain the urine in the organ, consisting of the sphincter vesicce muscle, and (2) that which is used to expel the urinary secretion from the organ, consisting of the detrusor iirincB muscle ; and, inasmuch as each of these muscles has a distinct reflex motor centre in the spinal cord, upon which its action or inaction depends, there are two distinct forms of vesical paralysis, one of which is manifested by retention, and the other by inconti- nence of urine. The reflex motor centre of the detrusor urinse, according to Dr. Bramwell,* is situated in the segments of the spinal cord which correspond to the 3d, 4th, and 5th sacral nerves, and the normally contracted state of the sphincter vesicJB is due to the action of a tonic centre which is situated in the segments of the cord corresponding to the 2d, 3d, and 4th sacral nerves. The reflex motor centres of these muscles are not only quite distinct in the anatomical sense, but they are likewise completely antagonistic in their motor action. The mechanism of normal micturition, then, appears to be as follows: 1. When the bladder becomes full enough, the sensory nerve-flilaments in its 1 Ibid., p. 453. « Diseases of the Spinal Cord, pp. 117-119. New York. 1882. DISORDERS OF THE URINARY ORGANS. 437 mucous membrane are stimulated, and an impression is conveyed along the sensory nerves to the reflex centres for the detrusor and sphincter muscles in the spinal cord, and to the sensorium. 2. As a result of the sensory impres- sion conveyed to the brain, the desire to urinate is experienced. 3. As a result of the imi)ulse carried to the reflex motor centres in the spinal cord, the action of the detrusor centre is excited, while the action of the sphincter centre is inhibited. If the circumstances for urination be favorable, an impulse is sent from the brain by the will to the tonic centre for the sphincter, inhibiting its action, and causing the sphincter muscle to relax ; also to the centre for the detrusor urinai, strengthening the excitation of that muscle to contract, whi(;h has already been aroused by the reflex impulse from the bladder. In health, all these processes are simultaneously accom- plished, and the result is micturition. When, however, the circumstances are not convenient for performing the act, it can be delayed or prevented (a) by voluntarily inhibiting the motor centre for the detrusor urin^e ; (b) by causing the urethral muscles at the neck of the bladder to contract, likewise by an eftbrt of the wi]l ; and, (c) possibly, by strengthening the tonic centre for the sphincter vesicae, in the same manner, and at the same time. (Bram- well.) Thus it will be perceived that three distinct sets of nerves are always concerned in the act of voluntary micturition, namely- , (1) a set by which the detrusor urin?e muscle is automatically operated ; (2) a set by which the sphincter vesicfe is also operated automatically ; and (3) the conducting fibres of the spinal cord through which the sentient being is enabled to perceive the need of micturating, and to send the mandate of the will down to mic- turate at once or to postpone the act, as circumstan(;es may determine. Moreover, these physiological data can all be usefully employed in diagnos- ticating the injuries and diseases of the spinal cord and spinal column. There are two forms of retention of urine which arise from lesions of the spinal cord. In one of them, the conducting paths in the cord alone are at fault, for the reflex motor centres which determine the action of the vesical muscles are not afl^ected. In such a case, the patient cannot micturate volun- tarily, because the mandates of the will are not conveyed by the conducting fibres of the cord down to the motor centres for the vesical muscles. In such a case, too, the bladder will continue to eiTipty itself automatically from time to time ; that is, as soon as the quantity of urine collected in the viscus becomes suflficient to excite reflex contraction of the detrusor urinre muscle, Avitli inhibition of the sphincter muscle's tonic centre, evacuation of the viscus ensues. Examples of this form of urinaiy retention are not unfre- quently afl:brded by lesions of the spinal coixl occurring in the cervical or dorsal regions, when the nerve-injury is restricted to the site of the lesions themselves, and when, consequently, the reflex motor centres for the vesical muscles are unaflected. In such cases, the act of urination usually occurs without the patient's knowledge, as well as Avithout his consent. In the other form of urinary retention, the difficulty arises from the fact that the reflex motor centre for the detrusor urinse has ceased to act, while the tonic centre for the sphincter still continues to work, that is, from the fact that the detrusor muscle is paralyzed while the sphincter is not paralyzed. In exam- ples of the first-mentioned form of urinaiy retention, catheterization may be unnecessary, and it is perhaps from his experience with this class of cases that Mr. Hutchinson^ has been led to think that catheterization is unnecessary in all cases of spinal injury above the loins, unless vesical hypereesthesia be also present. In the other form of urinary retention, however, that in which the detrusor muscle is paralyzed wdiile the sphincter continues in a state of tonic 1 London Hospital Reports, vol. iii. 1866. 438 INJURIES OF THE BACK. contraction, catheterization performed at suitable intervals is always neces- sary, and must never be neglected ; in fact, the operation is indispensable in such cases, for, if it be not performed, the urinary secretion will continue to accumulate in the viscus, until it becomes distended even to the point of bursting. I have myself seen more than one case, in civil as well as in military practice, of vesical paralysis arising from spinal injury, in which, from want of catheterization, the bladder became so much distended as to cause a notable tumefaction, discernible on external examination, and in which, on introducing a flexible instrument, a great quantity of urine, an ordinary chamber utensil more than half full, or considerably more than half a gallon, was withdrawn, and that, too, when there were no signs of urinary overflow present. Inasmuch as these two forms of urinary retention are clinically distinguishable from each other ou]y by experimentally ascer- taining whether reflex motor action can be excited in the detrusor muscle, the safest course for the surgeon to pursue, in both forms, is to draw off the w^ater at suitable intervals with a perfectly clean, flexible instrument. Incontinence of urine, when it results directly from injury or disease of the spinal cord, is always due to paralysis of the sphincter muscle, that is, to functional inactivity or destruction of the tonic centre in the cord upon which the contraction of its tibres, and the closure of the urethral orifice of the bladder, entirely depend. Paralysis of the sphincter vesicae arising from destruction of its reflex centre, is almost invariably associated with paralysis of the detrusor urinse, because its reflex centre is also destroyed. These reflex centres may be directly destroyed by injuries, e. g., by fractures or disloca- tions of the lumbar vertebrse, or by hemorrhage into or inflammation of the cord-substance. But, as already intimated, paralysis of the sphincter vesicae is very rare per se. It is nearly always accom^^anied by paralysis of the de- trusor muscle, and by paralysis of the rectum. Interruptions of the conducting parts to and from the brain, in the spinal cord above the reflex centres for the vesical muscles, are of frequent occur- rence in spinal injuries. When the lesion of the cord is suddenly produced^ it may be accompanied by a concussion of the cord which temporarily arrests the reflex motor functions of all the segments situated below the lesion^ including of course the urinary centres. In chronic cases, the eftect of the rachidian lesion varies with its position and extent. When the sensory con- ductors or sensory perceptive centres only are affected, the desire to urinate is not perceived ; the reflex arc is uninjured, and, as soon as the bladder be- comes sufficiently distended with urine, it is unconsciously evacuated. It, therefore, should be remembered that the involuntary discharge of urine and feces, in cases of paraplegia or coma, does not necessarily imply any paralysis of the bladder or rectum. When the motor and inhibitory conducting fibres of the cord alone are interrupted^ the desire to urinate is perceived, but the act itself takes place quite independently of volition. It can neither be assisted nor deferred by any effort of the will in such cases. Concussion of the spinal cord, especially when the lower part of it alone is affected, may be attended by paralysis of the detrusor muscle, indicated by retention of urine, when no other portion of the muscular system appears to be paralyzed. Concussion of the spinal cord, when severe enough to produce paraplegia (that is, both voluntary-motor and sensory paralysis in the lower part of the body), may also suppress for a time the reflex motor functions of the urinary centres, as well as the conducting functions of the rachidian fibres ; and then paralysis of the sphincter muscle, with incontinence of urine, will also be present. DISORDERS OF THE URINARY ORGANS. 439 Congestion of the spinal cord coming on some days, it may be, after falls or blows upon the lower part of the spinal column, sometimes causes paralysis of the detrusor muscle, with retention of urine, when no such paralysis fol- lowed the injury. Myelitis causes incontinence of urine because it destroys the tonic centre for the sphincter vesic8e, and thus paralyzes that muscle, as well as the sphincter ani, etc. Alterations of the urinary secretion very often arise from injuries and diseases of the spinal cord. Briefly stated, these alterations consist of alka- linity, which is often excessive ; of the presence of an abnormally great quan- tity of the phosphates ; and of the existence, in the urine, of blood, pus, and mucus. Occasionally the urinary secretion is entirely suppressed in such in- stances. It has long been noticed by surgeons that, after fractures of the vertebral column with consecutive lesions of the spinal cord, the composition of the urine very frequently and very rapidly becomes altered. In almost all cases of traumatic myelitis, it soon presents a remarkable alkalinity. I have also reported two cases of sphial injury with marked displacement between the fifth and seventh cervical vertebrae, and paraplegia, in which it was observed on the second day after the accident that the urine when withdrawn by catheterization had a strongly ammoniacal odor, that is, was strongly alkaline, although that operation had been thoroughly performed as often as needful ever since the accidents. A great many cases have likewise been mentioned in the foregoing pages, in which, soon after the reception of spinal injuries, the urinary secretion was found to be alkaline instead of acid. Sir B. C. Brodie* especially called attention to the characteristics presented by the urine in the case^of persons stricken with traumatic paraplegia. He observed the urine to be alkaline, and to exhale a fetid, ammoniacal odor at the moment of emis- sion, on the second, on the third, and on the eighth day. Soon afterward, this secretion contained blood-clots, muco-purulent matter, and deposits of aramoniaco-magnesian phosphates. It would be easy to collect from authors of repute a very great number of analogous cases. I shall mention but tw^o additional observations. Dupuytren pointed out tliat, in cases of spinal fracture with lesion of the cord, the catheter when allowed to remain in order to guard against retention quickly became coated with a calcareous incrustation. Mr. Shaw 'relates the case of a young man who had fracture of a dorsal vertebra and complete paraplegia, caused by falling from a tree. Extensive sloughs formed on the hates, but they healed, and he appeared to be recovering with paralysis, after surviving eight months. During most of this time his water flowed continuously into a urinal, and the catheter was not used. Eventually, however, his urine became turbid and fetid ; and he died with symptoms of aggravated disease of the bladder. The autopsy revealed a discolored and shreddy state of the vesical mucous membrane, with five phosphatic calculi as large as pigeons' eggs, and coated with mucus, in the bladder; also phosphatic calculi were found impacted in the calices, and lying loose in the pelvis, of each kidney. The alkaline and phosphatic characters of the urine are met with in lesions of the spinal cord so constantly, that their presence must be mainly due to the operation of some single cause which acts efficiently in nearly all the cases. Some hold that this condition of the urine is cau^ied principally by the introduction of septic matters from without into the bladder. But this ^ * Medico-Chirurgical Transactions, 1S36, p. 148. 2 Holmes's System of Surgery, vol. ii. p. 401, 2d ed. 440 INJURIES OF THE BACK. explanation utterly fails to account for a numerous class of cases in which no catheters excepting those perfectly free from septic matters are employed, or in which the urine is found to be ammoniacal and phosphatic on the very first occasion that the catheter is introduced, or in which catheterization is not employed at all from first to last, and still the urine is ammoniacal and phosphatic. Moreover, the use of catheters, and bougies, and sounds is a common thing in the practice of surgery, and yet no such effects appear in any other class of cases. I have no doubt that these effects mainly arise from neurotrophic or neuropathic disturbance of the kidneys and bladder, as was originally pointed out by M. Brown-Sequard. The sanguinolent or muco-purulent qualities of the urine, in such cases, result directly from congestion or inflammation of the kidneys and bladder. I have also seen some cases belonging to this category in which the quantity of the urinary secretion was much increased above the normal. Finally, excess of phosphates occurs in many cases of cord-disease, inde- pendently of bladder-paralysis (as is generally known and admitted); I, there- fore, claim that the neutral or alkaline condition of the urinary secretion, with its remarkable proneness to speedily decompose, which is often witnessed in the same, as well as in analogous cases, also occurs independently of bladder-paralysis, and, like the former, results from the rachidian lesion, in consequence of the disturbance it effects in the working of the kidneys. In this way alone can be satisfactorily explained the strongly ammoniacal odor perceived at the moment of emission, in urine that contains neither mucus nor pus, which I have observed in at least one instance of traumatic para- plegia arising from displacement of the lower cervical vertebrae, in less than thirty hours after the accident, when the subject (a man) was previously in perfect health, and when it was not possible for the kidneys or bladder to have sustained any direct injury. The urinary secretion became abnormal in this case, in consequence of the morbid excitation of the spinal cord which was produced by the injury. Inflammation of the Urinary Organs. — As we have seen that important alterations of the urinary secretion very often result from injuries and diseases of the spinal cord, and as we have found that acute bed-sores and other neuro- pathic sphacelations of the integuments not unfrequently arise from the same causes, so also we shall find that inflammation of the kidneys, and of the ureters, and of the bladder, or rather of the mucous membrane which lines these organs, often has an identical origin. This foi*m of renal and vesical inflammation is a very important disorder, because (1) it gives much trouble to patients and their attendants, and (2) it very often proves fatal ; for, as Mr. Bryant justly remarks, when death occurs as a result of injury to the dorsal region of the spine, suppuration of the kidneys, cystitis, and bed-sores, are the most common proximate causes thereof ^ M. Brown-Sequard first called attention to the neuropathic origin of this highly destructive form of renal and vesical inflammation. In 1858, he said : — "Another morbid change due to a mechanical excitation of the spinal cord may cause death after a fracture of the spine ; it is the alteration which takes place in the kidneys [and bladder], an alteration sometimes amounting to a real inflammation. We hardly need to say that the changes in the urinary secretion, owing or not to an inflam- mation of the kidneys, also the hoematuria, and the alterations in the mucous membrane of the bladder, in cases of fracture of the spine, are morbid phenomena depending upon > Op. cit., p. 202. DISORDERS OF THE URINARY ORGANS. 441 an irritation of the spinal cord, and not upon a paralysis due to a division of the cord. For on the one hand, a [mere] section of the cord is never followed by these alterations in the kidneys or the bladder ; and, on the other hand, we often observe these altera- tions too quickly after the spine has been fractured, to admit that they are due to a paralysis."^ In the same lecture he also said: — " The influence of a mechanical excitation of the spinal cord by a piece of broken bone [or of a pathological excitation of the cord by an inflammatory process], deserves the full attention of the physiologist and the practitioner. Among the alterations of nutrition, ... in cases of that kind, we will particularly notice the sloughs on the sacrum, and the various morbid changes that take place in the bladder and in the urinary secretion. These alterations in nutrition and secretion are certainly frequent causes of death after fractures of the spine. Therefore, it is of the greatest importance to find out the mode of production of these morbid changes, and to try to prevent or to cure them."^ The mode of causation^ as well as the 2'>^^^^^omena of the renal and vesical inflammations which result from lesions of the spinal cord, can be most briefly, as well as clearly set forth, by presenting a few examples ; and a very^ instruc- tive one has already been mentioned on page 343 : — A young infantry soldier, aged 19, fractured his fifth cervical vertebra, without dis- })lacement, while bathing in the Arkansas River, by diving headforemost into shallow water, and immediately became paraplegic from concussion of the spinal cord. Intra- thecal extravasation of blood ensued, and, on the following day, the cord showed signs of compression arising from this cause. But absorption of the extra vasated blood occurred, the symptoms of paraplegia gradually passed away, and in eight days he became able to pass his urine without a catheter. He continued to improve during the next four or five days, until traumatic spinal meningitis rather suddenly supervened, its invasion being marked by chills and by a rise in the body-heat. Myelitis followed. In two or tiiree days alterations in the urinary secretions began to appear. I will now quote the words of the oflicial report : " On the morning of the 18th, the urine became turoij." " By the morning of the 20th, the pulse had become so frequent that it could not be counted, the bowels were loose, the urine was ammoniacal and thick with mucus." ''A very high temperature (105°) followed. The patient at this time was still able to pass his urine without a catheter; but [haematuria supervened and], on the 21st, this instrument was used with difliculty, owing to the formation of clots in the bladder. The patient also suffered from decubitus [bed-sores], and, by the 24th, his stomach became so irri- table as to retain scarcely anything. On the day following his appetite was entirely gone. On the 26th the temperature was 91.8°. He died at noon on the 28th," t-v\'enty-five days after the accident, and ten or twelve days after his urine first began to be abnormal. The autopsy revealed the following urinary lesions : " The kidneys were enlarged and gorged with blood ; the pelvis of the left being filled with pus." " The ureters were very dark, and one of them contained a clot at the entrance of the bladder. The walls of the bladder were of a dark-purple color, inflamed, and thickened ; the raucous membrane being absent in patches."^ The urinary lesion.s in this case did not arise from injury (traumatism) of the kidneys or bladder, for the urinary discharge did not present any morbid appearances until a fortnight after the accident ; they were not due to par- alysis of the bladder, for the urinary paralysis had disappeared, and the man had passed his water at will for a week before it presented any abnormal change ; they were not caused by the introduction of septic matters from without, because catheterization had been discontinued for a week before " the urine became turbid," and was not again resorted to until three daj^s after- ward, when liBematuria had occurred, and the urethral outlet of the bladder 1 Op. cit., p. 249. 2 Ibid., p. 248. 3 Circular No. 3, S. G. 0., August 17, 1871, pp. 129-131. 442 INJURIES OF THE BACK. had become choked with coagiila. There" remains, then, no appreciable or perceptible cause whatever for the remarkably inflamed state of the kidneys, ureters, and bladder, which the autopsy revealed in this case, excepting the excitation of the spinal cord by the secondary meningitis and myelitis, which had supervened two or three days before the urinary secretion became tur- bid." Thus, it is shown that the urinary lesions in this case had a neuro- pathic source. Moreover, an acute bed-sore — that is, a neuropathic eschar — presented itself, at the same time, over the sacrum, in this patient; this cir- cumstance also affords presumptive evidence that the urinary lesions had a similar origin. The urinary lesions appear to have been the chief proximate cause of this patient's death, which occurred about ten days after the signs of these lesions first became visible. This neuropathic nephritis and cystitis, etc., therefore,' ran a remarkably rapid course, and quickly proved fatal. The symptoms presented themselves in the following order : On the first day, it w^as observed that the urinary discharge was "turbid no doubt it was also ammoniacal. Two days afterward, it was remarked that the urinary discharge w^as highly "ammoniacal and thick with mucus," that the "bowels were loose," and that 2;reat prostration ^vith "a very high temperature (105°)" was also present. After still another day, hsematuria supervened, and the urethral outlet of the bladder becoming plugged with clotted blood, it was necessary to introduce a catheter. On the same day it was noted in the clinical history that the patient was also suflering from bed-sores. In three days more there was extreme anorexia, wdth very great gastric irritability ; and in four days after that death ensued. This peracute inflammation of the urinary organs wa^ought the following structural changes : The kidneys were intensely hypersemic, and therefore enlarged, while the pelvis of the left one was filled wdth puru- lent matter. The coats of the bladder were intensely inflamed, dark-purple in color, and thickened ; its mucous membrane had also sloughed off in patches. The ureters, likewise, were very dark in color and intensely inflamed. In consequence of these structural changes, the urinary secretion speedily became loaded with muco-purulent matter and blood. The hsematuria which occurred during life w^as obviously caused by the rupture of the over-distended blood- vessels of the kidneys, etc. No wonder, then, that general prostration of an extreme character should rapidly come on in such a case of renal and cystic inflammation, and that death should speedily ensue. Another hio-hly instructive example of neuropathic inflammation of the kidneys, ureters, and bladder, has likewise been mentioned in these pages already (p. 414) ; but it is well worth further study, and I shall therefore speak of it again. It was originally recorded by . Sir W. Gull : — A man, aged 25, contracted acute myelitis of the dorsal region in consequence of straining his back in lifting a heavy weight. No bones nor Hgaments, however, were injured.'' On the morning of the second day after the accident he found himself para- plegic on walking, in consequence of the rachidian inflammation. On the fourth day after the injury^'he was admitted into Guy's Hospital. There was already complete [)araplegia, together with a sacral eschar ; and ammoniacal urine constantly dribbled from liir paralyzed bladder. Forty-one days after the accident, or thirty-seven days after entering the hospital, he died. At the autopsy, commencing suppuration in the cortical substance of the kidneys was noted. The mucous membrane of their pelves was green- ish in color, with patches of greenish-colored fibrinous exudation thereon. The mucous membrane of the ureters and bladder was in tlie same condition. The bladder con- tained a quantity of muco-purulent fluid. The substance of the spinal cord was changed into a tliick, greenish, muco-puriform liquid throughout its entire thickness, opposite the fifth and sixth dorsal vertebrae, while the cervical and lumbar portions of the cord were unchanged. DISORDERS OF THE URINARY ORGANS. 443 Is there any room for doubt in regard to the etiology of the renal and vesi- cal inflammation which the autopsy revealed in this case-'' Can the origin of this inflammation be assigned with propriety to any cause, excepting the extremely w^ell-marked myelitis, and the morbid excitation of the spinal cord which it occasioned? It cannot be ascribed to the introduction of septic matters from without, because there is no evidence nor probability that a catheter was ever used in this case ; and it does not appear that any necessity ever existed for using a catheter on this man, inasmuch as his urine is known to have been discharged by dribbling (from paralysis of the sphincter vesicae) almost from the outset, and probably was discharged in this manner from the very outset of the case. Moreover, an acute bed-sore of large size presented itself in the sacro-gluteal region, and this, together with the urinary lesions, destroyed the man's life ; and, as the sacral eschar had a neuropathic origin, even so the urinary lesions had the same origin. Although the inflammatory process in the urinary organs was much less acute in this than it was in the preceding example, the textural changes produced by it, and revealed by the autopsy, were quite well marked. Tliey were as follows : Suppuration in the cortical portion of the kidneys ; in- flammatory discoloration, and, no doubt, thickening of the mucous mem- brane lining the renal pelves, the ureters, and the bladder; also greenish- colored flbrinous exudation collected in patches on every part of this mem- brane. The greenish hue of the exudation, as well as of the inflamed mucous membrane itself, was due to staining with the red corpuscles of the blood ; hiematuria had doubtless supervened some time before death. Finally, the urinary bladder contained a quantity of muco-purulent liquid, the muco-puru- lent elements of wdiich had been produced by the inflammatory process. Many other examples belonging to the same category have been presented in the foregoing pages. Should, how^ever, additional evidence be required in regard to the etiology of the urinary disorders under consideration, it may readily be found in M. Charcot's Lectures, already so often quoted: evidence Avhich, although weighty and convincing, cannot be reproduced here for want of room. To briefly summarize the symptoms which usually attend the neuropathic inflammations of the urinary organs that very frequently supervene in cases of spinal injury: Soon after the accident, that is, w^ithin a period beginning on the second, and ending about the ninth day thereafter, it is observed that the urine, previously acid and clear, or perfectly normal, suddenly becomes alkaline, and exhales a pungent ammoniacal smell at the moment of emission. Shortly afterward, it is noticed that the urinary discharge has a cloudy and turbid look, arising from the admixture of mucus, as" well as a strongly ammoniacal odor. The quantity of this mucus gradually in- creases until the urinary discharge becomes ropy, tenacious, and so thick from this cause that it even adheres to the bottom of the vessel. In a short time, a white substance — the phosphate of lime — is found mixed with the mucus. Pus-corpuscles and blood-disks also present themselves. The quan- tity of the former may be so great as to cause a muco-purulent appearance. Oftentimes, the blood-disks present themselves in such large number as to constitute a veritable hemorrhage from the urinary organs, technically deno- minated hsematuria. But blood-disks will often be seen with a microscope, when to the unaided eye the urinary discharge does not present a sanguino- lent appearance. In the chronic cases, and near the end of most of the fatal cases, the urinary discharge consists apparently of a muco-purulent liquid, in which, how^ever, blood-corpuscles or their remains are almost always found by microscopical examination, intermingled with pus-cells and renal and vesical epithelium, that is, muco-pus, with vibriones and phosphates, etc. 444 INJURIES OF THE BACK. To epitomize the anatomical lesions which usually accompany the neuro- pathic inflammations of the urinary organs that occur in cases of spinal injury : They are hypersemia, more or less intense, according to the case, with tumefaction and dark-red or purple discoloration of the mucous mem- brane lining the kidneys, the ureters, and the bladder ; intense hypersemia with tumefaction of the renal parenchyma, and of the walls of the ureters and bladder ; fibrinous exudation in patches on the mucous membrane lining these organs ; extravasated blood in both a fluid and coagulated state in the pelves of the kidneys, the canals of the ureters, and the cavity of the bladder; suppuration of the secreting portions of the kidneys, and abscess of their pelves ; inflammatory thickening of the coats of the bladder and ureters, with softening and erosions of their lining or mucous membrane. In such cases, patches of the mucous membrane are apt to be cast oft' as sloughs, and the inflammatory process, being violent, generally involves also or extends to the other tunics of the bladder and ureters, as well as to the parenchyma of the kidneys : As a rule, the inflammatory process in such cases does not •appear to start in the bladder and spread thence into tbe kidneys, nor vice versa ; but it is simultaneously kindled in all parts of the mucous membrane belonging to the kidneys, ureters, and bladder. In chronic cases, phosphatic calculi fo'rm in the kidneys, as well as in the bladder, and in either place they may set up fatal irritation. Thus, it will be perceived that the inflammatory process which is set up in the mucous membrane of the urinary organs by certain morbid excitations of the spinal cord, bears, at least " in the acute" instances, no inconsiderable resemblance to the necrotic processes w^hich are set up in the integuments by the operation of the same causes. The destructive process in both is charac- terized by intense, dark-colored hypereemia, extravasation of blood from rup- tured capillaries, and sloughing of the tissues involved. In the less severe or chronic cases, the urinary mucous membrane exhibits pathological changes quite analogous to the cutaneous erythema and other diffuse phlogoses of the integuments which are caused by similar lesions of the spinal cord, that have been described above. Furthermore, it is highly probable that when the urinary secretion comes into contact with the inflamed mucous membrane of the bladder, ureters, etc., it suflfers decomposition in consequence of such contact, just as happens in ordinary cystitis ; by which decomposition it acquires highly irritating pro- perties that in turn may react upon the already inflamed mucous membrane, and augment its disorder. The urine rots wdiile lying in the bladder, in such cases, not because the walls of the bladder may chance to be paralyzed at the time, as Mr. Shaw and others have vainly asserted, but because it there becomes tainted with the products of the inflammatory process which is going on in the bladder, the ureters, and the kidneys. This statement is fully borne out by what occurred in the jperacute example just novv related— the example in which a young soldier had sustained fracture without dis- placement of the fifth cervical vertebra in consequence of diving headforemost into shallow water : on the fifteenth day after the accident, there supervened a neuropathic inflammation of his kidneys, ureters, and bladder, w^hich caused death in ten days, although he had been able to pass his w^ater at will for a week previously (which proves that the bladder-paralysis had been absent for a week), and although it was not necessary to use a catheter on him again until three days after tlie urinary disorder had appeared, and then the instrument was introduced, not Ijccause the bladder was paralyzed, but because its urethral orifice was choked with blood-clot arising from hsematuria. Moreover, to say that in such a case the rotting urine produced an inflammation of the TYMPANITES ARISING FROM LESIONS OF THE SPINAL CORD. 445 bladder which subsequently spread to the kidneys, would be to blindly put the effect in the place of the cause, and perhaps lead to erroneous practice. Treatment — From the foregoing account of the urinary lesions that result from certain morbid excitations of the spinal cord, it is obvious that any plan of treatment which does not fulfil the causal indications — which does not put to rest the agencies that create these sad lesions — cannot do much good in such cases. I have thus patiently and thoroughly inquired into the etiology of these disorders with no purpose to dig up and exhibit any pathological curiosities ; but, rather, in doing this I have been^ moved by a strong desire to devise, if possible, some plan of treatment which shall prevent and per- haps even cure these deplorable lesions. And, inasmuch as they generally arise from congestion or inflammation of the spinal cord, or of its mem- branes, or are greatly augmented by these affections of the central nervous system, the first indication to be fulfilled in treating the neuropathic lesions of the urinary organs, is to subdue the central nervous afiections upon which their existence depends. To this end I recommend the administration per orera of fluid extract of ergot, of potassium iodide, and of belladonna, in the doses and in the manner already laid down in describing the treatment of neuropathic bed-sores (page 434), which, it is not necessary to repeat in this place. All other means of fulfilling the causal indications which are there mentioned should be employed in these cases also; and less incon- venience w^ill be experienced in carrying out this treatment from the fact that when these neuropathic disorders of tbe urinary organs make their appear- ance, neuropathic bed-sores almost always present themselves at the same time. In regard to the results of this plan of treatment, I find, on a reperusal of some cases in which it was advantageously employed for bed-sores, that it proved equally useful for the accompanying urinary lesions. Belladonna plasters, applied over the kidneys, may do good in all such cases. The urine, as a rule, being strongly ammoniacal and therefore very pungent, should not be allowed to stand in the inflamed bladder, and in the case of any paralytics who cannot void it at will, or from whom it does i)ot flow spon- taneously, it should be withdrawn by catheterization as often at least as every four or six hours ; but, at the same time, every precaution must be taken, by using only a perfectly clean instrument, etc., to prevent entirely the introduc- tion of septic matter into the bladder. Hceriiatiiria often occurs in consequence of neuropathic inflammation of the kidneys, ureters, and bladder. When it proves dangerous or troublesome, it should be treated on the plan already prescribed for traumatic hematuria (page 298 supra), which it is unnecessary here to repeat. It will, however, be "necessary to break down and wash out the coagula by injecting warm water medicated Avith boracic acid through a large-sized catheter, more fre- quently in these than in the traumatic cases. The sloughs fallijig from the inflamed mucous membrane, with the muco- purulent and phosphatic, or mortar-like matter that may collect in the bladder in such cases, should likewise be washed out by injecting warm water impregnated with boracic acid through a double catheter. Tympanites arising from Lesions of the Spinal Cord. All lesions of the spinal column or spinal cord that cause paraplegia, niay be attended by distension of the abdomen with gaseous substances which are generated and held in the abdominal portion of the alimentary canal, that is, in the stomach, and in the small, as well as in the large intestines ; their most common seat, however, being the arch and sigmoid flexure of the 446 INJURIES OF THE BACK. €olon. In such cases, the distended belly is tense and elastic ; and, on per- cussion, it sounds like a huge bladder or a drum filled with air. This kind of abdominal tumefaction has with much propriety been called tympanites^ because, when struck, it sounds like a drum. The intestinal gases accumulate within the digestive tube in such cases, because the muscular wall of the abdomen and the muscular coat of the intestines, being paralyzed in conse- quence of the spinal lesion, are no longer able to contract and thus expel them ; and since, through loss of contractility, the abdominal and intestinal muscles can olFer no effective resistance to the accumulation of theee gases, it often goes on until the abdominal distension becomes enormous. The tympanites in such cases is symptomatic of the spinal lesion ; and, when enormous or even very considerable in degree, it is usually a fatal sign. But tympanites always tends in &uch cases to embarrass the patient's breathing by opposing the descent of the diaphragm during the inspiratory movement ; and, when it is very considerable, it causes corresponding dys- pnoea. It is, however, in those cases of spinal injury where the paraplegia extends up to the root of the neck — those cases wherein the respiratory move- ments ar© performed by the diaphragm alone, and where consequently the respiration is said to be diaphragmatic or abdominal — it is in such cases that tympanites does the most harm, and often aids with no inconsiderable force in shortening life, by increasing the difficulty of breathing, which perhaps is already very great. Many cases have been mentioned or referred to above, in which this very thing occurred. But probably the most notable example was presented on page 410. The cas^ was that of a cavalry soldier, who in a brawl received a shot- wound of the neck, which fractured the spinous pro- cess of the last cervical and the laminae of the first dorsal vertebra, opened the spinal canal, ruptured the theca vertebralis, and drove several small frag- ments of bone into the substance of the spinal cord. In this case, " the par- alysis of the abdominal and intestinal muscles allowed an accumulation of gases to take place within the intestines, to such an extent as greatly to aug- ment the already existing difficulty of respiration. It was found expedient to introduce an elastic tube, from time to time, through which the gases found vent, when pressure was made, externally, on the abdomen."^ Tym- panites, therefore, not unfrequently constitutes in cases of spinal injury a complication which urgently demands the surgeon's attention. Treatment. — The kind of tympanites in question is always symptomatic of some affection of the spinal cord which, as a rule, interrupts its reflex- motor, as well as its conducting functions. The nature of this central ner- vous affection should be ascertained, and, if possible, the disease itself should be removed ; which can often be done, if it consist in concussion, congestion, or one of the less severe types of inflammation of the spinal cord or its mem- branes, by carrying out the corresponding plans of treatment which have already been laid down in these pages. When immediate relief from the tympanitic distension is urgently de- manded, it has been proposed by some surgeons to resort to the operation of paracentesis^ performed on the descending colon with a long narrow trocar and canula ; but, inasmuch as this operation is never, in my opinion, justifi- able, I shall not take space to describe the steps that pertain to it. The best way to let the wind out in such cases is by introducing a flexible tube of suitable size and length, through the anus and rectum into the sigmoid flex- ure of the colon, as was originally done, I believe, with success in analogous cases, by Dr. O'Beirne, who used an oesophagus tube for the purpose — a method which likewise was successfully employed in the case just related, I CLrcular No. 3, S. G. O., August 17, 1871, pp. 21, 22. PRIAPISM IN CONSEQUENCE OF SPINAL INJURIES. 447 Should it be necessary to discharge the wind from the stoniacli, or from the small intestines, by an operation, it might be done with comparative safety by aspiration. Antispasmodics and carminatives, fether, ol. anisi, assafoetida, tinct. carda- momi, tinct. zingiberi, tinct. rhei, or ol. terebinthinse, will of coarse be administered, by the mouth or by the rectum, in these cases; and warm purga- tive medicines, and warm purgative clysters, should likewise be employed. Priapism in Consequence of Spinal Injuries. The term priapism is here used to signify a more or less complete erection of tlie penis (but most often it is incomplete), which is unattended by volup- tuous sensations, and which is caused by injury or disease of the spinal cord, instead of by sexual desire or normal excitation. This condition of the penis is very often observed in cases of spinal injury. It will therefore be instructive, as well as interesting, to consider briefly the clinical relations, the etiology, and the import or signification of this disorder of the male sexual organs. Phenomena of Pricqnsm. — Priapism is usually described as a mere "turges- cence," or bare "stifl:ness" of the penis, which does not amount to an erection in the true sense of the term. For it is commonly observed in priapism, that while the " turgescence," or stiftness," does not attain the rigidity of a true erection, it likewise does not cauvse the head of the penis to rise upward beyond a line drawn perpendicularly to the long axis of the body. Moreover, the penis does not of necessity become increased in length and breadth, or diameter, in priapism, as it does in normal erection, or in that state of the organ which renders it capable of intromission ; for I have observed at least one case of vertebral injury in which the penis, although in a state of undoubted priapism that lasted as long as life continued, measured only one inch and a half in length ; while after death^ when complete relaxation had taken place, it measured two and one-half inches in length. But the foregoing description does not embrace the phenomena tliat are witnessed in all the cases of priapism arising from spinal injury ; for while this description holds good in most cases, there are at least occasional instances of spinal injury in which the priapism amounts to a " strong erection," as was olDserved in an example already pre- sented for another purpose on page 423. The case, in brief, was that of a stable- man, aged 30, having transverse fracture with dislocation of the seventh cervical vertebra, caused by falling dow^n stairs, who was admitted into Bellevue Hos- pital twenty-three hours after the accident, with complete sensory and volun- tary motor paralysis of the lower extremities and trunk up to the third or fourth ribs ; also diaphragmatic breathing, retention of urine, etc., and, at the same time, " the penis was strongly erected." This state of vigorous erection must, in great measure, have subsided not very long after admission, for on the third day this entry w^as made in the clinical record gf the case : " pria- pism always induced by passing the catheter." That night the man died of asphyxia, caused by traumatic, ascending myelitis. Thus it appears that the clinical phenomena of priapism may vary in different cases, or in difterent periods of the same case, from those of bare turgidity or slight stiffness of the penis, on the one hand, through all the ascending grades of turgidity and stiffness up to strong erections of the organ, on the other. Another erroneous statement in regard to priapism is frequently made, namely, that it occurs only in cases where the cervical or the upper dorsal ver- tebrae are fractured or dislocated. But the truth is, that it is also met with not unfrequently in cases where the middle dorsal, or the lower dorsal, or the 448 INJURIES OF THE BACK. upper lumbar vertebrae are fractured or dislocated. For instance, I have already related for another purpose, on page 390, the case of a derrick-man, aged 41, who had his tenth dorsal vertebra fractured by being thrown from a cart, and was admitted into Bellevue Hospital two hours after the accident, in a state of profound collapse, with the pulse too frequent and feeble to be counted, and with the lower extremities and body completely paralyzed as to sensation and voluntary motion up to the sixth intercostal space ; still, there was moderate priapism observed. I have likewise already men- tioned, on page 375, the case of an officer, which was originally reported by Surgeon C. S. Tripler, U. S. Army, and in which there was a shot-fracture of the spinal column at the junction of the dorsal and lumbar regions, attended with paraplegia, retention of urine and feces, and priapism. Furthermore, I have mentioned^ on page 337, the case of a man, aged 25 (it was related by J3r. Parker), who sustained a dislocation of the twelfth dorsal upon the first lumbar vertebra, with slight fracture, in consequence of being struck by a fallino; door, and who had priapism as well as paraplegia ; and, no doubt, in several other instances of inferior dorsal or lumbar fractures or dislocations of the vertebrae that are related or referred to above, there was priapism as well as paraplegia present. In addition to these observations, I will take space only to mention a case reported by Dr. Hutchison,^ of Brooklyn, i^. Y., in which the eighth, ninth, tenth, and eleventh dorsal vertebrae were fractured, in a man, aged 35, by fall- ing fifteen feet from a scafibld, and in which paralysis, priapism, etc., ensued ; another case reported by MM. A. Pousson and F. Lalesque,^ in which a man, aged 40, sustained dislocation of the eleventh dorsal vertebra combined with fracture of its laminse, and in which, besides paraplegia, there were priapism, ete. ; and a third case recorded by Mr. Hilton,^ in which a man, aged 30, fell through a trap-door, sixteen or eighteen feet, fractured his eleventh dorsal vertebra, and completely divided his spinal cord, with the effect of producing complete paraplegia, etc., as well as priapism, which appeared, however, on the second day. I have no doubt that if a search were specially instituted for the purpose, a considerable number of additional cases could be collected m which fractures or dislocations of the vertebrae in the lower dorsal and lumbar regions were attended by priapism, as well as by paralysis. This peculiar disorder of the male genitalia is, however, met with much more frequently in the cervical and upper dorsal regions than elsewhere, but it should also be borne in mind that fractures and dislocations of the vertebrae occur much the most frequently in these regions. It may be of interest to remark, in this connection, that Professor Agnew states that he has seen priapism present itself after injuries of the head,^ as well as after those of the spinal column. But priapism may likewise appear in cases of concussion or contusion ot the spinal cord, and in consequence of those injuries. I have already pre- sented two examples belonging to this category on pages 384 and 38b ; one of these was reported by Sir W. Gull, and the other by Mr. Savory. In Sir W. Gull's case, the only lesions of the cord observable were ecchymosis and hyper^emia, mostly in the gray substance, opposite the fourth and fifth cer- vical vertebrae. The priapism disappeared in a few hours, but returned on the following day. In Mr. Savory's case, there was complete loss of sensa- tion and voluntary motion in the lower extremities, and in the trunk nearly » American Medical Times, 1861. 2 Medical News and Abstract, March, 1881, pp. 179, 180. 8 Guy's Hospital Reports, 3d series, vol. xi. 4 Principles and Practice of Surgery, vol. i. p. 829. PRIAPISxM IN CONSEQUENCE OF SPINAL INJURIES. 449 up to the clavicles, the respiration was entirely diaphragmatic, and no reflex action could be excited in the lower extremities or elsewhere ; still there was partial priapism. Death occurred in thirty hours; and the autopsy showed a clot of blood in the substance of the cord opposite the fourth cervical vertebra. Furthermore, priapism may be caused by inflammation of the spinal cord. There was a marked degree of priapism observed in a case of acute and very extensive myelitis, terminating fatally in ten or twelve days, that was re- corded by Dr. C. B. Radclifte.' Motor and sensory paralysis extended up to a line drawn around the body four inches below the ensiform cartilao-e. Reflex movements were also absent, but there was retention of ui-iiie.* Priapism may be an important indication that myelitis is present. Dr. Hammond enumerates among the symptoms of acute myelitis frequent and almost constant erections.^ Dr. Braniwell in describing the symptoms of acute myelitis states that priapism is often present among them.'* In Mr. Hilton's case, mentioned above, the priapism which supervened on the second day after the accident probably arose from inflammation of the cord-substance. Thus, we have shown that priapism not unfrequently occurs in cases of con- cussion, contusion, and inflammation of the spinal cord, as well as in cases of fracture and dislocation of the spinal column ; the conclusion to be drawn therefrom is irresistible that the essential lesion, or the peculiar patholoo-ical condition upon which the occurrence of priapism depends, is seated in* the spinal cord, and not in the spinal column nor in the exterior parts. What is the essential lesion^ what the physiological apparatus from the disorder of which priapism arises ? The fact tha^t the location or site of the essential lesion must be sought for in the spinal cord itself, at once disposes of the theory which ascribes the causation of priapism to lesions of the cervical or dorsal ganglia of the nervi sympathici which lie alono- the spinal column. It, however, does not dispose of another theory which ascribes the cause of priapism to lesions of those filaments of the nervi sym- pathici which exist in the spinal cord, and to vaso-motor paralysis of the bloodvessels arising therefrom. Professor Agnew seems inclined to adopt this theory, for he says : " These erections of the penis are not due to action of the muscles, as the latter partake of the general paresis, but are the result of inefliciency of the vaso-motor nerves allowing the blood to flow into the spongy structure of the corpora cavernosa and corpus spon2:iosum, through the want of resistance in the muscular walls of the vessels."* "P>ut this theory of erections arising from passive congestion of the penis is untenable, because it utterly fails to account for the rather numerous examples of priapism in which there are strong or even moderate erections observed, and in which the distension of the organ is produced obviously by an active process. More- over, vaso-motor paralysis is always attended with a notable rise of tempera- ture in the part of the body where it exists, especially if such paralysis be suddenly eftected. How, then, can the occurrence of priapism be explained by the theory of vaso-motor paralysis in such instances as the followino- which was reported by Mr. Hutchinson,^ in which "there was marked pria- pism," but attended with a remarkable depression of the body-heat, both general and local, below the normal standard :— ' The patient was a man, aged 24, who fractured liis fifth cervical vertebra and severely injured his spinal cord by falling from a ladder with a load of bricks on his * Lancet, December 3, 1864. * New Sydenham Soc. Year-Book, 1864, p. 83. 8 Diseases of the Nervous System, p. 457. New York, 1881. * Diseases of the Spinal Cord, p. 243. New York, 1882. s Qp. cit. p. 829. ^ ^ New Sydenham Soc. Biennial Retrospect, 1S73-74, pp. 351, 352. ' *' ' VOL. IV. — 29 450 INJURIES OF THE BACK. shoulder. When seen on the following day , his lower extremities were completely paralyzed, and the line of anaesthesia extended as high as an inch above his nipples. The breathing was solely diaphragmatic. There was marked priapism. The tempera- ture was 98°. The pupils were equal and of a small size in a dull light. Next day the pulse was noted at 36 per minute, and small. In the evening, the temperature in the rectum was only 95.8° ; in the distended penis it was only 93°. He died on the sixth day after the accident. The vaso-motor theory of the production of priapism is insuffi- cient to account for such cases, as well as for those instances in which the erections are more or less vigorous, and in which the distension of the penis is obviously effected by the operation of active agencies. The nervous apparatus, the disordered action of which produces priapism, is doubtless the same as that by which normal erections are efiected. The pro- cess is a reflex one, the centre for which (that is, the sexual centre) is situated in the lumbar portion of the spinal cord. The sexual centre may be put into action by peripheral impressions conveyed to it from the penis, especially the glans, by the sensory nerves ; also, by cerebral impressions (they are usually emotional influences) conveyed to it by the conducting fibres of the cord. " As the result of the stimulation of the sexual centre, an impulse is gene- rated which travels along the nervi erigentes and inhibits the local nervous mechanism in the bloodvessels of the corpora cavernosa ; vascular dilatation, engorgement, and erection follow."^ Thus, it is not difficult to conceive how priapism may be caused in cases where the spinal cord is injured or diseased in the cervical or dorsal regions ^ etc., and where paraplegia, both sensory and voluntary-motor, is present in consequence thereof, namely, by irritating the " excitor" fibres which pass from the cerebrum to the reflex sexual centre, as pointed out by Dr. Bramwell.^ In the same way, cerebral injury or disease may also produce priapism. This view as to the reflex origin of priapism in spinal injuries is supported by a fact noted in the clinical history of a para- plegic case related above, from Bellevue Hospital, viz., that the introduction of a catheter always brought on priapism. Finally, in order to show that the paralysis of the muscular apparatus is not of necessity so complete in cases of seemingly perfect paraplegia that priapism cannot be caused in l^his way, as asserted by Professor Agnew, it is only necessary to state that, in practice, priapism is very often found associated with retention of urine and feces, and that the presence of the latter condition is due to the fact that the sphincter muscles are not paralyzed. In regard to the significance of priapism as a symptom, or as a prog- nostic, in cases of vertebral injury, while it shows that the spinal cord is involved in the lesion, it can be stated with certainty that it is not necessa- sarily a fatal sign, inasmuch as recovery resulted in two cases mentioned above, in which Its presence was recorded. One of these cases was reported by Dr. Parker, and the other by Surgeon C. S. Tripler, U. S. Army. Special treatment is seldom required for priapism. In severe cases, how- ever, pulverized camphor, camphor monobromate, or potassium bromide, may be administered with benefit. Injuries of the Sacrum and Coccyx. Fractures of the Sacrum.^ — Simple, uncomplicated fracture of the sacrum sometimes, though very rarely, occurs. The structure, shape, and position of this bone in the skeleton are such as to render it peculiarly free from a liability to sustain solutions of continuity, by itself, in the ordinary accidents « Bramwell, op. cit., p. 129. 2 Ibid., pp. 61, 131. INJURIES OF THE SACRUM AND COCCYX. 451 of civil life. It is more often found fissured and even comminuted in the severe crushes of the pelvic bones in general, which are not unfrequently met with. In simple, uncomplicated fracture, the lower half of this bone is the part most liable to be found broken, (1) because it is less strong, and (2) because it is more exposed than the upper half. Specimens illustrating this lesion are exceedingly uncommon in pathological cabinets. The museum of the Royal College of Surgeons, however, contains one example, according to the statements of both Erichsen and South. In it the sacrum is vertically fractured ; the patient died of suppuration six weeks after the accident, and no union of the fragments whatever had taken place.^ Erichsen has seen but one instance. The injury was caused by a blow from the butfer of a railway carriage, and proved rapidly fatal, ^^'ot long ago the follow^ing remarkable case was observed in Paris : — * A woman, aged 36, was brouglit into the St. Lazare Hospital with the history of having fallen about eight feet upon her buttocks ; she fainted, and, when she became conscious, was quite unable to sit. A slight transverse depression, corresponding to the middle of the sacrum, was readily felt from behind ; the injured part was very tender, and pressure gave fine crepitus. Extensive ecchymosis quickly occurred over the whole sacrum. The line of fracture was readily feU also from the rectum and vagina ; the projection forward of the lower half of the sacrum was readily verified, and this part of the bone was easily moved, with crepitus. Reduction was effected without difficulty by the finger pressing backward from the front, and displacement did not recur. A bandage was firmly applied round the pelvis and the patient kept in bed. Defecation gave intense pain, and the woman was unable to lie on her back for a fortnight ; but she sat up in bed on the twenty-eighth day, and got up in the ward on the forty-second day. There were no signs of pressure upon, or other injury of, the lower sacral or coccygeal nerves.'^ ° In this case the sacrum was fractured transversely ; in the specimen con- tained in the Royal College of Surgeons Museum, mentioned above, it was fractured vertically; it is also stated that this bone may be fractured obliquely; but, in simple, uncomplicated cases, these fractures are most commonly trans- verse. Etiology.— ThQ most frequent causes of the simple, uncomplicated fractures are powerful blows struck directly over the sacrum, as, for example, a blow from the buffer of a railway carriage; heavy falls with direct impingement upon the sacrum, as was observed in the instance just related; and the sudden application of great weight or pressure, such as may occur, for example, in 1he passage of a cart-wheel over the sacrum. Great force, when indirectly applied, may also cause such fractures; but the indirect fractures of the sacrum are usually associated with similar lesions of the other pelvic bones, as already intimated. Mr. Erichsen has seen one case of simple, uncompli- cated fracture of the sacrum which was caused by a blow from the buffer of a railway carriage, and which rapidly proved fatal. Symptoms. — The pain in the injured part is usually very acute, and aggra- vated by all muscular movements which disturb the injured part, such as flexion or extension of the body, etc. All straining efforts in defecation, urination, coughing, or sneezing, produce extreme suffering. All pressure applied externally likewise increases the distress ; and the patients themselves will generally have noticed that from the moment of receiving the injury they have been, from this cause, unable to sit upright. On examina'tion, angular deformity may be visible posteriorly, as well as a subcutaneous ecchymosis, which quickly spreads over the whole sacral region. On applying the fingers » South's Notes to Chelius's System of Surgery, vol. i. p. 595, Am. ed. 2 Lancet, November 20, 1880. 452 INJURIES OF THE BACK. to the injured part, great tenderness is discovered, together with crepitus and one or more lines of depression corresponding to the fracture and displace- ment. On introducing a finger into the rectum, and pressing against the coccyx, both crepitus and abnormal mobility may be detected. With a linger of one hand in the rectum and the lingers of the other hand applied externally, the kind and degree of the displacement can for the most part be readily de- termined. The displacement usually consists in a forward projection of the inferior fragments, as was observed in the example of sacral fracture above related, and is due to the operation of two causes, (1) the blow itself, and (2) the contractions of the gluteus maximus, coccygeus, and sphincter ani muscles. Lateral distortion is not likely to occur, because the lesser and the greater sacro-sciatic ligaments would counteract such a change in the position of the fragments. Moreover, paralysis of the bladder and rectum may likewise be present, inasmuch as both organs receive nerves from the sacral plexus. Prognosis. — Of the three examples mentioned above, two ended in death, and but one in recovery. The successful case, however, shows that when simple fracture of the sacrum is not complicated with other lesions, especially with injuries of the pelvic viscera, the fragments on being placed in apposi- tion readily unite, and recovery speedily ensues ; for in that case the union on the twenty-eighth day was already so firm that the patient^ sat up in bed, resting of course the whole weight of her trunk upon the injured bone in so doing. When, therefore, fractures of the sacrum do not end in recovery, the fatal result is 2;enerally due, not to the fractures themselves, but to lesions of the adjacent pelvic viscera with which they are associated. Unhappily, how- ever, any application of force that may suffice to disrupt the sacrum, is very liable to do so much harm to the neighboring pelvic organs, at the same time, as to make a fatal result inevitable. " Thus, it appears that the prognosis m sacral fractures depends rather upon their complications than upon the frac- tures themselves, and that it is generally unfavorable. When the lesion consists in the breaking off of a layer of bone attached to the cartilage at one or both of the sacro-iliac synchondroses, that is, in modi- fied diastasis, the issue is not of necessity mortal. Dr. Banks^ has recorded an example of this lesion in which there was displacement upward to the extent of one inch, and still the patient recovered. Moreover, a cure is sometimes obtained in still more unpromising instances, where the fracture is compound, and at the same time complicated with injury of the bladder ; for Dr. Bur- lingham^ has reported a very remarkable case of compound fracture of the sacrum in which the urine flowed for some time through the wound, and m which, notwithstanding this condition of affairs, the patient entirely re- covered. Treatment— Fvd^iiiuvQ^ of the sacrum should always be reduced when prac- ticable, and the reduction can generally be effected without much difficulty when the fracture is situated in the lower half of the bone (which is the part most liable to be broken), especially if it happen to be transverse. Eeduction is to be effected even when the displacement is but slight, because, from the close proximity of the rectum, any displacement whatever of the fragments that might be allowed to remain, would correspondingly tend to irritate that viscus, and to excite suppurative inflammation in the loose connective tissue between it and the injured bone. It should be remembered in this connection that death resulted from such a suppuration, six weeks after the accident, in the case the sxjecimen from which is preserved in the Eoyal College ol Sur- geons (mentioned above), and that, as might well be expected under the circum- 1 Atalanta Medical and Surgical Journal, May, 1866. 2 American Journal of the Medical Sciences, April, 1868. INJURIES OF THE SACRUM AND COCCYX. 453 stances, no union of the fragments whatever had taken place. Xo doubt too the remarkable success which attended the treatment of tlie illustrative ex- ample related above, was mainly due to the fact tliat the displaced bone was put back again into its normal position without delay, and that an exact appo- sition of the fragments was uninterruptedly maintained. Oftentimes, reduc- tion can easily be accomplished by pressing upon' the displaced bone with a finger in the rectum. The second indication in the treatment of sacral fractui'cs is to keej) the fragments in apposition. This indication was readily fultilled in the illustra- tive example presented above, by firmly ai)plying a bandage around the [)elvis, and by keeping the patient in bed. But the main difficulty in the treatment of these cases, where the fracture is the sole injury, is the intense degree of pain with whi(di the act of defecation is accompanied, and the local disturb- ance wdiich it produces. Some surgeons have, by administering opium, kept the bowels in a state of confinement ; and then emptied the rectum every week or ten days by means of an enema. It is, however, still better to diet the patient very carefully with a view to restrain the production of feces to the smallest possible (juantity, w^hich may then be easily and almost painlessly removed every three or four days by means of an enema. Whenever pain is present in these cases, it must be subdued by administering opium or morphia in doses that are sufficiently large, and at intervals that ai-e sufficiently briet Should intra-pelvic inflammation arise, it must be combated by leeches and hot fomentations, as w^ell as by opiates. Should retention of urine be present, catheterization must be employed every eight hours. Should the bladder be wounded in a male patient, but es^DCcially should it be ruptured, it may be advisable to open it at once by perineal section in order to allow the urine to escape as fast as secreted, and thus avoid all chance of urinary infiltration. Cases belonging to this category may be saved by the timely performance of this operation, which is not dangerous per se^ and which, if I remember aright, has already proved successful in one or more examples of this sort, simply because it prevented the pelvic fractures from becoming complicated with urinary infiltration. But should the broken bone manifest a disposition to slip out of place again after its reduction has beeu effected, notwithstanding the firm applica- tion of a bandage around the pelvis, a mechanical api)aratus must be em- ployed to overcome this disposition. For this purpose, Al. Indes used simply a piece of wood, cylindrical in shape, five inches in length by three inches in circumference, which w^as inserted into the rectum, and there retained in position by graduated compresses together with a T-bandage. On every third day this plug or splint was temporarily withdrawn, and the bowel was washed out with an enema. The patient recovered. For the same purpose, M. Bermond used a silver canula, with a bag attached, which when stuffed formed an inner and an outer tampon. The end of the tube was kept closed Avith a cork, in order to prevent the escape of feces. It was removed only twice during the course of treatment, namely, on the seventh and nineteenth days respectively. This patient also recovered. The patient should be rigidly confined to bed until the fragments have united. The posture therein should be that which is attended with the smallest amount of discomfort to the patient, and with the smallest liability to the recurrence of displacement. Gunshot Fractures of the Sacrum. — Hennen mentions three cases in each of which a musket-ball passed through the sacrum, about three inches above the tip of the coccyx, and penetrated obliquely upward. In two of them the rectum w^as also wounded. In the third, the bladder was perforated as well as 454 INJURIES OF THE BACK. the rectum, and " urine passed after the first few hours from the posterior wound." This patient expired on the third day, "laboring under the symp- toms of the most violent peritonitis." In each of the other cases the missile lodged, and was passed by stool about two months after the casualty. One of these unfortunate men " survived for two years, when, a discharge of feces coming on through the orifice in the bone, he died, exhausted by a complication of sufterings ; but no paralytic afiection ever appeared." The remaining case was seen by Dr. Thomson in the military hospital at Berlin, under the care of Dr. Reich, but the result is not stated. ^ From this it would appear that shot fractures of the sacrum are highly dangerous to life. Pare, however, asserted that he had many times seen the sacrum fractured by bullets when the subjects recovered. During the late civil war one hun- dred and forty-five cases were reported. In three of them the result has not been determined. Of the remaining one hundred and forty-two instances, sixty-two, or 43.7 per cent., were fatal.^ Thus it appears, (1) that gunshot fractures of the sacrum not unfrequently occur, and (2) that more than one- half of the cases recover. The following very instructive example eventuated in recovery : — Lieutenant W. A. C. Ryan, Co. G, 132d New York Volunteers, aged 21, was wounded at Bachelor's Creek, N. C, February 1, 1864, by a conoidal ball, which frac- tured the last lumbar vertebra, and lodged in the sacrum. He was at once taken to a general hospital where simple dressings were applied to the wound. On June 12, it was noted that the wound discharged very freely ; that the patient although feeble was in a very good condition ; that an ulcer had formed across the sacrum, about three inches in fength by one and a half inches in width, with a sinus leading to the ball ; and that the missile was extracted, with some difficulty, from the bone in which it was firmly imbedded, on that day. The wound healed rapidly after the operation. The treatment consisted of tonics, with a generous diet. On October 9, the patient was dis- charged. There is no record of him at the pension-office.^ His recovery was, therefore^ in all probability complete. Recovery resulted in the next example also : — Lieutenant S. W. Russell, Co. B, 49th New York, and A. D. C. Sixth Corps, aged 26, was wounded at Rappahannock Station, November 7, 1863, by a conoidal ball which "entered the left hip, passed across the upper portion of the sacrum, and emerged from the rio-ht hip. The surface of the sacrum was fractured." On the 9th he was admitted into Armory Square Hospital, and on February 3, 1864, he was transferred to Seminary Hospital, Georgetown. He returned to duty on May 16 following, where he appears to have remained until June 27, 1865, when he was discharged from the service and pensioned. The pension-examiner noted at the time that the wound was still unhealed. On June 4, 1873, he was still on the pension list.'' Among the cases of recovery from shot fractures of the sacrum, reported during the late civil war, were four in which the bladder was penetrated. In nine instances the rectum was wounded, and eight of these_ cases resulted favorably. In addition to the complications attending shot injuries of the OS innominatum, paralysis and other disorders referable to lesions of the nerves were common after shot fractures of the sacrum.^ In the cases of shot fracture of the sacrum which were observed during our late civil war, it was common for one or both of the posterior spinous processes of the ilium to be found fractured at the same time, as is shown in 1 Hennen, op. cit., p. 351. . i i oAa 2 Medical and Surgical History of the War of the Rebellion, Second Surgical Volume, P- 246. 3 Ibid., First Surgical Volume, p. 461. " Ibid., Second Surgical Volume, p. ^46. 6 Ibid.' INJURIES OF THE SACRUM AND COCCYX. 455 the preparation represented by Fig. 884, and as probably happened in the case of Lieutenant Russell, which has just been related.^ Shot fractures of the sacrum were Jiot unfrequentl}^ found by our military surgeons to become complicated with pycema, as was observed in the follow- ing instance : — Private George F., aged 23, was wounded at Cold Harbor, June 3, 1804. He was treated in the field hospitals until the 12th, when he was transferred to Washington, and admitted to Douglas Hospital. At this time he was suffering from partial para- plegia. He died from well-marked pyaemia on the 21st, eigliteen days after the casualty Fig. 884. Fig. 885. Shot fracture of the sacrum and ilium. Shot perforation of the sacrum. (Spec. 1353, A. M. M.) (Spec. 3o68, A. M. M.) occurred. Autopsy.. — The ball was found in two pieces in the sacro-ischiatic notch, having perforated the sacrum to the right of the median line, as shown in the accom- panying wood-cut (Fig. 885), which represents the osteological specimen that was ob- tained from the case, and is now preserved in the Army Medical Museum. Both lungs contained extensive pyaemic patches ; the liver and spleen were softened, and the latter enlarged. There had been icterus before death .'^ Pypemia was reported as the cause of death in eight of the sixty-two fatal cases belonging to this category, or 12.9 per cent.^ The specimen represented by Fig. 886 was obtained from the corpse of a soldier, aged 41, who was wounded at Petersburg, July 30, 1864, by a conoidal ball. He was Fig. 886. Fig. 887. Upper two-thirds of the sacrum obliquely fractured Right half of the sacrum ^Tooved by a conoidal by a conoidal musket-ball. (Spec. 3oS6, A. M. M.) musket-ball. (Spec. 2.30, A. M. M.) admitted to Douglas Hospital on August 3, and died after symptoms cliaracteristic of pyaemia on the 10th, twelve days after the casualty occurred. For three days after 1 Ibid. 2 Ibid., p. 247. Ibid. 456 INJURIES OF THE BACK. admission catheterization was required, but after that his water passed freely. There was no other sign of paraplegia.^ The specimen represented by Fig. 887 was obtained from the cadaver of a soldier, aged 19, who was wounded at West Point, Va., May 7, 1862, and who died in Judiciary Square Hospital, at Washington, on the 23d, with symptoms of pyaemia, sixteen days after the wound had been inflicted. The injury was reported as a "gunshot wound of the lumbar region near the nates, and also through the lower part of the right chest." "Pos<- mortem section of the injured parts showed a deep wound of the sacrum ploughing the bone," as is well shown in the accompanying wood-cut.^ In the following instance the sacrum was transversely grooved or perforated by a small-arm missile : — Corporal Amos E. C, aged 18, was wounded at Chancellorsville, May 3, 1863, by a conoidal musket-ball, which entered the left buttock behind and above the great trochanter, and emerged through the right side of the sacrum. He remained in the hands of the enemy for nine days, during which time his wound was entirely neglected. On June 14 he was sent to Washington, and was admitted to Douglas Hospital in a very nervous, weak, and anaemic condition. There were bed-sores over the projec- tions of the hips, back, and sacrum, so that it was impossible to lay him in a comfortable position. He died on July 9, apparently in consequence of these bed-sores. Autopsy. — Pleuritic adhesions were found, but no signs of peritoneal inflammation. The sacrum, as shown in the accompanying wood-cut (Fig. 888), was perforated from side to side, with loss of substance at the junction of the fourth and fifth pieces of the bone. The fragments were carious, and there was a slight osseous deposit on the anterior surface.' The specimen of shot fracture of the sacrum which is represented by Figs. Fig. 888. Fig. Showing the sacrum grooved transversely by a conoidal musket- ball. (Spec. 1642, A. M. M.) The sacrum and last lumbar vertebra. A ball is impacted in the left upper sacral foramen. (Spec. 2902, A. M. M.) Posterior view of the same specimen. 889 and 890, was obtained at the autopsy of a soldier, aged 23, with the fol- lowing history : — He was wounded at Spottsylvania, May 10, 1864, and taken to a field hospital of the Fifth Corps. On the 14th he was transferred to Carver Hospital, at Washington. " The missile entered about two inches to the left of the sacrum, passed a little down- ward and to the right, fractured the sacrum, and remained in the wound. When admitted, the patient was not much emaciated; there was great pain, with tumefaction of the aodomen ; the bowels were constipated, and there was complete retention of urine. The bladder was greatly distended with urine ; the pulse about 140; the tongue thickly coated with dark-colored fur ; sordes on the teeth. There was also partial 1 Ibid. 2 Ibid, 3 Ibid., p. 248. INJURIES OF THE SACRUM AND COCCYX. 457 paraplegia* The catheter was introduced and the bladder relieved. The missile was searched for unsuccessfully. Opiates were then administered. He continued to sink and was perfectly unconscious. The pulse was IGO." He died May 15, that is, five days after the wound was inflicted.* The cause of death is not stated, but, judging from the symptoms as de- tailed above, it was traumatic peritonitis. At any rate, peritoneal inflam- mation must be a frequent consequence of shot wounds such as this. This case is doubly interesting because of the paralysis of the bladder and lower extremities which resulted from the injuries sustained by the sacral nerves. The following example is very instructive, as well as interesting, because of the peculiar form of paralysis, and the haematuria, which resulted from the primary lesion : — Private Peter K., aged 32, having been wounded at the South Side Railroad, on April 1, 1865, was sent to Washington, and admitted to Douglas Hospital on the 6th. A conoidal musket-ball had entered the left buttock nearly on a level with the second vertebra of the sacrum, about four inches from the spinous process thereof, had passed through or across the sacral portion of the spinal canal, and had lodged in the right wing of the sacrum, near its junction with the ilium. There was complete paralysis of the bladder and rectum, with constant hoematuria; but no paralysis of the lower extremities. On the 8th, the patient failed rapidly, and became partially insensible. He died on tiie 9th, from exhaustion, eight days after the casualty occurred.^ The specimen is repre^ sented by the accompanying wood-cut (Fig. 891). The vesico-rectal paralysis observed in this case is easily accounted for ; but what caused the haematuria? Did it arise from a neuropathic congestion of the kidneys, such as we have seen occurs not unfrequently in cases of spinal injury ? Showing the sacrum with a ball impacted at the left Showing a shot fracturp of the sacrum, second intervertebral notch. (Spec. 2542, A. M, M.) (Spec. 3001, A. M. M,) In the next case there was a complete transverse fracture observed : — Private P. McC, aged 20, was wounded at Carrion Crow Bayou, La., November i>, 1863. He was treated on the field until the 8th, when he was admitted to Univer- sity Hospital, New Orleans, where he died on the 22d, nineteen days after the infliction of the wound. The case is described as a gunshot fracture of the sacrum ; " the missile, passing obliquely from the left, entered near the median line at the junction of the second and third sacral vertebras, and escaped into the pelvis tlirough the right portion of the second vertebra. The sacrum was completely fractured transversely at that point." The specimen is represented by the accompanying wood-cut (Fig. 892).^ In the following example, traumatic spinal meningitis with tetanic spasms occurred : — Private W. M. R., aged 22, was wounded at Winchester, July 20, 1864, by a conoidal musket-ball, which penetrated the sacral region five inches above the anus, and one I Ibid. ' Ibid. ' Ibid., p. 249, 458 INJURIES OF THE BACK. inch to the left of the median line, passed obliquely upward and forward, and lodged. There was retention of urine, but no paralysis of sensation or voluntary motion. On the 25th he was very restless, and suffered great agony from the wound. But little change was noted until August 6, when slight tetanic spasms, with delirium and un- consciousness, occurred. They continued with increasing severity. On the 8th, opisthotonic spasms recurred at frequent intervals, the pupils were largely dilated and fixed, and he died on that day. Autopsy — The missile was found about three inches from the point of entrance, embedded in muscular tissue. The spinal column was in a suppurating condition. The osteological specimen, represented by Fig. 893, was sent to the Army Medical Museum. It consists of a wedge-shaped portion of the sacrum, showing a fracture into the spinal canal at the second sacral vertebra, with the first and second spinous processes wanting from being broken off.^ Fig. 893. Fig. 894. Showing a shot penetration of the sacral canal. (Spec. Showing the sacrum and a part of the right iliam, 4258, A. M. M.J with the bullet which perforated the former. (Spec, 1245, A. M. M.) This case, in whicli the upper part of the sacral canal was opened hy a gun- shot missile, is a very important one, becalise traumatic spinal meningitis ensued. The symptoms appeared on the fifth day, and were extreme rest- lessness, and "great agony" from pain in the wound, followed hy tetanic spasms, which steadily "increased in severity until opisthotonos followed, with delirium, unconsciousness, and death. The autoj^sy revealed a suppurating condition of the spinal canal. Another instance of shot-fracture of the sacrum in which death resulted from spinal meningitis and myelitis, is likewise re- ported in the same volume, on page 248. (Case 726.) ^'^'The lower part of the spinal cord was softened, and of a dark appearance." In this case, too, the missile after striking the sacrum lodged. The very interesting specimen w^hich is represented by Fig. 894, was obtained at the autopsy of a soldier, aged 26, who was wounded by a conoidal musket-ball at Chancellorsville, May 3, 1863, and died at Douglas Hospital nineteen days afterward, apparently from septicaemia. The case is also remarkable for the absence of peritonitis and paralysis.^ In the next example the missile lodged in the spinal canal, and, notwith- standing that the Cauda equina was compressed hy it (through the meninges), the sensibility and motility of the lower extremities were not affected : — Private Michael H. was wounded June 27, 1862, at Gaines's Mills, Virginia, and died of exhaustion on December 27. The wound closed, and there were no symptoms i Ibid. 8 Ibido INJURIES OF THE SACRUM AND COCCYX. 459 for about three months. On October 20, after dissipation, lie complained of pain in the left knee, at times very intense, depriving him of rest. The wound reopened and dis- charged freely ; a slough formed over the lower part of the sacrum, tliree or four inches in diameter, and so deep as to lay the bone bare. A lumbar and psoas abscess developed itself ; the pain in the left knee increased greatly, and the left leg be- came swollen and tender to pressure. The abscess in the loin was opened by a valvular incision, and three pints of pus were discharged, with great relief to the pain in the leg, etc. Both legs became swollen about December 20, and he died as stated above, exactly six months after the occurrence of the casualty. At no time was there any paralysis of motion or sensation in the lower extremities or elsewhere. Necroscopy — An immense abscess extending from the left kidney to Poupart's ligament was found. In the pelvis, in contact with the sacrum, there was another abcess, while the tissues of the pelvis, at its back part, were buried in effusions of plastic matter. The ball was found lodged in the spinal canal, opposite the fifth lumbar vertebra, as shown in the accompanying w^ood-cut (Fig. 895). It had en- tered on the right side of the spinal ridge of the sacrum, about its middle, passed diagonally upward, and spent its force on the left wall of the canal of the first sacral and fifth lumbar vertebrte. The left lamina of the first sacral bone was carried away. The missile had passed up the spinal canal outside of the theca verte- bralis. The bodies of the fourth and fifth lumbar vertebrae were ca- rious, and the intervertebral cartilage between them was entirely destroyed. The first and second sacral vertebrae were necrosed and discolored, as was also the fifth throughout its thickness. The first and second left sacral nerves seemed most involved by the diseased bones, but the left lumbar plexus was entangled in the diseased mass which occupied the basin of tlie pelvis.^ Showing the sacrum and last three lumbar vertebrae, with a ball lodged in the spinal canal opposite the fifth lumbar vertebra. (Sp. 1198, A. M. M.) The^ complete closure of the wound, and the development of caries and necrosis in the bony structures which had sustained the shock or impact of the missile, after the lapse of three months, are worthy of special remark in this place, as well as the fact that no paralysis whatever occurred. Frorn the foregoing, it appears that the chief risks which were encountered in treating' shot fractures of the sacrum during our civil war, were the super- vention of (1) pymnia or septiccemia, (2) tmumatic spinal meningitis and mye- litis^ {^)p>eritonitis^ and {^) caries and necrosis oi the injured bones, with the formation of corresponding abscesses in the pelvis, as well as in the sacral and lumbar regions. Treatment. — When the missile lodges, in cases of shot-fracture of the sacrum, it should, if possible, always be extracted. One case has already been related in which this was done with an excellent result. I shall now present two additional cases in which important operations wqvq performed to the same end, with good effect. Surgeon J. J. Chisolm relates^ the case of a young Confederate soldier belonsing to the 26th Alabama Regiment, who was shot in the back. The missile passed througli the sacrum an inch from its spinous processes, and one inch below the level of the crest of the ilium, and lodged. Eight months after the reception of the wound, he applied to Dr. G. for relief, inasmuch as he had a constant discharge of pus from both the wound in the back and a fistulous passage in the left groin. Upon examination with a probe, which penetrated four inches, traversing the sacrum, the foreign body was detected, the bulb of the probe entering the cup of the minie ball. By enlarging the hole through the sacrum with a gouge, room was obtained to draw the ball from the pelvic cavity. The patient recovered. 1 Ibid., First Surgical Vol., p. 449. 2 Manual of Military Surgery, 1863, p. 356. 460 INJURIES OF THE BACK. In the following instance a trephine was applied for the same purpose : — Private H. F. Norcross, aged 20, was wounded in the right gluteal region, at Drury's Bluff, May 16, 1864. The track of the ball was traced to the second segment of the sacrum, and the missile was apparently embedded deeply in the bone. On March 9, 1865, Dr. E. B. Lyon reported that " there was an open sinus on the right buttock communicating with the lodgment of the ball in the sacrum, and discharging freely. The constitutional condition was comparatively good. Ether was administered, and an oblique incision, six inches in length, was made, exposing the orifice in the sacrum. A trephine was then used to enlarge the orifice in the bone. The ball was divided and removed in seventeen parts. Simple dressings were applied." The wound healed kindly. On July 10, he was discharged from the service and pensioned. In Septem- ber, 1873, he was still on the pension hst, his disability being rated at one-half.^ For the removal of injured or diseased bone, or for the extraction of im- pacted projectiles, there were in all twenty-five operations performed during our civil w^ar, in cases of shot fracture of the sacrum. In one instance, where the missile was discovered " firmly embedded in the body of the sacrum, beyond the reach of forceps, it was extracted by means of a common ramrod, a piece of which remains in the bullet as when taken out." The spe- cimen is represented by the accompanying wood-cut (Fig. 896). It is pre- served in the Army Medical Museum.^ Fig. 896. Showing a conoidal ball which was extracted from the sacrum with a ramrod. (Spec. 1123, A. M. M.) The most important points in the treatment of shot fractures of the sacrum are the following : (1) The removal of all foreign bodies, under which term all loose fragments of bone, all pieces of clothing and accoutrements, etc., as well as the missiles themselves, are included ; (2) the application of antisep- tic dressings to the wounds ; and (3), the early and thorough use of Chassaig- nac's drainage-tubes. By antisepsis and prompt drainage of the wounds the risk of pyaemia and septicaemia will be greatly lessened._ Any tendency to peritonitis or to inflammation of the spinal membranes, which may be evinced, must be combated by administering opium or morphia in full doses at short intervals. Should spinal meningitis supervene, it will require the exhibition of ergot and potassium iodide in full doses, as already pointed out. Simple Fractures of the Coccyx. — In the years 1859 and 1860, 1 made the surgical examination of an old pensioner from the war with Great Britain, of 1812-15, whose disability had resulted from simple fracture of the os coccygis caused by the kick of a horse, and found that bone bent strongly forward and to one side, and rigid in that position. He stated that his injury ^yas still the source of almost constant discomfort, that it always interfered with the act of defecation, and sometimes made it painful, and that it still made it impossible, most of the time, for him to sit while working at his trade of saddler and harness-maker. , Professor Ash hurst' mentions a case taken from the records of the Pennsylvania Hospital, in which there was fracture of the coccyx, as well as comminuted fracture of 1 Medical and Surgical History of the War of the Rebellion, Second Surgical Vol., p. 251. 2 Ibid. ^ Op. cit.,pp. 116, 117. I>^JURIES OF THE SACRUM AND COCCYX. 461 tlie lumbar vertebrae and fractures of both legs, caused by falling from the sixth story. Death ensued in one day. The autopsy showed that the cause of death was internal (post-peritoneal) hemorrhage and exhaustion. Professor Agnew' states that he has known a case in which this accident resulted ^rom a rider's coming down upon the back of the saddle in an attempt to mount a res- tive horse. Mr. South'^ says he has known two cases where this accident was not recovered from for nearly two years: " The one followed sitting down suddenly on the edge of a snuff- box, whicli was jammed in between the side of the coccyx and the spine of the haunch bone ; and the other by the patient having been thrown from a horse upon a heap of stones. In these cases the pain was not so great as usually said to be in walking, because the patients learned to walk without disturbing the bone ; but the pain was agonizing when they incautiously sat down on a soft seat. Leeching afforded only temporary relief; and the cure was at last effected, after months, by protecting the coccyx from all possibility of pressure, by constantly wearing a pair of very thick oblong pads on the ischial tuberosities, so that in sitting the point of the coccyx was in a deep pit." Simple fractures of the coccyx are said sometimes to occur during parturi- tion, in consequence of the pressure exerted by the foetal head while passing through the inferior strait of the pelvis ; but it is probable that such cases often consist of luxation, or rupture of the coccygeal ligaments, instead of fracture. This accident is of infrequent occurrence. It may be caused by kicks, by blows, by falls, and by injuries sustained during parturition. Though seem- ingly a very trivial accident, it is often exceedingly painful and annoying for many months or years, or even for a lifetime. The displacement in fracture of the coccyx is forward, and it is produced by the same agencies as those which cause the deformity in simple fracture of the sacrum, namely, the contractions of the muscles which are inserted into the coccyx, as well as the general direction of the fracturing force. Treatment — Although the injury at first sight may appear inconsiderable, the victims of this accident, for reasons presented above, should always be confined to bed, in that posture which is least painful, and which causes least disturbance of the injured bone. Any forward displacement should be cor- rected by inserting a finger, well oiled, into the rectum, and pressing the bone back into its normal position. If the deformity returns, it may become advisable to employ such tampons as have been described while discussing fractures of the sacrum. Should much inflammation supervene in the in- jured part, the application of leeches, followed by a lotion composed of lead- water and laudanum, will prove useful in subduing the inflammatory action, and in diminishing the liability to the occurrence of neuralgia, necrosis, abscess, and fistula. Should, however, the ligamentous tissue surrounding the bone continue inflamed and painful, notwithstanding the treatment, and especially should the apex of the injured bone be incessantly dragged forward by spasmodic action of the sphincter ani and other muscles which are inserted into the os coccygis, it may be proper to forcibly stretch the sphincter, under ether, as in cases of anal fissure, so that the fibres of that muscle may be paralyzed for a time, and that defecation may take place without spasm and without restraint. After such patients leave their beds, it will often be use- ful for them to protect the coccyx from injury by constantly wearing a pair of thick oblong pads on the tuberosities of the ischium, as recommended by Mr. South. 1 Op. cit., vol. i. p. 923. * Notes to Chelius's Surgery, vol. i. pp. 595, 596, Am. ed. 462 INJURIES OF THE BACK. Fig. 897. Gunshot Fractures of the Coccyx. — In shot wounds of this sort, the lesion of the bone is commonly but a small part of the whole injury. There were seventeen cases of shot fracture of the os coccygis reported during our civil war, of which six, or 35.3 per cent., were fatal. In twelve cases, with five deaths, the coccyx was the only bone involved ; in four cases, terminating favorably, there were attendant fractures of the sacrum ; two, one of which was fatal, were associated with fractures of the pubis. In one case a ball is said to have been found imbedded in the coccyx. In all the fatal cases, death a]3pears to have resulted from the injuries sustained by other parts. Still, visceral lesions were less frequently present as complications of shot fractures of this bone, than would be anticipated from its anatomical relations.^ In regard to treatment, the irregularity and variety of the complications preclude the establishment of any special rules. The early removal of sequestra and foreign bodies is, of course, indispensable. Free though cau- tiously directed incisions may -be requisite to prevent the burrowing of pus. Extreme attention to cleanliness, and to the prevention of fecal accumulation in the rectum, as well as watchfulness over the state of the bladder, are precautions that must not be overlooked.^ The wounds must be dressed antiseptically, and drainage tubes must likewise be inserted, in many cases, in order to insure that no confinement of inflammatory products shall take place. CoccYaoDYNiA. — The damage sustained by the sacro-coccygeal and other spinal nerves, in connection with injuries of the os coccygis, often gives rise to an exceedingly painful state of the soft parts overlying the bone, which has been denominated coccygodynia. The accompanying wood-cut (Fig. 897), which indicates the numerous nerves of sensation that are distri- buted over the coccyx, and to the lower part of the rectum as well as to the margin of the anal aperture, shows at a glance the anatomical and physiological explanation of this dis- tressing affection. For the relief of coccygodynia, it was advised by the late Sir James Y. Simpson, to introduce a narrow bis- toury between the soft parts and the bone, and completely sever the con- nections between them. Should this simple procedure fail, and the symp- toms continue severe, it may be neces- sary to excise the bone itself When a, Sacrum, b, Coccyx, c, Tuberosity of ischium. CarlcS Or llCCrOsis is prCSCUt, CXcisioil d, Greater sacro-sciatic ligament, e, Lesser sacro-sci- ^^f -j-J^^ boUC is alwayS UCCCSSary. atic ligament, with pudic nerve on its posterior aspect. j . OpCrativC prOCCdurCS, /, Sphincter am. ^, Levator am. 7i, Fatty and con- ^^i?*^ i t ' nective tissue. Van Onscuoort and 01 her have extir- 1, Pudic nerve and its branches. patcd thc coccyx for caries, and i^ott, 2, Posterior branches of the 2d, 3d and 4th sacral gji^pgoi, ^y^^ ^laUV OthcrS haVC pCr- nerves proceeding to posterior aspect of the coccyx. n i " j.' • ^.X^ ' .3, Sacro-coccygealnerve distributed over apex of the lOrmed thC SaUlC OpCratlOU With im- coccyx and adjacent soft parts. (Hilton.) pUllity for nCUralgla (cOCCygodyuia). 1 Medical and Surgical History of the W&r of tlie Rebellion, Second Surgical Vol., pp. 252, 253. 2 Ibid., 253, 254. KEMOTE EFFECTS OF SPINAL INJURIES. 463 Dr. James E. Garretson^ has proposed and successfiillj performed the operation of removing the coccyx without disturbing the perinoid anatomy, by the employment of a dental engine. This operation was done at l^eini Manor, on the person ot a lady who had suffered from coccygodynia for thirteen years. Exposure of the coccyx revealed it as fractured and stand- ing at right angles with the sacrum. Dr. Garretson's proposition was to remove the bone by simple enucleation ; in other words, to remove the osseous tissue from its envelope of periosteum without disturbing the under layer thereof which is the surface of attachment for the soft parts constitutinii; the posterior perineum, and, of course, without disturbing the relations of the structures which constitute the perineum itself. The operation was performed in the following manner : — The patient being etherized and placed partially upon her abdomen, an arm being under the body at the region of the diaphragm, to secure freedom in respiration, an incision was made through the skin and superiicial fascia, the length of tlie coccyx. These tissues being carried to either side by means of retractors, a second incision was made through the periosteum, and by means of a chisel-sliaped knife this structure was raised and everted. In this last is the peculiarity of tlie operation : it is as though one might cut down the centre of the upper surface of an envelope, exposing, in the turn- ing aside of the paper, a letter lying on the lower face of the envelope, the turned- aside upper part being of continuity with the bottom of the paper. A succeeding step employs the engine. A circular burr, the face side alone of which is cut, is placed in the grasp of the handpiece, and while in revolution to the extent of ten thousand times to the minute, is applied, with delicacy of manipulative touch, to the surface of the bone. In the case here recorded, live minutes sufficed for the disappearance of the coccyx in the shape of bone dust, the under face of the periosteum remaining as undis- turbed as though it had never been in relation with the coccyx. The wound, a super- ficial one, was put up to heal by first intention. I believe this operation to be a very good one, and therefore I have taken the space requisite to describe it. Remote Effects of Spinal Injuries, Railway Spine, etc. When fractures or dislocations of the spinal column eventuate in recovery, there occurs, as a rule, anchylosis, with immobility or inflexibility of the injured part of the column. Any vertebral displacement which may have been allowed to remain will constitute a deformity. Among the remote effects of spinal fractures and dislocations, anchylosis, stiffness or inflexi- hility, and deformity must therefore be enumerated. In cases Avhere the cer- vical portion of the column has been thus injured, the inflexibility and defor- mity may cause much inconvenience in many ways, and may also interfere, seriously and persistently, with the act of swallowing. These points are well illustrated by the following case : — George Reid, aged 29, a tailor, was admitted into Bellevue Hospital (Dr. Stephen Smith's Ward) on August 5, 1858, for cephalalgia, the result of an injury. He was short in stature, but well made and well nourished, and free from constitutional taint and tendency. Upon external examination, the fifth cervical vertebra, its spinous process, etc., were found displaced fbrward ; upon examination througli the mouth, the body of this ver- tebra was felt projecting forward, and forming a large prominence in the pharynx. He was unable to swallow solid food to any considerable extent. This dysphagia and the necessarily awkward position in which he was forced to carry his head were the only 1, Annals of Anatomy and Surgery, March, 1882. 464 INJURIES OF THE BACK. local difficulties now present, which resulted from the vertebral displacement. The vertebrae themselves were firmly fixed in their new position. His general health was ^^^History In September, 1856, the patient fell backward down fifteen stairs, and struck upon the back of his head and neck. He was rendered insensible, and remained so for three hours. He has never been able to recollect anything in regard to his fall, his memory otherwise being unimpaired. There was no wound nor contusion, nor any other external evidence of injury upon his neck. With returning consciousness he did not become aware of his injury until he attempted to rise from the bed. He then felt an acute, spasmodic pain in the back of his neck, which subsided immediately on lying down ao-ain. This pain in the back of his neck, on motion, continued three months. Tliree weeks subsequent to the accident, he began to have severe pain in the back of his head— usually nocturnal— and at that time was admitted to this hospital in the service of Dr. Charles D. Smith. Excepting the pains just mentioned, and dysphagia, he has not had any subjective symptoms of spinal injury. There have been no anaes- thesia, no paralysis, no difficulty in breathing, micturating, or defecating, and no in- crease of temperature. . i • j. His general health being good, he was discharged as affiardmg no particular indica- tion for treatment.^ The " awkward position" mentioned above in which the patient was com- pelled to carry his head is not described in words, but it was doubtless the following : Inasmuch as the original lesion of the spinal column consisted m a forward dislocation of the body of the fifth cervical vertebra upon that of the sixth, there occurred in consequence of the action of the muscles directly or indirectly involved, together with the superimposed weight of the head, a forward bend in the spinal column ^t the place of injury, which widely sepa- rated the spinous process of the fifth cervical vertebra from that of the sixth, and likewise caused the neck and head to present a " thrust-forward" appear- ance, as well as to acquire a " thrust-forward" position. It certainly must have been very awkward for the patient to carry his head always m that manner. And had the deformity been removed at the outset by reducing the dislocation, it would have been much better for the patient, because by so doins: his difficulty in swallowing would have been obviated, and his head would have been placed in a much more comfortable position. The pain in the back part of this patient's neck and head which followed the accident, and still persisted two years afterward in a troublesome or dis- tressful degree, was probably due to meningeal irritation, or a low grade ot meningeal inflammation, which itself resulted from the fact that the disloca- tion was not reduced, and that the theca vertebralis was consequently stretched and irritated by the injured vertebrse in their abnormal positions. Thus it appears that pains arising from meningeal irritation and inflammation (both spinal and cerebral) must also be enumerated among the remote etiects ot vertebral fractures and dislocations. Moreover, much difiiculty will otten be experienced in controlling this meningeal disorder, unless perchance the causal indication in its treatment has previously been fulfilled, by " setting the fractured or dislocated vertebrae, and thus removing the displacement upon which its existence mainly depends. The remedial measures to be employed in such cases are dry cupping and setons, together with the administration ot potassium iodide in fulf doses, alternated with corrosive sublimate, for a long Among the remote eflTects of sprains, wrenches, and twists of the sphial column are chronic ivflammation of the vertebral joints that are implicated, which is often suppurative in character, destruction of the articular cartilages and the intervertebral substances that are involved, and canes or 7iecrosis ot I New York Journal of Medicine, March, 1859, p. 246. REMOTE EFFECTS OF SPINAL INJURIES. 46^ the adjoining vertebral bodies. In such cases, tlie destructive process begins more frequently at the junction of the vertebrae with the intervertebral sub- stances than in the intervertebral substances or vertebrae themselves, because, as Mr. Hilton has pointed out, we know that in accidents, at least as far as we have been able to discover, " the most frequent lesion in injury to the spine is a partial severance of the vertebra from the intervertebral substance."^ A number of illustrative examples have already been presented,^ and inasmuch as this topic has already been pretty thoroughly discussed, no apparent need exists for presenting any additional instances of the same sort. I will, however, take space to present a very instructive case, in which there simultaneously occurred lurabo-sacral abscess and suppurative spinal menin- gitis, ii^ consequence of a blow on the spinal column : — A lad, aged 15, employed with his parents in a travelling show, was in good health until May 12, 1856, when, while playing with another lad, he received a blow on the back with the fist. He thought little of' it at the time ; but, subsequendy, the pain becoming severe, he applied for and obtained admission into Guy's Hospital on May 15. After the application of leeches he was so much relieved that he thought of going out, but the pain soon returned more severely, and fever ensued. An abscess formed on tlie right side of the sacrum, which was opened, and continued to discharge, tlie flow of pus being increased by pressure on the abdomen. He continued to get worse daily, having much irritative fever and severe pain in the back. During the last week of his life he was exceedingly restless, and often delirious ; and he complained of pain in all parts of his body, but particularly in the extremities. His head was generally drawn backward as in tetanic opisthotonos. On one or two occasions he had loss of power over the bladder and rectum, but had no other symptoms of paraplegia, and could move freely in bed. On June 4 he died, twenty-two days after the casualty, and nineteen days after entering the hospital. Autopsy — An aperture in the integuments at the right side of the sacrum led into a very extensive abscess, external to the peritoneum, which occupied the forepart of the sacrum behind the rectum, and extended to the ilia on both sides behind tiie psoas muscles. The bones were exposed but not diseased. Although the abscess had dis- charged externally on the right, it was most extensive on the left. It had burrowed up to the left side of the last lumbar vertebra, and through the sacro-vertebral foramen into the spinal canal. When the theca was opened, it was found to contain a quantity of greenish pus, spread over its inner surface and over the cord itself. The spinal dura mater (theca) at the point indicated, was softened and destroyed, and the cauda equina was lying bathed in the pus which filled the sacral canal. The membranes of the cord were inflamed throughout their whole extent, and there was purulent eflTusion as high as the dorsal region. The spinal dura mater was thickened, its inner surface had lost its smoothness and transparency, and was of a dull-green color. Pus could be squeezed out from beneath the visceral arachnoid in considerable quantity. The spinal cord itself was firm, and the microscope revealed no morbid condition in its substance. On opening the cranium, traces of acute arachnitis were found over the whole surface of the brain, greenish-colored lymph being effused into the sub-arachnoid tissue, especially at the base. The inner surface of the dura mater, around the foramen magnum and on the adjacent part of the occipital fossa, was of a greenish color, from lymph effused upon it. Bronchial tubes filled with tenacious mucus. Lumbar and bronchial glands slightly enlarged. All other organs entirely healthy.^ The purulent infiltration of the spinal meninges w^hich was observed in this case, occurring coincidently with the formation of a lumbo-sacral abscess, but without the production of paralysis, could scarcely have happened unless the sacro-vertebral articulation had previously been opened, both externally and internally, by disease of the articulation itself, in such a manner as to allow the products of inflammatory action to flow freely out of, as well as 1 Op. cit., pp. 47, 48. 2 See pp. 280-303 supra. 3 Guy's Hospital Reports, 1856, pp. 158, 159. VOL. IV. — 30 466 INJURIES OF THE BACK. into, the spinal canal. Otherwise, the suppurative meningitis would pretty certainly have caused paralysis by compressing the spinal cord with the in- fiammatory products. The clinical history of this lad's case, interpreted by the post-mortem ap- pearances, appeai-s to have been as follows : The blow on his back wrenched the sacro-vertebral articulation, and caused a suppurative inflammation to be lighted up therein, particularly on the left side, and in consequence of this, purulent matter escaped in an outward direction, and led to the forma- tion of an immense lumbo-sacral abscess ; it likewise escaped in an inward direction, and caused the theca vertebralis to become softened and perforated, and extensively destroyed, and a diffuse suppurative inflammation, which extended upward to the brain, to be kindled in the spinal arachnoid. More- over, the account of the case presented above gives the symptoms by which each of these periods, or stages, in the progress of the case was characterized. The symptoms indicative of the joint inflammation were pain in and sore- ness of the joint itself, and these were to some extent relieved by leeching. The Fig. 898. Showing the lower part of the spinal cord, and the distribution in the trunk of the corresponding spinal nerves. (Swan.) a, The spinal cord, h, The posterior branches of the spinal nerves, proceeding to the muscles and integu- ments of tlie loins, etc. c, The radiating lines indicate the anterior branches of certain dorsal nerves which are distributed to the muscles and integuments of the upper half of the abdominal walls, d, The anterior branches of the lumbar nerves which are distributed to the lower part of the abdominal walls, ee, Anterior part of the abdominal walls. /, The rectus abdominis muscle, p-, The obturator nerve. 7t, The diaphragm. (Hilton.) formation of the lumbo-sacral abscess was attended by a return of the joint- pain, followed by pyrexia, and by the appearance of a swelling which, on being opened, discharged purulent matter. The spinal meningitis set in with severe pahi in the spinal column, and irritative fever, followed by extreme REMOTE EFFECTS OF SPINAL INJURIES. 467 restlessness and general bypersesthesia of a severe character. Tetanic spasms and opisthotonos ensued. The remote effects of spinal injuries a^-e to be still further traced in the occurrence of chronic spinal arachnitis of a fatal character, without the super- vention of any vertebral joint inflammation whatever. Sir W. Gull has recorded the following instructive case of traumatic, chronic, spinal arachnitis : — ^ A railway porter, aged 22, strong and muscular, had his neck and shoulders squeezed between the buffers of two carriages, on September 20, 1855. For three or tour weeks afterward, he was unable to work, and felt much pain in the right arm, as also in the scapular region and down the back, especially between the seventh and tenth dorsal vertebra?. The pain was increased by any sudden twist of the body, and extended to the abdomen. About the first of February, 1856, he was again obliged to quit work, on account of the severity of the pain along the spine. On Feb. 6, he was admitted to the hospital under Dr. Addison's care. There were pain on pressure over the lower d©rsal vertebne, pain in the abdomen, and occasional tingling in the hands and feet. The abdomen itself was full and hard, with pain on suddenly turning the back, extend- ing from the ribs below the umbilicus. Nothing abnormal was found in the chest; pulse 78 ; tongue furred in the centre; bowels regular; appetite defective. He was treated by cupping, mercurials, and laxatives. On the 11th, the pain in the back w^as increased He also had headache, and his nights were restless and disturbed by dreams. The shooting pain in the abdomen continued, and it was noted that the integuments were remarkably hot and dry. The pulse was 72, with a noticeable sharp- ness in the beat. From this date he became slightly affected by mercurial action, and was apparently improving. He left his bed for several hours in the day, without incon- venience ; still, however, complaining of his former symptoms, and of pain through the chest. On the 28th he had general febrile symptoms, with cough, and hurried breathing, and signs of pleurisy at the base of left lung. The abdomen was tense ; constipation ; pulse 112 ; sleep disturbed by dreams, and by frequent spasmodic twitch- ings of the extremities. He complained very much of pain in the lumbar region, on each side of the vertebral column, and down the sacrum. On March 11, there was retention of urine. On the 13th, slight delirium, and a marked decline of strength. He was scarcely able to move his legs, but the sensation on pinching was acute. He lay supine, sinking to the foot of the bed, his arms being too weak to help him to sup- port himself From this date he rapidly became worse, with much cerebral oppression. The urine drawn off daily by the catheter w^as ammoniacal, with large deposit of phos- phates The feces escaped involuntarily. Frequent convulsive twitchings, both of the upper and lower extremities. Breathing hurried and laborious. Tongue dry and brown. Pulse 108 On the day before death, he lay nearly insensible, frequently moaning and sighing, pulse 90, feeble and irregular; urine copious, and drawm off by catheter, feces passed involuntarily. On the 17th he died, about six months after the accident Autopsy. — No injury of the vertebrce or ribs was discovered ; spinal canal and exter- nal surface of the spinal dura mater healthy. On opening the dura mater, the spinal arachnoid appeared remarkably thickened and flocculent, from the effusion of lymph beneath it. The effusion was greatest on the posterior surface of the cord along the me- dian line, but at the lower part of the cord (a segment of it corresponding to the lower cervical and eighth upper dorsal vertebra3 only was allowed by the friends to be exam- ined), the effusion extended around it to the anterior surface, and upward for a short distance. The cord itself was not softened ; and, on repeated microscopical examination of the cord-substance, at different sections, no traces of exudation were discovered. The theca vertebralis had undergone no alteration, excepting that the inner layer was rather opalescent. One or two very small fibroid plates on the visceral arachnoid. The fiocculent effusion covering the cord (that is, found in the meshes of the pia mater), presented under the microscope the usual appearances of inflammatory exudation on serous surfaces in the stage of organization into permanent adhesions. Examination Guy's Hospital Reports, 1856, pp 156, 157. 468 INJURIES OF THE BACK. of head not allowed. Old adhesions over the surface of the upper lobes of both lungs. At lower part of left chest, about a cupful of purulent fluid was found. Parenchyma of both lungs stuffed with softish, yellow, miliary tubercles, equally diffused from apex to base. Kidneys large ; their cortical portion studded with miliary tubercles. The splenic tissue similarly affected. Heart and liver healthy. The phenomena of subacute, traumatic, spinal meningitis, when it runs a chronic course to a* fatal termination, are well shown by this case. The symptoms characteristic of the disease were pain in the affected part of the spinal column, increased by suddenly twisting or bending it ; also pain felt in the peripheral extremities of all the spinal nerves issuing from the affected part of the spinal column, particularly in the abdomen, in the loins, and in the lower extremities. The abdominal pain was attended with hot and dry integuments, and probably, if carefully looked for, oscillations of temperature would have been observed. These peripheral pains arise from the excitation of the sensory filaments of the corresponding spinal nerves by the inflammatory action that is going on, within the spinal canal, in the membranes of the cord adjoining their roots ; for instance, in cases where such peripheral pains are felt at the epigastrium, the sensory filaments of the sixth or seventh dorsal nerves are excited by the inflammatory process in the spinal arachnoid and pia mater mvesting them before they enter the intervertebral foramina. When the sensory filaments of the eighth or ninth dorsal nerves are irritated in this manner, the peripheral pains are felt lower down in the abdominal walls, in the parts thereof which are supplied by the irritated nerve-fibres ; and when the sensory filaments of the remaining dorsal, or of the lumbar nerves, are excited in a similar manner, the peripheral pains are felt still lower down, in the respective terminal extremities of the excited nerve-filaments. ^ Excita- tion (intra-spinal) of the motor filaments of the spinal nerves arising from the same cause, in this case, was denoted " by frequent spasmodic twitchings of the extremities," by the " tense" and " hard" condition of the abdominal muscles which arose from tetanoid (tonic) spasm thereof, and by the per- sistently stiflt' or contracted feeling in the muscles of the extremities, particu- larly the lower ones, which doubtless was present, and would have been re- vealed by asking the patient about it. . t „ -, i The altered sensations of the patient in this case, the " tingling and the " numbness" in his feet and hands, and the acute sensation produced by "pinching" his legs (hypersesthesia) after paraplegia had set in, were due either to inflammatory excitation of the cord-substance by the contiguous membranes, or to compression of the cord-substance by the inflammatory products effused in the meshes of the spinal pia mater. The vesical paralysis, the alkaline urine, the anaesthesia (insensibility) and motor paralysis (or paraplegia) which appeared near his end, were caused by compression of the cord-substance efiected in the way just mentioned. The inflammatory eflPusion was found at the autopsy of this case, as usual, under the so-called visceral layer of the sphial arachnoid alone, that is, m the interstices of the pia mater, but principally on the posterior surface of the cord, to which it had probably settled by gravitation. The exudation itvself did not contain pus-corpuscules, and would have been capable of becoming organized, if it had not caused death by its quantity, and by the compres- sion which it exerted upon the cord substance. The tabercular infiltration of the pulmonary, renal, and splenic tissues, which was revealed by the autopsy, must be held to have probably resulted from the pathological state of the spinal cord-substance. . . But, among the remote eftects of spinal injuries, chronic spinal meningitis, combined with chronic myelitis, and running their joint course pari passu, REMOTE EFFECTS OF SPINAL INJURIES. 4(39 must likewise be mentioned. The following example will serve to illustrate the phenomena of traumatic spmal meningitis and myelitis, when they are subacute, and run a chronic course together to a fatal ending. Sir W. GulP relates the case of a coal wagoner, aged 49, w'no was forced backward from his seat by striking his head against a beam, whilst driving under an archway i several ribs on the left side were fractured. Some montlis afterward, he began to sulfer pain extending from the occiput down over the shoulders ; and, in about a year, the muscles of tiie upper extremities began to waste. After two years, incontineixce of urine gradually came on. He was admitted to Guy's Hospital, February 11, IH;)?, three years after the accident. He then presented a remarkable example of muscular atrophy without actual paralysis. The upper extremities were princi{)ally affected. The extensors of the right hand, the muscles of the thumb, and the interossei were extremely wasted. The wTist dropped. The muscles of the shoulder and arm, including the pectoralis major and minor, were much w^asted, but in a marked degree less so than those of the forearm and hand. Very slight diminution of sensation. He could still lift the arm over the head. The left arm was similarly, but less affected than the right, as far as regarded muscular atrophy, but there was numbness through the whole arm down to the fingers, and the patient suffered severely from neuralgic pains in it which greatly depressed him, and which he described as a compound of smarting and numbness. The trapezii, serrati postici superiores, rhomboidei, and all the long mus- cles of the neck and backj were remarkably atrophied. The spinous processes were very prominent. No deformity nor tenderness on pressure at any point. Theintercos- tals were so weak that the only respiratory movement was through the diaphragm. The supra-spinati were atrophied, but not to the same extent as the infra-spinati and the levatores angulorum scapularnm. The legs were wasted and weak, but he was able to walk. Sphincter weak. Dribbling of urine. Constipation. The thorax looked narrow and ill-developed from the w^asting of the pectorals, the mtercostals, and the erectores spinae muscles. The muscles of the back of the neck, and the sterno-mastoids, were so weak that the head could not be supported erect. Sight dim ; drooping of left eyelid. Frequent hiccough for many months. After admission, his principal complaint w^as of pain in the left arm from the clavicle to the fingers- He described it as a severe smarting with a sense of numbness. His distress from this cause was very great. Early in March, febrile symptoms set in ; tongue became dry and brown ; frequent hiccough and vomiting; pain in left arm severe. On March 25th, he died, more than three years after the accident Autopsy. — The cranial arachnoid was opalescent, with spots of white, from fatty degeneration, mottling the more opaque parts ; subarachnoid fluid in excess ; ependyma of lateral and fourth ventricles granular, in the latter extremely so. The spinal dura mater was much thickened on the posterior surface of the cord ; the arachnoid adhered to it in patches along this surface, and was much thickened by the effusion of lymph of an old date. Sections of the cord, examined with the naked eye, gave no distinct evidence of disease There was a slight yellowishness of the posterior columns, with increased vascularity and thickening of the pia mater covering them. In these columns, but especially in the right one, an abundance of granule cells was discovered by the microscope. The exudation was greatest in the middle and lower thirds of the cervical enlargement The gray substance was hyperasmic. No exuda- tion into its tissue, nor into the anterior columns. The ventricle of the cord was Op. cit., p. 172. REMOTE EFFECTS OF SPINAL INJURIES. 483 The symptoms- of sacrodynia often continue for a long time. When once they have fairly set in, they will last for many months, and not unfrequently for a year or two. Moreover, the pain does not follow the anatomical course of any nerve, and, therefore, it cannot be classified with the neuralgias. It appears to arise directly from bruising and spraining of the ligamentous structures. The sacro- vertebral, the ilio-lumbar, the sacro-iliac, and the sacro- ischiatic ligaments may all be more or less strained in the bumps, twists, and wrenches to which the pelvis and lower part of the spine are subjected in the accidents under consideration. And, according as the violence falls more or less directly on one or other of these ligaments, so the patient will suffer more or less in the part where it is situated. (Erichsen.) The long continuance of pain in cases of sacrodynia is exactly what we find in cases where the liga- ments are strained in other parts of the body. (4) yomiting. — It will be remembered by some that about twenty-five years ago Sir W. Gull, in Guy's Hospital Reports, called attention to vomiting as a symptom or effect of hypersemia or inflammatory irritation of the rachi- dian substance in the cervical region, and recorded an example in which the existence of myelitis in the cervical region (caused by a blow on the neck) was proved by post-mortem examination. This case I have used above to illustrate the remote effects of spinal injuries. It will likewise be remem- bered that any slight muscular effort on the part of my own patient who suffered from railway-injury of the spine, and whose case I have so often referred to, always produced nausea, and sometimes caused vomiting, and that these symptoms of cervical myelitis lasted for several months. Mr. Erich- sen,i too, relates a very instructive case in which concussion of the spinal €ord caused by a blow on the nape of the neck received in a railway-collision, and the rachidian inflammation which ensued, were attended by vomiting as a prominent and a very persistent symptom. It is obvious that medication for the relief of this symptom, in such cases, should be directed tow^ards the removal of its cause, namely, the rachidian hypersemia and irritation in the •cervical region, upon which its existence depends. Treatment — Inasmuch as the spinal injuries arising from railway-collisions may be followed by inflammation of the vertebral articulations, inflammation of the spinal membranes — but particularly of the spinal arachnoid and pia mater — and inflammation of the rachidian substance, the first step consists in making, as far as practicable, a differential diagnosis. Almost always, in such cases, spinal meningitis and myelitis will be'found creeping up the cord together into the cranium ; and, not unfrequently, all three disorders will' siniultaneously present themselves. The principles upon which the treatment of each of these inflammatory affections of the spine, whether acute or chronic, should be conducted, have already been laid down, and the several remedial measures which experience has shown to be the most useful in such cases, have already been mentioned ; it does not seem necessary to restate them here.^ One thing, however, I will say, namely : The importance of rest in bed, in these cases, caimot be overestimated. "^Furthermore, insomnia occur- ring per se, that is, without pain, should be overcome by administering the bromides or chloral hydi-ate rathei- than opium or morphia ; but pains m the spinal membranes, lig^aments, or joints must be subdued by exhibiting the last-named drugs. When the morbid process in the rachidian substance has reached the stage of atrophy, the primary galvanic current passed downward through the cord may prove very useful. But whatever the treatment may be, no speedy benefit can, as a rule, be expected. I Op. cit., pp. 216-219. 484 INJURIES OF THE BACK. [Additional Remarks on Railway-Injuries of the Spine. Mr. Gore's case, quoted from Mr. Erichsen, on page 479, lias been much relied upon by surgeons called as expert witnesses for the plamtift, m suits for damages against railway companies, as showing the grave and well-de- lined lesiSns of the spinal cord, which may follow m instances of what is ordinarily called " spinal concussion;" and it has, on the other hand, been subiected to sharp criticism by experts for the defense, m such suits, on the oTound that it stands alone, and that the lesions observed were Pfsibly due to ordinary locomotor ataxia, and not really caused by the accident which preceded their development. It is to be observed, however, as pointed out by Mr. Jacobsoi; in the third edition of the " System ot Surgery, edited by Messrs. Holmes and Hulke, that unmistakable cord-lesions, only recogniza- ble by the microscope, have also been observed in cases ot spmal concus- sion " due to other than railway-injuries. Thus, in the case reported by Dr. Bastian in the 50th volume of the Medico-Chirurgical Transactions, and quoted bv both Jacobson and Page (by the former incorrectly attributed to Dr Gowers), the patient lived nearly six months after falling, while asleep, twenty-live feet from the top of a hay-rick; at the post-mortem examina- tion, the vertebrae were found uninjured, and to the naked eye the spmal cord appeared perfectly healthy. Under the microscope however, ruptures of varyins: size were found in the right and left halves of the grey matter ot the cervical cord, and distinct areas of degeneration in the anterior columns of the cervical, dorsal and lumbar cord, best marked above, feimilar, but less extensive, areas were also found in the left lateral column. Beside the descendino' lesions of the anterior and lateral columns, there was ascending degeneratfon in the posterior columns of the upper cervical cord and "^ms^case is reported by its observer, and accepted by Mr. Jacobson, as one exhibiting tvpical concussion-lesions," but Mr. Page (whose excellent work Iniuries of the Spine and Spinal Cord without apparent Mechanical Lesion," etc., appeared after Dr. Lidell's article had been completed) objects to the term " concussion " as applied to injuries of the spmal cord, and points out that thouo-h Dr. Bastian referred to the case as one of concussion-lesion, such as mio-hf be met with after railway-collisions, no record ot any case at all comparable with it has been published since. Mr. Page maintains, and my own exi )erience disposes me to agree with him, that m certainly the very • laro-e maiority of severe spinal injuries received in railway-collisions or by similar accidents, there is found some tangible lesion, recognizable during life such as a twist or sprain of the vertebral articulations, or a rupture, partial or complete, of the spinal nerves ; and he believes, with Le Gros Clark, that the milder cases, in which recovery often follows after some months or vears, are attributable to general ^' shock to the nervous system rather than to any condition peculiar to the spinal cord I see myselt no obiection to the term spinal concussion," and believe that the spinal cord may as the result of severe shaking and knocking about, as well as trom falls 'or other forms of diffused violence, be the seat of such lesions .as are acknowledged to be i)resent in the brain in cases of cerebral concussion- slight and qui(;kly recovered from in most instances, but under other cir- cumstances more severe, and followed by inflammatory or degenerative changes which may cause prolonged disability or even death. At the same time there can be no doubt that in many cases of so-called railway-spme, the condition is a general one, affecting the whole nervous system, and more REMOTE EFFECTS OF SPIxXAL INJURIES. 485 analogous to certain examples of Avhat, for \\'ant of a better name, we call hysteria, than to any local aftectiom The suffering in these cases maybe really quite as severe as in more dangerous conditions, and tliough the prog- nosis may be more favorable, the patient's disability is, for the time at least, indisputable. " It is all very well to say," remarks Mr. Page—" and it is an easy enough diagnosis to make— that so-and-so, who recovered as soon as his claim was settled, was ' shamming,' and that his sym[)toms were altogether untrue or wilfully exaggerated •^'"but this will hardly sufK.ce, nor can we accept It, to explain the symptoms which have caused so nnrch anxiety and trouble, and have been so little amenable to treatment. The man recovers quickly because the goal, whose prospect unsettled him, has at leno;th been reached, and because it no longer stands in the way of his making tlie requisite and successful effort to resume his work." Mr. Page refers to some interesting cases reported by Mr. Bruce-Clarke in the sixteenth volume of St. Bartholomew's nosi)ital Reports, which show that not only do well-marked changes in the optic disc often accompany injuries in the upper part of the spinal cord, but that, in cases which end in recovery, these changes— hypersemia and oedema— may be only transient ; and the inference is therefore reasonable that similar changes may exist at some period in many cases of minor spinal injury, and are not detected sim- ply because they are not looked for at the right time. Resection of the Spine. On page 379, reference has been made to the statistics of spinal trephin- ing or resection collected by the Editor. To the 41 cases there mentioned, nine examples of the operation have been recently added bv Stemen (two cases), Pinkerton, Halsted, Macewen, Lucke, Albert, Lauenstein and R. T. Morris, so that the figures now stand as follows : — Whole luiinber of cases .... 50 33 or 6G per cent. 7 " 14 " " 4 c. 8 " " 2 " 4 " " In ^Vfacewen's case, which, with the exception of Lauenstein's, is the only one in which the operation can be said to have been follo^ved bv recoverv, the fracture involved the vertebral laniin«i only, the injury being, therefore, soniewhat analogous to that of Louis's patieiit (see pao:e 379), and the prog- nosis being exceptionally favorable. The following table includes the 50 cases referred to: — Patients died . Patients not benefited Patients relieved Patients recovered . Resnlt unknown 486 injuries of the back. Table of Cases of Resection of the Spinal Column for Injury. No. Result. Operator's name. 1 Died Cline 2 (( Wickham 3 <( Oldknow 4 (( Tyrrell 5 Id. 6 (( Barton 7 (( Boyer 8 (( Rogers 9 (( Attenburrow 10 (( Laugier 11 (( Uolsclier 12 Relieved A. G. Smith 13 Died Mayer 14 (( South 15 Blackman 16 Not known Edwards 17 (( Blair 18 (C Goldsmith 19 Died Stephen Smith 20 Hutchison 21 Jones 22 <( Potter 23 <( Id. 24 Not benefited Id. 25 Died McDonnell 26 Relieved Gordon 27 Died Tillaux 28 u Willett 29 Not known H. J. Tyrrell 30 Died Maunder 31 Not "benefited Eve 32 Died Cheever 33 < ( Id. 34 (I 35 (( Nunneley 36 (( Id. 37 <( Id. 38 Relieved Id. 39 Died Willard 40 Relieved Stemen 41 Not benefited Id. 42 Died Id. AO Not benefited 44 a Id. 45 Died Pinkerton 46 Halsted 47 Recovered Macewen 48 Lauenstein 49 Not benefited Albert 50 R. T. Morris Chelius's Surgery, ed. by South, vol. i. p. 590. Lancet, 1827. Hutchison, Am. Med. Times, 1861. Malgaigne, Fract. et Luxations, tome i. p. 425. Ibid. Malgaigne (Packard's translation), p. 343. Heyfelder, Traite des Resections (trad, par Boeckel), p. 244. Am. Journ. Med. Sciences, 0. S., vol. xvi. Chelius and Heyfelder, op. cit. Malgaigne, op. cit. Brown-Sequard, Diseases of the Central Nervous System, p. 256. N. A. Med. and Surg. Journal, vol. vm. p. 94. Heyfelder, op. cit. Notes to Chelius's Surgery, vol. i. p. 591, etc. Hutchison, loc. cit. Brit, and Foreign Med. Review, 1838. Ballingall, apud Hutchison, loc. cit. Gross, System of Surgery, 2d ed., vol. i. Hutchison, loc. cit. Ibid. Brown-Sequard, op. cit., p. 255. Hurd, N. Y. Journ. of Med., 1845. Am. Journ. Med. Sciences, N. S., vol. xlv. Ibid. Ibid., vol. 1. Med.-Chir. Trans., vol xlix. p. 21. Brit, and For. Med.-Chirurgical Review, 1866. Med. Times and Gazette, Feb. 2, 1867, and St. Barthol. Hosp. Rep., vol. ii. p. 242. Dub. Quart. Journ. Med. Sci., Aug. 1866. Med. Times and Gazette, Feb. 23, 1867. Am. Journ. Med. Sci., N.S., vol. Ivi. Boston City Hosp. Reports, p. 577, 1870. Ibid., p. 580. St. Barth. Hosp. Reports, vol. vi. Med. Times and Gaz., Aug. 7, 1869. Ibid. Ibid. Ibid. Am. Journ. Med. Sci., N. S., vol. Ixiii. Fort Wayne Journ. of the Med. Sciences, April, 1883. Ibid. V Ibid., Oct. 1883. Revue des Sciences Medicales,' Avril, 1880. London Medical Record, March 15. 1887. Medical News, Jan. 3, 1885. Ibid. Glasgow Med. Journal, March, 1886. London Medical Record, March 15, 1887. Ibid. Annals of Surgery, June, 1886.] MALFORMATIONS AND DISEASES OF THE SPINE. FREDERICK TREVES, F.R.C.S., ASSISTANT SURGEON TO, AND SENIOR DEMONSTRATOR OF ANATOMY AT, THE LONDON HOSPITAL. Spina Bifida. The term " spina bifida" is applied essentially to a hernia of the mem- branes of the cord through a congenital fissure in some portion of the bones forming the spinal column. Pathological Anatomy.— Speaking generally, the congenital deficiency that leads to spina bifida is in the posterior segments of the column, and is at the expense of the laminae and spinous proce'sses. Through the bony gap the spinal membranes protrude, distended by an abnormal amount of cerebro- spinal fluid. Often the cord itself, or some part of it, takes a share in the protrusion. The spina bifida, therefore, appears as a tumor of variable size, situated in the middle line, covered w^ith normal or more or less modified integuments, and presenting the essential features of a simple cyst. Causes.— As to the causes of spina bifida nothing definite can be said, and the etiology of the afiection n?ust for the present be hidden under the general term, "arrest of development." A vast number of theories have been pro- pounded upon the subject, supported for the most part by a minimum of facts; and it must be confessed, that in spite of long argument and a multi- tude of opinions, little real addition has been made to our knowledge of the causes of this and like deformities. Perhaps the most essential question that requires to be answered is this: Which is the primary defect, the arrest of development in the bones, or the dropsy of the membranes ? Does the defici- ency in the bony canal encourage a protrusion of the membranes, or has the protrusion prevented the proper formation of the osseous canal ? Those who are interested in this discussion will find the matter fully argued out by Follin and Duplay, in their Traite de Pathologic Extcrne. Site.— The common situation for spina bifida is in the lumbo-sacral region. ' Indeed, it may be said that the deformity is rare elsewhere, i^ext in fre- quency to the lumbo-sacral region comes the upper cervical region, and then the rest of the cervical spine, while the least frequent spot for a spina bifida is the mid-dorsal res-ion. KuMBER.— The spina bifida is usually single. In rare cases, however, there may be two examples of the deformity in the same person. Thus there may be a spina bifida in the lumbo-sacral region, and another in the neck. Bryant (487) 488 MALFORMATIONS AND DISEASES OF THE SPINE. figures a case where there was one tumor in the lumbar region and another in the sacral.' Condition of the Bone.— An examination of the vertebra at the site of the spina bifida will show that the spinous process is absent, and that the corres- pondincr laminae are also entirely absent, or more or less defective, i he re- mainder of the bone is usually perfect and well developed. The osseous detect is rarely limited to one vertebra. It usually involves two or three or more. In some few instances, in monsters, all the vertebrse have been found involved —a condition not compatible with existence. Follin and Duplay^ cite some instances where the defect in the bone extended as a cleft through the entire body of the afiected vertebra ; and Bryant^ has reported the case of a woman, a2:ed 25 who died from accident, and who presented an anterior spina bifida. Dr John Ogle, has recorded a remarkable case of spina bifida opposite the upper lumbar vertebra, where the body of the second lumbar vertebra was deficient, and was so pushed backward that the first and third vertebrse came almost in contact. The defect was associated with a very marked and abrupt cur- vature of the spine backwards at the seat of the spina bifida.* The Tumor.— The tumor varies greatly in size, and may range from a pro- trusion the size of a walnut to a mass larger than an infant's head. Broca ex- hibited a case in an adult man, where the circumference of the tumor was 45 centimetres (17.5 inches). The usual size of the tumor at birth is from that ot a bantam's egg to that of a small orange. According to Follin and Duplay, there mav be no tumor at all, but merely a cordiform or oval patch on the skin, asso- ciated with no elevation of anv kind. It is asserted that this condition may occur with division of many vertebrse. The tumor is usually round, or oval, with its greatest axis longitudinal, and is of regular outline. The wall of the sac is thin and ultimately adherent to the skin or its representative In cases that have existed for some years, the sac wall may become great! thickened, and may present some calcareous change. In certain large tumors the outline ot the mass may be bossy and irregular, probably from unequal resistance of the envelopes. The tumor may be sessile, but it is usually peduncu ated. Ihe size of the pedicle depends upon the size of the hole in the vertebral canal. In process of time the pedicle tends to become lengthened, a condition that depends much upon the weight of the tumor, the size of the opening into the spinal canal, and the maintenance of the vertical position.^ The skm covering the spina bifida is rarely normal. It is usually thinned and deficient, often shining and purple, and not unfrequently inflamed. In other cases the skm mav be hard and coriaceous ; it may be hairy, or in a condition of ichthyosis. Sometimes it is found to be hypertrophied, although more commonly it is deficient, and may be entirely absent. In the latter case the spinal dura mater is exposed as a bluish-red and vascular membrane. Ihe defective skm, moreover, may be represented by a scanty fibrous material, not un ike cicatri- cial tissue, or the integuments may be hypertrophied at the periphery ot tfie * tumor and atrophied at its centre. The deficiency m the integuments may depend upon congenital defect in those parts, or may be due to a wasting of the coverings of the tumor, consequent upon increasing pressure from within. In many cases the coverings of the spina bifida are curiously in- flamed and appear very vascular and rugose ; or they may be sloughing, or 1 Manual for the Practice of Surgery, 2d ed., vol. i. page 256. 2 Traits de Path. Externe, tome iii. p. 709. ' Medical ^razette, 1838. : a • "•l^&.'^d Surg. Joum., July, 1862, page 4.6, the pedicle is said to have been "about a foot m length." SPINA BIFIDA. 489 the seat of more or less considerable ulceration. A nse void condition of the skin is by no means uncommon, either over or about a spina bifida. ^ When the skhi is dissected off, the true sac of the tumor is met with. This is formed from the membranes of the cord matted together. X() layers, however, can usually be made out, nor can the integuments be distinctly separated from the protruded membranes. In cases where the skin is quite normal, however, a layer of loose comiective tissue often exists between the membranes and the most external coverings of the protrusion. Mr. Thomas Smith has recorded a remarkable case where the tumor contained two distinct sacs. The tumor, in this instance, was large and pendulous^ and opened from the lower lumbar region. It was translucent, but presented no impulse on crying. The child was 14 months old, and, apart from the tumor, in perfect health. The mass was tapped, and 8 ounces of clear fluid drawn off. The patient died in ten days from spinal meningitis. At the autopsy, a second and smaller cyst was found at the upper part of the mass, that had not been punctured. Between the two cysts was a strong membrane, and in this position also ran the cauda equina. The bony opening was at the last lumbar vertebra. The larger or lower cyst communicated with the spinal canal and contained a few nerves. The smaller cyst led by a funnel-like process to the centre of the cauda equina and subarachnoid space.^ Sir James Paget has also recorded a case of two sacs in a spina bifida, one inclosing the meninges and cord, and the other occupied by fibrous and fatty tissue. Contents of the Tumor. — The sac of a spina bifida contains more or less • fluid, which is identical in composition with the cerebro-spinal fluid. There is no doubt, moreover, that this fluid and the fluid in the sac of the tumor are one. The fluid may be found either between the cord and its membranes (hydro rachis externa or hydro-meningocele), or may be found in the central canal of the cord (hydrorachis interna or hydro-myelocele). In the latter case, the cord is usually found spread out so as to form a thin covering over the wall of the sac,^nd its condition may be compared to that of the brain in severe hydrocephalus. Follin and Duplay believe that in at least three-fourths of all cases the fluid is formed within the centre of the cord. In all cases where the fluid has apparently accumulated in the central canal, an extensive spread- ino- out of the substance of the cord is not necessary. In mau}^ instances the cavity of the sac has been found to communicate by a funnel-shaped opening with the central canal of the cord, while yet the thinning or expansion of the cord was very slight.^ In all these cases the communication has been at the lower part of the medulla spinalis ; and while it is probable that in these instances the fluid originally accumulated in the central canal, it is equally probable that the collection communicated at an early period with the sub- arachoid space. In some cases cerebro-spinal fluid may form the sole contents of the sac in spina bifida ; but such cases are exceptional. As a rule, the spinal cord, or some part of it, and a certain number of the spinal nerves, are included in the protrusion. Follin 'M\d Duplay state that some nerve-tissue is found in the sac in five-sixths of all cases. Out of twenty cases of spina bifida, reported by Sir Prescott Hewlett, in one instance only was the sac free from nerve-structures.^ The relation of the cord or of the spinal nerves to the sac varies greatly. In some cases the cord may bend into the sac, and, having possibly contracted some adhesions there, may re-enter the spinal canal ; or the cauda equina, with more or less of the lower end of the cord, may 1 Trans. Path. Soc, vol. xxi. page 1. 1869. 2 See drawing of a dissection in Bryant's Surgery, vol. i, p. 255. s London Medical Gazette, vol. xxxiv. 1844. 490 MALFORMATIONS AND DISEASES OF THE SPINE. pass through the bony opeiniig, and, enteriDg the sac, become adherent to its inner wall." In such cases th"e termination of the medulla spinalis is often indicated by the point of its adhesion to the protruded sac; and this adhesion is, in some cases, marked by a depression on the outer surface of the cyst. Sometimes the cord-structure is found spread out as a thin coating of nerve- tissue over the inner surface of the cyst, a condition depending upon great accumulation of fluid in the central canal of the cord. In other instances the cord may be fairly sound, and the cauda equina may be spread out as a lining to the cyst wall ; or the extremity of the cord may be, as it were, dissected up into bundles, and thus be made to represent an unduly large and coarse cauda equina. Sometimes only a few nerves are to be found in the sac, scattered about its posterior wall, or hanging loosely in the fluid with which it is tilled. Speaking generally, the nerve-structures, when they occupy the sac, tend to observe, for the most part, the middle line and the posterior aspect of the tumor ; and it may be said that the larger the opening in the bones, the more probable is it that a large amount of nerve-tissue will be found in the cyst, and vice versa. In spina bifida not only may the cord be defective, or its parts disturbed in the manner just indicated, but the great nerves concerned in the deformity may also show certain deficiencies. Thus, Dr. Fisher^ found in two cases of spina bifida that he examined, a fusion of two or more of the sacral ganglia, and observed that the corresponding nerves passed through the spinal membranes in one bundle. South,^ commenting upon this observation, says that he has himself verified it in a case which he examined after death following puncture. Some few, rare instances have been recorded where the sac contained, in addition to cerebro-spinal fluid and some cord or nerve-struc- tures, a certain amount of fibrous and fatty tissue.^ [See page 560.] Symptoms and Diagnosis. — The tumor in spina -bifida is congenital, is always in the middle line, and always closely and distinctly connected to the subjacent bone. In many cases the defect in the bone can be felt when the tumor is drawn away from its attachments. The tumor is round or oval, and usually of regular outline. It feels tense and elastic, and, as a rule, presents very distinct fluctuation. If the coverings of the cyst be thin, the mass may be as translucent as a hydrocele. The Integument over the tumor may be normal, or may present any of the conditions that have already been described. The mass is generally constricted at its . base, if not distinctly pedunculated. Careful attention must be paid to those symptoms that mark the connection of the cyst with the interior of the spinal canal. Chief among these symp- toms are the following : The size and tenseness of the mass can be diminished by pressure. Such pressure will often cause evident pain or convulsions, or limited muscular spasms, and if continued may induce a state of coma in many instances. When hydrocephalus exists at the same time, pressure upon the tumor causes increased tension at the anterior fontanelle; and, in like manner, pressure at the anterior fontanelle produces some increase in the sac of the spina bifida. These mutual pressure-effects cannot be seen unless the head is hydrocephalic. If the pelvis be raised above the bead,^ the tumor becomes softer, while its tension is increased during the act of crying. These evidences of a communication between the sac and the spinal canal are more marked in large tumors than in small, and in those without a pedicle than in those possessed of one. It will be obvious that the smaller the orifice between the sac and the canal, the less marked will be the evidences of the communi- 1 London and Edinburgh Philospli. Mag., vol. x. p. 316. 1837. 2 Chelius's System of Surgery, voL ii. p. 466. 1847. « Holmes's System of Surgery, 2d ed., vol v. p. 804. SPINA BIFIDA. 491 cation. The complication of hydrocephalus tends to render the symptoms of communication much more distinct. Spina bitida is very commonly associated with some gross nerve disturbance, due to injury or defect in the cord or great nerves at the seat of the deform- ity. Thus talipes is very frequent, and especially talipes equino-varus. There may be a loss of power in the lower limbs that may present any grade from« mere muscular weakness to absolute paraplegia. With this paraplegia there may be paralysis of the sphincters, although this latter symptom may exist independently of paraplegia. With the loss of movement in the lower limbs, more or less loss of sensation may be associated, and, as a rule, both move- ment and sensation are impaired together, the impairment of motion, how- ever, being the more marked of the two. According to Follin and Duplay, there may be loss of sensation only in the lower limbs, but such a condition must be quite uncommon. In some equally rare histances the affected limbs are hyptsrsesthetic. Launay^ has recorded a case where there was loss of both motion and sensation in the right lower limb, with loss of movement only in the left. Hydrocephalus is commonly associated with spina bitida, and in. the course of any case convulsions are not infrequent. It is difficult to say positively, in all cases, whether the cord is or is not in the sac of the spina bitida. It may be safe to suspect its presence in the tumor, unless there are indications to the contrary. The larger the opening into the spinal canal, the more probably will the cord be found in the sac, whereas such a complication is but little to be suspected when the bony opening is small and the pedicle, long and narrow. In those cases that are associated with hydrocephalus, the cord, or at least some part of it or of its main nerves, are very usually to be found in the cyst of the spina bifida. The existence of talipes, or of paralysis, the occurrence of convulsions, the readiness with which nerve symptoms are produced by pressure, are all in favor of cord tissue being associated with the protrusion. Follin and Duplay have pointed out that when the termination of the cord is adherent to the posterioi* wall of the sac, the site of the adhesion is often indicated by a depression on the surface of the tumor in the middle line. In man}' cases also where the cord is adherent to the sac, its position is indicated by undue thickness of the cyst wall at one part, and possibly also by some loss of translucency. A vascular and reddened condition of the skin is said by some to indicate adhesion to the parts beneath. It is probable that complete paraplegia will in all cases depend upon hydrorachis interna. The diagnosis of spina bifida is rarely a matter of difiiculty. The disease has been confused with certain tumors that have occupied the middle line, and have been congenital ; but in such growths the laminae and spinous processes of the vertebrae have been felt intact beneath the tumor, and it has been possible to demonstrate the absence of any adhesion between the tumor and the bone. In such cases, moreover, there has been an absence of those symptoms that indicate a communication between the tumor and the spinal canal. Some- times the sac of a spina bifida becomes cut ofi' from all communication with the vertebral canal, and then the diagnosis between such a cyst and a con- genital cystic growth in the middle line is practically impossible. Xot only is the diagnosis often impossible in such cases, but it is also quite unim- portant, inasmuch as the treatment in the two affections is identical. The points of difference between spina bifida and certain congenital growths in the regions common to spina bifida, will be dealt with hereafter. 1 Bull, de la Soc. Anat., 1859, page 342. 492 MALFORMATIONS AND DISEASES OF THE SPINE. Progress and Prognosis. — The commoD tendency of spina bifida is towards rupture of the sac. The tunnor usually increases steadily, and in time reaches such dimensions that the skin or coverings of the protrusion give way. The contained cerebro-spinal fluid is then discharged, and death very commonly follows from convulsions, or less frequently from inflammation of the spinal membranes. The rate at which the tumor increases varies greatly, and can hardly be definitely laid down. In several instances the sac has ruptured in liter 0^ and the infant has either been born dead, or has survived its birth but a few hours or days. Often the tumor has given way during birth, and its contents have been discharged with a more or less rapidly fatal result. Some- times the rupture is represented by but a small hole in the skin ; this heals and the sac refills. In such a case, a second rupture of the sac may end in death, or the opening caused by the rupture may remain patent and a fistula be established that is, however, soon attended by a fatal termination. In cer- tain instances the contained fluid may escape through the greatly thinned skin without any opening being apparent. In the minority of all cases spontaneous cure takes place. Such a cure is most likely to occur in cases where the tumor is small, possessed of a small and narrow pedicle, and occupied by no part of the cord, or of the great spinal nerves. In such a tumor the abnormal opening may gradually close, the fluid in the sac may be absorbed, and the mass may shrink and almost disappear ; or this end may be brought about by some ad- hesive inflammation at the root of the tumor, whereby the obnoxious orifice is closed and a good result follows. Many cases are recorded where a com- plete cure has followed upon the spontaneous rupture of the sac, and Holmes cites a case where a like fortunate result followed upon the suppuration and bursting of the cyst in a child aged six months.^ The tumor may increase in size for years, and then suddenly cease to grow, and begin to exibit a retrograde movement that in time will end in a cure of the deformity.'^ In the Transactions of the Pathological Society^ is an account of a case where a spina bifida, the size of the patient's head at birth, was rapidly undergoing spontaneous cure at the age of twelve months. Patients with spina bifid'a have reached the ages of 28, 37, 43, and 50 years.^ Treatment. — The treatment of spina bifida may be classed as 'palliative and curative. Palliative treatment consists simply in protecting the part from friction or injurious pressure, and in retaining in as healthy a condition as possible the coverings of the protruded mass. These ends can be best eftected by enveloping the mass in a pad of cotton-wool smeared with vaseline, and secured to the part by means of a circular bandage so applied as to exer- cise some pressure upon the tumor. By these simple means the growth of the tumor has been arrested or greatly modified, the amount of inflanmiation in the skin has been lessened, and any progressive thinning of the cyst- wall has been considerably retarded. I believe that this very rudimentary plan of treatment is better than that of keeping the part constantly painted with collodion. The pressure exercised by the contracting colk)dion is slight and superflcial, the application itself often increases rather than diminishes the inflammation of the skin when it exists, and wdien that inflammation 1 Surgical Treatment of Children's Diseases, page 82. 2 a case in Med.-Chir. Trans., vol. xl, page 19, where the tunior continued to grow steadily for three years and then began to decrease. 3 Vol. xvi. page 13. 4 Case by Behrend, Journ. fiir Kinderkrankheiten, 13d. xxxi. S. 350, SPINA BIFIDA. 4^3 has proceeded to actual ulceration, I presume that the use of collodion would be very generally considered as inapplicable, even if possible. Before any more active measures are proposed, it is well to consider the relations and surroundings of the tumor. The true spina bitida communi- cates with the cavity of the spinal membranes, aiid usually contains either the cord or some part of it, or a certain number of tlie lowest spinal nerves. Any operation, therefore, upon such a tumor must involve the spinal mem- branes, and probably the medulla spinalis itself, and it is unnecessary to point out that an operation with such incidents must be among the most serious that can be entertained in the practice of surgery. lu the face of these serious features in any operative proceedings for the relief of spina bitida, it has been pointed out that the cases most suitable for operation are tho^e where the bony defect is trilling, the tumor well pedun- culated, and the cord and its nerves free from any participation in tlie pro- trusion. This is obvious ; but these very cases that are considered the best suited for operation, are the very cases that are the most prone to undergo spontaneous cure. I would venture to urge that the possibility of sponta- neous cure in spina bifida has been a little too lightly estimated, and thtit, while perhaps harm may be done by temporizing with a case, that harm is not so very unevenly balanced by the mischief that has followed upon hasty, premature, and ill-conceived operations. There are not a few cases on record that, like the following example, would urge a greater tolerance of the possi- bility of spontaneous cure. A man, aged twenty, had a spina bifida that had of course existed from birth. It was of great size, but, apart from the inconvenience attending its large bulk, it gave him no trouble. For twenty years, then, it had caused no serious or even very troublesome symptoms. At the age of twenty, the tumor was tapped. With wdiat result ? AVithin six days of the second tapping the man w^as dead.^ Looking over the records of the treatment of this deformity, one is struck with the nninense number of cases of spina bifida that have been subjected to operation within a few days— nay some even within a few hours— of the birth of the victim. In such cases, the possibility of spontaneous cure can hardly have been considered, and it remains with those who have undertaken such operations to show upon what grounds these apparently premature and hasty measures have been adopted. I would then urge a little patience as the first factor in the treatment of spina bifida. Let the first measures be pal- liative, and let operative measures be considered when some definite indica- tions for further treatment arise. These indications may be aftbrded by the rapid growth of the tumor, by the probability of its speedy rupture,^ by the onset of convulsions or other nerve disturbance, or by the increase in a paralysis that has perhaps always existed to some extent. The principal curative measures (so called) may be considered under the head of (1) Puncture, (2) Injection, (3) Ligature, and (4) Excision. (1) Puncture. — There are many cases where the only symptom that requires to be immediately dealt with is the rapid increase in the size of the tumor, or in the degree of its tenseness. I think that such cases can — for a while at least — be very well treated by puncture. I might best illustrate the matter by reference to two cases at present under my care at the London Hospital. One patient is aged nine, and the other six months. Both tumors are in the lumbo-sacral region ; they are both large, and have but thin coverings. In each case the skin inflamed about the summit of the cyst, and has been many times ulcerated. There is reason to believe that the cord, or some part of it, has a share in the protrusion in each instance. For some weeks after 1 Trans. Path. Soc. vol. viii. page 10. 494 MALFORMATIONS AND DISEASES OF THE SPINE. birth, the tumors were simply kept covered up with cotton-wool smeared with vaseline, and some slight pressure was maintained over the part by means of a banda2:e. The history and progress of the two cases are so similar that they may be treated as one. In time the tumor increased in size and in tense- ness, the child became restless and convulsed, and the undue tension in the cyst appeared to be the cause of these fresh symptoms. The tumor was then tapped as far from the middle line as possible, with the finest trocar, and enough fluid (about 1} drachms) let out to relieve the tension. The wool was then reapplied, and the pressure of the bandage again maintained. Im- mediate relief followed. In the child aged nine months I have thus punc- tured the cyst, I dare say, a dozen times, but the necessity for such punctures has become less and less frequent, and the operation has not been performed for the last three months. The tumor is now apparently stationary. The €hild is still — as it always has been — partially paralyzed in its lower limbs ; but it has had no convulsions for months, and it is in fair health. As far as I €an judge, there is in this case a large defect in the bone, and the cord is in the sac. But what operation can be done — as far as our present knowledge goes — to close this defect and restore the cord to its proper place ? To ligature or to excise the mass would probably be to ligature or excise the cord or some part of it, and I can hardly believe that iodine injection could loosen any adhesions that may exist between the cord and the sac, restore the cord to its proper canal, and close the defect in the bone. In the child aged six months, the tumor is increasing, but is kept within bounds by fre- quent tapping — sometimes once a week, or once a fortnight^ — and the child appears, apart from the tumor, to be well. I think, then, that in certain cases, the treatment by puncture and gentle pressure may be advised, not, perhaps, so much as a means of cure, but as a measure for prolonging life and rendering; the existence of the patient less distressing than it might be. I can, however, well believe that it may in some cases lead to a cure, although a paraplegia or other gross nerve-lesion may persist. It would appear that . the smallest possible puncture is the best, and that it should always be made, when available, through healthy skin. The less fluid drawn oft' at each operation the better. It is m^erely required to lessen the tension. The sub- sequent pressure should be slight and evenly applied. I believe that this treatment ori2;inated with Sir Astley Cooper. That surgeon at least reported two cases where he had adopted this measure and with very good success.^ The practice of simple puncture, with evacuation of the entire amount of the contained fluid, is strongly to be condemned. It would appear to have led in most cases to severe and fatal convulsions, and in certain instances to almost' sudden death. It must be remembered that puncture under any cir- cumstances may be followed by inflammation of the sac. (2) Injection. — This mode of treatment has so far been the most successful that has been made use of in this deformity. Many fluids have been used for injection, but the only one that has proved of any practical use is iodine. The tumors best suited for this method of treatment are those that present the condition most favorable for spontaneous cure, and it is in such cases that successful results have, for the most part, been obtained. When there is a free communication between the sac and the spinal canal, and when the cord or the large nerves enter into the protrusion, the success of the operation, and indeed its very advisability, are matters of considerable doubt. There are many who maintain that the treatment by injection is not justifiable when the hole leading from the sac to the cavity of the spinal membranes is 1 Med. Chir. Trans., vol. ii. page 324. Bryant, in his "Surgery," 2d ed., vol. i. page 257, gives an account and a drawing of a case cured by repeated puncture with a needle. SPINA BIFIDA. 495 large and free, or when the contents of the cyst are other than simple fluid. If then only selected cases are considered suitable for this measure, its success must be estimated at a proper value. I am aware of no case of cure from iodine injection where it was distinctly proved that a free communication existed between the interior of the sac and the spinal canal, that could not be even temporarily cut otf, and where at the same time the cyst contained the cord or some considerable portion of it. The methods of using this iodine treatment vary. Brainard, c>f Chicago, adopted the following plan : Six ounces of the fluid in the cyst were drawn ofl:*, and half an ounce of an iodine solution was then injected. This, after a few seconds, was allowed to flow out, the sac was then washed out with water, and the operation was completed by the injec- tion of two ounces of the original cerebro-spinal fluid that had been kept in the meanwhile at the temperature of the body. After the operation, pres- sure was applied. Brainard's solution consisted of iodine, 5 grs., potassium iodide, 15 grs., and water, one fluidounce.^ Velpeau withdrew all the fluid in the cyst, and then injected a solution of tincture of iodine and water, after the manner adopted in the treatment of hj'drocele. Morton's method appears to have the advantage over both these plans, and is probably the most successful method of using iodine that has been proposed. Morton uses a solution of tec grains of iodine and thirty grains of iodide of potassium in one ounce of glycerine. The operation is not advised until the child has passed over the accidents of birth," unless a speedy bursting of the tumor is threatening. A little of the cerebro-spinal fluid is drawn oft', and then from half a drachm to one drachm or more of the " iodo-glycerine solution" is injected. This is allowed to remain in the cyst. The puncture is then painted with collodion. The operation may need to be repeated several times at intervals of a week or ten days, or longer. Some little inflammation commonly follows each injection, but it usually remains limited.^ If a good result follows, the mass shrinks, and soon ceases to give trouble. In a recent communication, Dr. ^Morton^ states that, as far as he knows, 29 cases have now been treated by this method. Out of this number failure has occurred in six instances only, and from this Dr. Morton argues that the iodo-glycerine solution treatment has brought about a saving of life to the extent" of 79.31 percent. Before, however, this very pleasuig conclusion is accepted, it would be desirable to have more full details as to the exact condition of the various cases operated upon, and especially as to the anatomical relations of the parts concerned in the tumor. The failures from the injection treatment have depended upon inflammation involving the spinal membranes and cord, upon convulsions independent of such inflammation, or upon suppuration and premature bursting of the sac. (3) Ligature and (4) Excision. — These operations can only be undertaken in those comparatively infrequent cases where the sac is quite free from either the cord or any of the spinal nerves. The smaller the tumor, the smaller the bony hole, and the narrower the pedicle, the greater is the chance of success. The real danger is, that the inflammation incident upon healing and upon the closure of the aperture in the bony canal, may extend inwards and extensively involve the spinal membranes. It would be of no avail to detail the many modes in which these operations have been carried out. The ligature has been applied gradually, and it has been applied suddenly. The mass has been allowed to fall oft', and it has been taken oft* at once with the kraseur, Ex- J Am. Journ. Med. Sciences, vol. xlii. page 65. 1861. 2 See Lancet, vol. ii. 1876, pages 776 and 881. 3 Glasgow Medical Journal, 1881, page 401. 496 MALFORMATIONS AND DISEASES OF THE SPINE. cision has been preceded by ligature ; excision has been performed with or without the preliminary use of a clamp. It has been executed in a great variety of w^ays: by excising the whole, or by excising a part; by invaginating the collapsed membranes, or by cutting them off close to the bone. It has been followed by the use of the cautery, and b}' the application of divers kinds of suture. It has, indeed, been practised wdth all the ingenuity that is a feature in the history of so many surgical procedures. The modus ojmrtndi is of little moment. If the sac contain cord-elements, the result w^ill prove fatal ; if not, success may possibly follow. The opera- tions are, as far as surgical science at present goes, restricted to cases that present in a marked degree the elements necessary for spontaneous cure, and to cases where that cure has so far advanced that the opening in the bones has become closed, and the tumor gives trouble only by its bulk. If the liga- ture be used, a superficial cut should be made in the skin at the base of the mass, and a silk ligature should then be applied and drawn sufiiciently tight to strangle the mass. In excising the cyst, it should be removed by an oval incision at its base, so planned that after removal the edges of the wound may come together in a clean, straight line. The operation should be done antisep- tically, and firm pressure should be maintained until the wound has healed. An account of the chief operations alluded to under this heading will be found in Mr. Holmes's monograph in his " System of Surgery," 2d ed., vol. V. p. 807. [See page 560.] False Spina Bifida. This term has been applied to many difi:erent tumors that have, however, for their common characters a congenital origin and a communication with the spinal canal, but not with the spinal membranes. Some of these tumors are solid, some are multilocular cysts, and some are simple cysts. Both pathologically and clinically, they present striking points of difference, and as there" appears to be no great advantage in classing these various growths under a common head, I would venture to question the value of this term in its present extended sense. The term false spina bifida should be applied to one tumor onl}- , namely, to a spina bifida whose communication with the spinal membranes, and, perhaps, with the spinal canal itself, has been cut oft'. Such a tnmor is the result of the process of natural cure in cleft spine, and of it many examples have been furnished. The false spina bifida will be found in some region common to this deformity — most probably in the lumbo-sacral region — will be of congenital origin, cystic in structure, and situated accu- rately in the middle line. It will present no evidence of communication with the spinal membranes ; will be, in almost every instance, pedunculated and will probably have been of some duration. There may possibly be a history to show that such a mass did at one time present all the features of a true spina bifida. Lacking this fact in the history of the case, the diagnosis of false spina bifida is by no means eo^sy. There are certain congenital tumors of a cystic character that may appear in the middle line in regions common to spina bifida, and that may furthermore have an intimate connection with the column. These tumors may closely resemble false spina bifida, but the resem- blance will, in most instances, not be of long duration. The cystic tumor is usually multilocular ; the false spina bifida a simple cyst. The cystic tumor is apt to grow rapidly, is usually not very distinctly peduuculat^ed, often con- tains more solid masses in its interior, and is nearly always irregular and bossy in outline. The false spina bifida, on the other hand, tends to diminish rather than to increase in size ; its pedunculation is nearly always very dis- CONGENITAL SACRO-COCCYGEAL TUMORS. 497 tinct ; it contains no separate, solid masses, altlioiigh it may present a uniform thickening of its sac ; and lastly, its outline is nearly always quite smooth and regular. The diagnosis, however, is of no great moment, as it would suggest no plan of treatment that, while applicable to a false spina bifida, would not be equally applicable to such a cystic tumor as would closely resemble the simple cyst. Excision is probably the most suitable mode of treating these cases, and is the method that has been attended with the greatest success. Injection with iodine has been proposed, but would appear to have no great claim to atten- tion, for the sac of the false spina bifida is often thick, and, even if the sac should become obliterated as a result of the injection, the cyst-wall would still remain with probably a considerable pedicle. If the case should prove to be a multilocular growth, the injection would then be obviously useless. On the whole, therefore, considering possible errors in diagnosis, a cautious excision of the mass is probably the most certain and the safest procedure. Certain of the following tumors may be— and have been— mistaken for spina bifida. Congenital Sacro-coccygeal Tumors. The sacro-coccygeal region is peculiarly liable to be the seat of certain con- genital tumors. Some of these grow from the sacrum alone, and others from both the sacrum and the coccyx, but the majority would appear to have their primary origin from the coccyx alone. As to the reason w-hy this region is so frequently the seat of congenital growth, nothing definite can be said. It is a problem that still requires to be worked out. It is remarkable that the congenital tumors about the sacrum and coccyx should be much more frequent in the female than in the male. Molk gives 58 cases in which the sex was noted, and of this number 44 were in females, and 14 in males. These tumors are very varied in their external characters, and are, I think, best classed in the following manner : (1) Attached foetuses, (2) Cono-enital tumors with foetal remains, (3) Congenital cystic tumors of various Tvinds, (4) Congenital fatty, fibrous or fibro-cellular tumors, and (5) Caudal ex- crescences. Attached F(ETUS.1— The most common example of this condition is afibrded by a third lower limb that is attached to the sacral region, and that hangs down between the normal legs of the patient. The condition has been known as " human tripodism." The superfluous limb consists usually of the two leo-s of another foetus blended into one. The size and development of this addi- tional member vary. It is usually dwarfed, and often contracted at the knee, and the foot, or feet, commonly much deformed. It may, however, appear wxll developed, and may even exceed the natural limbs in the de2:ree of its development. In some instances, one of the natural lower extremUies of the patient may be wasted and deformed, and in a condition but little better than that of the additional member. This abnormality is associated with certain alterations in the anatomy of the pelvis, and some variation is shown in the manner in wdiich the additional limb is attached to the trunk. In certain less frequent instances, the attached foetus has been represented by a confused, pendulous mass that exhibits the rudiments of several limbs. * Representations of the principal varieties of attached foetus are given in Dr W Braune's Die Doppelbildungen und angeboren Geschwulste der Kreuzbeingegend. Leipzig 186*2 VOL. IV. — 32 498 MALFORMATIONS AND DISEASES OF THE SPINE. Such an instance is represented by Braune in his well-known monograph (Plate 3, Figure 7). Usually the superfluous limb is obvious at birth, but it may be concealed for some time within a fibrous sac, and may thus resemble the cystic tumor with foetal contents to be next dealt with. In two or three recorded instances of this condition, the child was born with a sacral tumor that continued for some time to increase, and then gave way, allowing a foot and les; to come out. ^ _ The^ treatment of these supernumerary limbs is by amputation. The chief difiiculty in any such operation is the connection of the member to the pelvis. But in these cases a disarticulation is not necessary in all instances, nor is it of course desirable to in any way interfere with any pelvic abnormality. It is sLifiicient to remove the projecting part of the additional meniber, and this operation would appear from recorded cases to be both fairly simple and more than fairly successful.^ Congenital Tumors with Fcetal Remains. — These tumors present them- selves under a 2:reat variety of aspects. Usually they appear as roundish or irregular tumors, pendulous from the sacro-coccygeal region, and covered with a thin and often purplish skin. Beneath the skin is a sac, lined with a smooth membrane, and within this sac is a certain amount of fluid, and fcetal remains of the most variable nature and aspect. These foetal i-emains usually present themselves in the form of an irregular, solid mass, bony, pendulous, and imperfectly pedunculated, This mass is composed of fatty and fibrous tissue, and presents usually a number of multilocular cysts, variously disposed. Some part of the mass may present fingers or toes, or rudimentary limbs. In other cases the tumor may contain portions of bone, most usually portions of the vertebrge, or fragments of cartilage, with here and there some ill-formed and indefinitely arranged muscular tissue. In other instances the mass has presented a knuckle of gut, that has sometimes contained a material like meconium. Some few of these masses would appear to have been dermoid, and have contained hair, teeth, and fragments of bone. These tumors may occupy the subcutaneous tissue, but usually they are more deeply seated, and they are, as a rule, closely adherent to the bone. They may communicate with the spinal canal, but such communication is quite rare. Sometimes they extend deeply into the pelvis, and a large congenital tumor may in addition be found in that region ; their size varies greatly ; they are apt to be pendulous, but are seldom well pedunculated. Stanley has reported a case where the tumor reached almost to the feet.^ Braune has detailed the case of a girl, who presented a congenital mass of this nature that w^as pendu- lous and attached to the buttock by a stout pedicle. The tumor contained the rudiments of limbs. It increased in size, and at the age of 16 was 26 inches lono-, and weighed 20 lbs. It was then successfully amputated. These tumors usually grow after birth, and, as a rule, their growth is rapid. The skin covering the mass may give way, and the foetal remains contained within may protrude. This may or may not be preceded by more or less inflamma- tion or slouo-hirig of the excrescence. In one or two instances these tumors have been associated with a spina bifida in the sacral region. Sometimes the foetal remains are not contained within a sac, but are freely exposed. Such a condition rather approaches that alluded to under the term " attached fcBtus." Such tumors are very irregular in outline, and still more irregular in composition. They may present, in addition to much fatty and ' For an account of the cases operated upon, see Braune's work, and also an excellent article by Mr. Holmes, in his System of Surgery, 2d ed., vol. v. page 801. 2 Med.-Chir. Trans., vol. xxiv. page 235. CONGENITAL SACRO-COCCYGEAL TUMORS. 499 cjstie tissue, the rudiments of limbs, portions of bone or cartilao-e, or repre- sentatives of the head and of the intestinal traet. A complex variety of such a tumor I have described in Vol. XXXIII. of the Patholocrical Society's Transactions. Treatment—These tumors have been subjected to many operations for the purpose of ejecting their removal, but the most successful measure of this kind that has been proposed is excision. If the mass is considered suitable for removal, there is no better plan of accomplishing this than by the knife The ligature is strongly to be condemned, and the galvanic cautery has no ijx vantages over the knife, while it entails certain grave additional risks ihese tumors are not extremely vascular, and such hemorrhao;e as has occur- red during their removal appears to have always been readily Shocked. Exci- sion of the mass is only to be advised in those cases where the tumor can be entirely removed without great difficulty, and without damage to neio-hboriuir important structures. These tumors are usually well defined at the?r origin and show less inclination to invade the pelvis than do those which are treated ot in the next section. They sometimes communicate with the spinal canal, .and, unfortunately, the existence of that communication cannot always be foretold lu c^ses, therefore, where the mass is well limited as to its oridn, where the pelvis is quite free, and where no communication with the spinal €anal is expected, the tumor may be excised, provided that the genei^al condi- tion of the patient afford no counter-indications. Molk notes eight examples ot removal of these masses, and of this number seven were successful The statistics given by Holmes show a like good result. If the tumor be left, it will probably in time bring about a fatal result, the patient dying of maras- mus, or of the etfects of inflammation, suppuration, or sloughing of the mass. A great number of the subjects of these growths are born dead. . Congenital Cystic TuMORs.-These constitute the 2:reater number of the Sn^P ZT" if '^]'^' ^^'^^y ^'''^ considerable diffeience^, both in their external appearance and in their internal structure, ^ome few are single cysts, but the bulk are multilocular growths. The single Z^il^eSl^ ^-'^ "'"''"''^ ""''"^ ^^^'^ 'P'"^ ^^^^^ It is well^ known that spina bifida in the sacral region alone is rare, and L nnrLo ; '^^^^'^^ ^^'""^ coccygeal spina bifida does not, and cannot, exist. Into the features of spina bificfa of the sacral region it IS unnecessaiy to enter, after what has been already said. With re-ard to false spina bifida, it is probable that it constitutes the sole form of simple cyst 2,^±'lf^^^^ sole form of deep-seated simple cy.t. In a number of instances, these simple cysts in the sacro-coccy- iltlV^lf'l^^r ^^^^^ time directly connected cyst in this part do not appear to oppose the idea that they also are to be regarded as examples of false spina bifida. ^ ^J^''' '/'''^f^^^^ form the most important series of tumors encountered m this region They arise usually from the anterior surfa^of both of To'J r'^^'^' ^re^^enaj from the posterior surface of one or wii .1 ^""T' ^'^^ ^^a^'ies greatly. It may be no & i l"^"^ ^^^^^ '""''''^ '^'^ dimensions of the childl head? rSvS ^""^^ ^'''^'^ ^^'^^^^^ tumors tends to XSh vpvv 7''^^' dimensions. In outline they are roundish or oval, My\ d^?^.T^'"J^'l f^™"^^^ pendulous masses. T-here is 4W in tL ne^^^^^ those growths that have no extensive ramifi- ««^^ usuaUy of fibrocellular tilsue. It contains no bone, and springs from the subcutaneous connective tissue. Being long, narrow, and perhaps pointed, it lesemb es the tail of some animals" Gosselin^ quotes a case where the appendage was five centimetres (two inches) in length, and was curled forwards a ong the perineum. Chauvel' also gives a case where the excrescence was of the same fength, and of the thickness of a little finger. These tumors are all readily removed with the knife. In addition to the works of Braune, Holmes, Hutchinson and others already alM^^^^ to reference maybe made to the following monographs dealing wth the subject o lo'n'enital sacro-coccygeal tumors: Molk, Des tumeurs congemtales de I'extremite •n^r^uir/u tronc, s'?asburg, 1868, These, Se serie, No. 106^ ^uplay Des tumeurs congenitales de la region sacro-coccyg.enne Arch. Gen de Med., 1868 tome xn. Wag staffe, St. Thomas's Hospital Reports, N. S. vol. iv. (1873), page 213. Antbro-postertor Curvatures of the Spine. Under this term are included two precisely opposite conditions, viz cyphosis, or a curving of the spine backwards, and lordosis, or a curving of the column forwards. Cyphosis —In this condition there is abnormal curvature of the column, or of some part of it, directly backwards ; and as the term " curving backwards of the sp ne" is open to some varied interpretation, it is necessary to add that, in all cases, the abnormal curve has its convexity directed posteriorly. Cy- phosis maf involve the whole of the column, although, as a rule, but a por^i^on of H is implicated. In the majority of instances, indeed, ?t consists mereiV in an exaggeration of the posterior curve that normally exists m the dorsal region. Cyphosis may be temporary or permanent. . Path. Soc. Trans., vol. viii. page 16 ' i'if i^KerWopfts Sci. I,Kdicales. » Cllnique Chirurgioale, tome n. p. 665. Art. m Liici. Jincyo op ANTERO-POSTERIOR CURVATURES OF THE SPINE. 503 Etiology. — In dealing with the etiology of cyphosis, it will he most con- venient to classify the causes of the aft'ection according to the period of life at which it has commenced. The cyphosis of infaids and of quite young children depends for the most part upon rickets, and consists of a very general and equable curving back- wards of the whole column. This rachitic curvature will be treated of here- after. Quite independent of rickets, however, cyphosis may be developed at this period of life, and under such circumstances will depend upon a normal muscular weakness, if such a term can be allowed. It is well known that the spine at birth is straight, and that the curves that normally mark the adult spine are the result of a subsequent development, and are dependent upon the establishing of a proper equilibrium in the erect posture. For a consider- able time after birth the erect position is not required. The normal posture of an infant, indeed, is the posture of lying flat upon its back. Thus it happens that the spinal muscles long remain'but imperfectly developed, and it will be seen that the spinal column in infancy may readily be induced to assume almost any species of curvature. In cases of general muscular debility, some cyphosis naturally develops when the erect posture is attempted, and that cyphosis is, indeed, but the outward sign of an inability on the part of the muscles to properly support the spinal c'olunm. A cyphosis from a like cause, will commonly develop in the backs of in- fants who are continually being nursed in the sitting posture. Such a position is unnatural, and the spinal muscles are usually unable to retain the colunm erect; the child's spine yields to the pressure of the superincumbent weight, and a more or less extensive posterior curvature is the result. Besides "the pernicious habit of nursing infants in the sitting posture, some mothers take particular pleasure in making their children sit upright at as early a period as possible. They appear to consider that an ability to assume this position is an evidence of precocity and rapid development, and is an accomplishment to be fostered as tending to strengthen the back. The result, however, is often a very definite cyphosis, that may become more or less permanent. It must be allowed, however, that the posterior cui-vature that may develop in the spines of infants and young children shows some tendency to more or less correct itself when the child begins to walk, and begins in consequence to de- velop those curvatures that are normal to the adult spine. A cyphosis may develop about pi/^er^?/— especially in weakly girls— either, it would appear, from debility of the spinal muscles in common with the other muscles of the body, or from an undue or disproportionate use of those struc- tures. The causes of cyphosis at this period are, probably, very nearly iden- tical with those that tend to produce a lateral curvature of the spine. The child, perhaps, is engaged for a long time in a sitting posture without proper support to^ the back. In learning the pianoforte, or in the ordinary routine of school life, this position is often assumed for hours at a time. The nuiscles, either from inherent weakness or from undue use, become wearied, the back aches, and the child throws the burden of supporting the column upon the hganients that are not susceptible to a sense of weariness. To effect this the back IS arched backwards, and a temporary cyphosis produced ; but in time the over-stretched ligaments yield, the elements of the column undero-o slight structural changes, and the curve becomes permanent. Cyphosis is the posi- tion often assumed by the tired child who is compelled to still retain the upright posture, and it requires merely a frequent repetition of the malposition to render it definite and permanent. As active causes therefore in producincr this form of cyphosis, one must recognize any debilitating infiuences,prolono;ed sitting or standing without support to the back, too earlv study, laclJof proper muscular exercise, and, as some would urge, the early and continued 504 MALFORMATIONS AND DISEASES OF THE SPINE. use of rio-id corsets, that, ^vhile mechanically supporting the spine, tend to discoura-n! a proper development of the spinal muscles. u • ^ a The c3Tho is of adults may depend upon mam' causes It may be induced bv an employment that involves prolonged arching of the back, or prolonged stoop n", or ^bendiug forwards of the head, or it may depend upon chronic rhe?mat c arthritis^f the spine (spondylitis deformans . In most cases, h"er, the cyphosis of adults is secondary to some previous morbid condi- tion, and is therefore " symptomatic," rather than " essential. Thus, any disease inwlving frequent or prolonged dyspnoea may lead to some cvphosis as the result of an attempt to increase the chest capacity by an aiXino- If the dorsal vertebra. Asthma and emphysema are not infrequently associated with this form of curvature. Chronic pamful affections of the ab- domen may lead to cyphosis as to a means of relieving pam by avoiding preiure upon tender parts. Thus FoUin and Duplay' enumerate metritis and chronic peritonitis among the causes of cyphosis. . ^v. a ^ . Muscular Jlieumatism, either by directly causing ««"^raction of the flexor of the spine, or by rendering the extensors painful and thereby to some extent useless may lead to this posterior curvature of the column. Jacques Del- ; ch' iSsIhe case of 2 man, aged 25, whose back be^Be so arche^^^^^^^^^ Lid from rheumatism that he could not support himself without crutches. Gymnastic exercise was advised, and in time a complete cure followed _ Cyphosis is very common in the aged, and especially among the laboring classes. It depends in many instances upon a general enfeeb mgot the mus- cuTar System, with probably- some loss of elasticity in the elastic tissues Not intently t is the result of chronic rheumatic arthritis, and the case figured by r.f Agnew,' of an old woman with general cyphosis so severe that when in the sitting posture her chin touched the knees, was probably of this natur^ in otheHnstances the arching of the back has been determmed by the patient s employment, or by some of the causes just detailed. Lastly, it must be remembered that cyphosis may be hereditary, and this remark-especially applies to a limited cyphosis of the "PP^r clorsal region Pathological J««tomj/.-Cyphosis may be general or partial. If gen^nal, thfwhole^of the spinal column is involved, including even the lunibar region but Ih s form of the disease is quite rare. The great majority of the cases ot cypho is aJe of'limited extent, and are restricted to the dorsal region. Such instances of limited cyphosis consist indeed merely of an increase in the natural curve of the dorsal spine. The curvature is most usually about the (Centre of the dorsal region, the summit of the curve being represented by one vertebra alng the A 6th, 7th, or 8th; and of these it would appear tfia Ihe 6th dorsal .-ertebra is the one that most commonly marks the greatest TOint in the curvature.^ The curve, however, may involve the upper doi-sal reSalone, or the dorso-lumbar region alone, or all the vertebm from the cefvical to the lumbar may be implicated in the deformity. It is also to be remarked that cyphosis may coexist with lateral curvature of the spine or seSiosis In the slighter firms of the disease, there is merely some relaxa- ion of ihe vertebral^ligaments, with a separation of the laminse and spmou processes but without any gross alteration in the bones _ themselves. In Sed and confirmed exaun^les of this deformity, the anterior Holmes's System of Surgery, 2d ed„, vol. ii. page 367. « Path. Soc. Trans., vol. iv. 1853, page 27. * Ibid., voL xv. 1863, page 1. pott's disease of the SPlxNE. 515 nite, general features. The spine becomes rigid and tends to develop an angular deformity, an abscess with some peculiarities may form, paraplegia may ensue, and, after death, the anterior segments of the column will be found more or less extensively damaged by a destructive process. Various names have been given to this disease, and some explanation may be offered as to why the particular name that is adopted here has been selected. Among the terms applied to, or associated with, this malady, may be mentioned caries of the spine, vertebral tuberculosis (Xelaton), vertebral arthritis (Ripoll), osteitis of the spine, angular curvature of the spine, and Pott's disease. The term " Caries of the spine" is very definite, but its very preciseness is an objection to its use in the present instance. The morbid process in this malacly is indeed, in the vast majority of all cases, a caries of the bone, but at the same time cases are recorded where the bone has been exempt and the disease has been limited to the intervertebral fibro-cartilages. On the other hand, it can by no means be said that all cases of vertebral caries are asso- ciated with the general symptoms above mentioned, so that, if the clinical -entity of the "Pott's disease" is to be maintained, the term now criticized is both too narrow and too wide. The terms " vertebral tuberculosis" and "vertebral arthritis" are to be discarded, inasmuch as they commit the user to certain very definite and limited views, in the one case as to the nature of the morbid process, and in the other as to its primary seat. The term ^'osteitis of the spine," on the other hand, is too indefinite to express the peculiar clinical attributes of the present aftection. Inflammation is common enough in the bones of the column, but it is only in a comparatively small number of instances that that process leads to the definite disease known by many as Pott's disease. It would certainly be no gain to clinical surgery to forcibly associate this disease with such other forms of osteitis of the spine as necrosis of the spinous processes after injury, or inflammation of the odontoid body. The common and much used term "angular curvature" is open to the gravest objections. In the first place, the term is in itself ridicu- lous, involving, as it does, an obvious contradiction. An angular curve must, from a geometrical point of view, be classed with a square circle, or a round triangle. Then, again, the angular deformity is but one symptom of the disease, and that symptom, be it noted, not of necessity a constant one. ^[oreover, unwholesome ideas as to the treatment of the disease may be per- petuated by the prominence thus given to an important but isolated symp- tom. Finally, I would urge the use of the term " Pott's disease" upon these grounds. The meaning of the expression is well known, and its clinical associations are familiar. The term is extensively employed, not only in England and America, but especially on the Continent. In France, indeed, the title " mal de Pott" is the generally accepted name for this malady. Then, again, the term commits the user to no particular pathological opinion, and may be used by men holdino- the most opposed views in pathology, to express the same association of clinical features. Lastly, the term serves to l)erpetuate the nanie of a man who well deserves the honor, and who was the first to remove this disorder of the spine from the region of a confused igno- rance, and from the especial province of the quacks. Etiology. — Age. — Pott's disease may occur at almost any period of life. It has been met with in infants in arms, and in patients far advanced in years. l>ryant,i indeed, details an instance where the disease attacked a foetus in utero. The specimen is preserved in Guy's Hospital Museum, and shows '"the bodies of three or four of the dorsal vertebrae .... clearly fused I Manual for the Practice of Surgery, vol. i., 2d ed., p. 278. 516 MALFORMATIONS AND DISEASES OF THE SPINE. together from disease, giving rise to angular curvature." Cases, however, of Pott's disease at these extreme periods of life are exceedingly rare. The malady is usually met v^dth between early childhood and adolescence, and in the great majority of all cases the disease commences between the ages of two and ten years. Instances are met with of the disease commencing in adults, but such instances are comparatively few, and the onset of Pott's disease in patients past middle life is very rare. This affection is indeed essentially a disease of childhood. Sex. — Sex appears to have little or no influence in the etiology of the dis- ease. It has been asserted by many — and especially by those who urge a traumatic origin for Pott's disease — that it is more common in male than in female children. My own observation would lead me to believe that it is equally common in the two sexes, but Mr. Fisher's^ statistics show a greater number of cases among females. These statistics are probably the most valu- able that have been published. Of 500 cases of angular deformity treated at the ^sTational Orthopsedic Hospital, 261 were in females and 239 in males. Allowing for the preponderance of females over males in the general popula- tion, these figures would make it appear that the disease is, perhaps, equally common in the two sexes, and would at least correct the assertion that the malady particularly affects boys. Constitutional Condition. — Pott's disease is usually met with in unhealthy children, and especially in those who present that phase of ill health known as scrofula. It must be confessed that on this point there has been no small amount of dispute, and while some have urged that every case is directly due to scrofula, others have maintained that that diathesis has nothing to do with the production of the disease. Many of these discrepancies are to be ex- plained by the various conceptions that are held as to the nature of struma. Those who expect every patient with Pott's disease to present a certain phy- siognomy, will certainly be disappointed, as will also those who may expect every such patient to present glandular disease, or to come of a decidedly " tubercular" stock, or to finally die of some tubercular malady. Scrofula, as I have tried to demonstrate in a recent work on the subject,^ is rather a ten- dency to a peculiar form of chronic inflammation. Of the character of this inflammation I will speak subsequently. The diathesis is rather to be esti- mated by certain morbid tendencies in the tissues, than by any peculiarity of feature or descent. In support of the assertion that angular deformity is most usually met with in the strumous, I would draw attention to these facts. ^ In a great number of instances, the patient's immediate relations are the subjects of^acknowledged scrofulous disease. • In many instances there is a history of phthisis or of tuberculosis in the family. The patient often exhibits some other evidence of a strumous habit. This may be seen by a tendency to chronic catarrhs, by the occurrence possibly of certain skin affections, or by a disposition, it may be, to certain glandular enlargements. In not a few in- stances I have notes of cases where the spinal disease was cotemporary with, or preceded or followed by, some such gross, strumous ailment as " white swell- ings" of , a joint, or caries, or necrosis of some bone. Lastly, as I shall point out when dealing with the pathology of this disease, the morbid changes that take place in the vertebrse are very often identical with changes occurring in acknowledged scrofulous disorders. Some authors have objected to Pott's disease being classed among strumous affections, because many of those who suft'er from the disease do not present at the same time great glandular swell- ' Essays on the Treatment of Deformities of the Body, p. 11. London, 1879. ^ Scrofula and its Gland Diseases. London, 1882. See also my article on *' Scrofula," in Holmes's System of Surgery, 3d ed. London, 1882. pott's disease of the spine. 517 ings, or other strumous malady. A few do show these eomplications, while the majority do not ; and the condition of these latter is, I think, to be ex- plained by that antagonism that appears to, exist between the various stru- mous disorders, and that does not favor the appearance upon tlie same patient, and at the same time, of more than one gross manifestation of the disease. In the book just ahuded t(^, I have endeavored to fully demonstrate this antagonism. While then, I would not for one moment insist that all the victims of Pott's disease are of necessity scrofulous, I would urge that the majority of such patients present reasonable evidences of this diathesis. I have, for exam[»le, met with several instances of this spine-affection in (diil- dren who have appeared in perfect health as regards their general condition, and who have moreover presented no suspicion of struma in their families ; but such instances are exceptional. Lastly, I believe it will be very gene- rally allowed that Pott's disease is more common among the poor than among the rich, or well to do, and that it is most common in association with those i>:eneral conditions which are the most favorable to the production of struma. Some few writers have maintained that angular deformity may be due to rheumatism or gout, but there would appear to be little or no foundation for this statement. On still scantier grounds has masturbation being assigned as a cause of this disease.^ Lijtiry. — There can be no doubt that injury bears an important part in the etiology of Pott's malady. In those cases in wdiich the disease attacks children who are apparently in robust health, and who present no constitutional taint of any kind, I believe that an injury is to be assigned as the actual cause of the mischief in the spine. In those cases, moreover, in adults who appear to be in all other respects in perfect health, a history of injury, distinct and grave, is seldom, if ever, absent. The frequency with which the disease would appear to commence about the junction of a vertebra with its interarticular tibro-cartilage, supports the theory of an injury as an essential cause. For it is well known that the point of junction of a rigid with an elastic segment of a column is a point of weakness. Allowing, then, that an injury is, in certain cases, an essential cause of angular deformity, I doubt if the majority of sur- geons would go further, and assert with Dr. Sayre that this disease "is almost always, if not alwa3^s, produced through some injury to the bone or car- tilage."^ There must be very few children who reach the age of ten years without having met with some accident, trifling although it may be, in which the back has been, directly or indirectly, involved. Any inquirer who starts with a bias in favor of injury as an essential cause of Pott's disease, will not lack material to support his opinion. The only question is as to the value of that material. Of how many children at the age of ten, could it not be probably said that "so many months ago it fell and hurt its back," or had a bad tumble," or " had something strike it in the back?" Those who maintain the importance of injury in this disease, must also accept the onus of explaining why Pott's disease is not more common than it is, and why a given injury will produce the malady in one child, while it has no permanent effect upon another. In scrofulous children, in children already predisposed by heredity or acquired defects to certain phases ot chronic inflammation, it is easy to understand that a very slight lesion may excite a carious action in the vertebrae. Whether such a lesion is essential, or not, it is difficult to say, and still niore difficult to prove. There is the further question as to wdiether this lesion must of necessity be " an injury" in the usual meaning of that word, or whether it may not be caused by undue use of the part, by dispro- ' See, for example, South's edition of Chelius's Surgerv, vol. 1. page 280. * Spinal Disease and Spinal Curvature, p. 2. London, 1S77. 518 MALrORMATIONS AND DISEASES OF THE SPINE. portion between the strength of the column and the weight it maintains, or hy undue pressure exercised upon some especial part of the vertebral segments. Lastly, if traumatism were so essential a feature in Pott's disease, it would not be unreasonable to expect that some definite relation should exist, other things being equal, between the injury and the consequent disease. But no such relation exists. A severe, extensive, and acute form of spinal caries may occur with the absence of a history of any definite lesion, while, on the other hand, a severe injury to the back may be attended with no ill results other than those immediately connected with the accident. Considered generally, the etiology of Pott's malady bears a very striking resemblance to the etiology of " white swelling," or strumous joint disease, and there is an almost complete identity between the various opinions that have been advanced as to the causes of the two complaints. Pathological Anatomy. — The morbid change that constitutes the essential feature of Pott's disease is, with some slight reservation, a caries or molecular disintegration of the vertebral bodies. This change may attack any part of the column, but is more commonly met with in the lower dorsal region than elsewhere. In some rare cases, two distant parts of the spine may be involved at the same time, or may be attacked independently at difi:erent periods. An example of this latter circumstance is recorded by Shaw.^ Although the disease may be limited to a single vertebra, such an occurrence is rare, and in most instances many of these bones are involved, and often in very varying degrees. Bryant^ reports a case where no less than twelve vertebrae w^ere in- volved. The morbid process nearly always commences in the bone ; it may, however, commence in an intervertebral fibro-cartilage, and there are some who assert that the earliest change may take place in the periosteum, or in the spinal ligaments. There does not appear to be any positive evidence to support the theory of the origin of this disease from the tw^o last-named structures. The whole pathological process in Pott's disease may be divided into two distinct periods or phases : first, the period of destruction or softening ; and, secondly, the period of repair. The changes themselves can be best con- sidered (1) as they affect the bone, and (2)^as they affect the intervertebral cartilage. 1. Period of Destruction or Softening.^ — (1) Changes in the Bones. — These changes consist in a caries that has some few peculiarities. The morbid action is sin2:ularly limited to the anterior segments or bodies of the vertebrae. The body may be extensively and even entirely destroyed, yet will the morbid, action have little or no tendency to extend to the posterior segment of the bone, to the laminae, the pedicles, and the various processes ; seldom, indeed, does it extend as far posteriorly as the articular processes and intervertebral joints, although, as a somewhat rare occurrence, these parts of the bone may be involved. The disease may commence in any part of the body of the vertebra, or at several parts at one and the same time. Most usually the earliest changes would appear to be in the anterior part of the bone, not far from the anterior surface. Another common spot for the commence- ment of the disease is that part of the body of a vertebra nearest to the inter- vertebral disk. It must be remembered that this part of the centrum is an epiphysis, and the disease would appear in many cases to begin as an epiphy- 1 Holmes's System of Surgery, 2d ed., vol. iv. p. 112. London, 1870. 2 Manual for the Practice of Surgery,vol. i. p. 277. 3 After d(iscribirig the process as it affects the bones and cartilages it will be well to include under this heading an account of the " deformity " and the " abscess." pott's disease of the spine. 519 sitis, as it is called. Certain it is, that for some time the miscliief may remain limited to that portion of the bone which corresponds to the epiphysis. Folliu and Duplay state that the earliest change in Pott's disease is often to be noticed about the posterior part of the body, near its junction with the pedicles; and other observers have cited the centre of the bone as a frequent spot for the conmiencement of the disease. The change itself would be described, in the language of the text-books, as an osteitis interna^ or as a caries fangosa, and, very briefly, the following are the alterations that are to be noted in the part: A certain area in the cancellous substance of a vertebral body becomes congested, and all the spaces in the bone become engorged with blood. Into the immediate cause of this limited congestion we cannot now enter. This vascular disturbance is soon followed by grosser changes, which consist, in the main, of two distinct processes — a softening and- breaking down of the bone structure, and a development of certain fungous granulations. To properly appreciate these changes, it is needful to recall to mind the fact that two elements enter into the formation of bone, viz., inorganic matter and an organic matrix. The relation which these two elements bear to one another may be compared to the relation that exists between the plaster and the laths in a lath-and-plaster wall. Just as the laths support or hold together the plaster, so does the organic matrix of bone serve to support the inorganic elements or lime-salts. Kow, it is obvious that the morbid process in inflammation of bone must be limited to the organic matter of the afi:ected tissue, and that the inorganic material can take none but a purely passive part in any pathological change. Inflammation, to speak roughly and generally, has a tendency, in the flrst place, to soften the tissue that it invades. When inflammation attacks bone — or, rather, when it attacks the organic matter of a bone — it softens that material, and one might almost say that it dissolves it. The result of such a change is, that the matrix is no longer able to support the inorganic elements, and the structure crumbles down, just as would a lath-and-plaster wall if it were possible by some pro- cess to dissolve out the laths without seriously disturbing the plaster. It is needless to say that this softening and disintegrating change is no mere chemical process, but is brought about by active changes in the part itself, and in the bloodvessels that are concerned in its nutrition. Into the minute features of the process, it is unnecessary here to enter. Suffice it to say that the partition walls between neighboring cancellous spaces are broken down, and that one large and irregular space results from the fusion of several small ones. Thus, the bone becomes lighter and more spongy, more cancellous apparently in its structure, and more^ friable undoubtedly to the touch. These bony spaces are by no means empty, nor have they for con- tents but the debris that has resulted from neighboring disintegration. On the contrary, they are occupied by a " fungous" granulation-tissue that has been derived partly from the altered cell-elemenT:s of the bone, and partly from an exudation provided by the bloodvessels in the area of disease. The fungous" character of these granulations can hardly be said to be apparent until there is such a loss of parts that they find themselves projecting from a free surface. These granulations are very intimately connected with the dis- integration of the bone. Indeed, they appear to penetrate the parts and carry destruction in their wake. It is by them that the process spreads, and it is to them that the pathologist has turned for a clue to the nature of the entire process. When the disease reaches the periosteum, the granulations are described by Lannelongue-as perforating that membrane, and as piercing it, as it were, often at many points. The periosteum, readily altered, Avould become a part of this granulation-material, and would in time be destroyed, as the bone had been destroyed. Thus would the bone be bared and an erosion in 520 MALFORMATIONS AND DISEASES OF THE SPINE. its substance be exposed, or a deeper cavity in its interior be made manifest. Such are the main features of this caries fungosa. The mischief most usually would appear to commence at some little distance below the surface of the bone, but hi certain instances the layer of compact bone next to the periosteum has been credited with exhibiting the earliest evidences of disease. Pos- sibly — as above remarked — the mischief may sometimes commence in the periosteum. ! The gross and visible result of the carious change, however, is this : Irregu- lar cavities are formed in the diseased vertebral bodies. There may be several cavities in the same centrum, or one only, and the situation of, the loss of sub- stance may vary considerably. If the cavity forms deep down in the bony substance, it may continue to increase until nearly all the cancellous portions of the body are destroyed, and nothing is left but the outer shell of compact bone. This probably soon gives way, and the cavity opens upon the surface. In other cases the destructive action may early make its way towards the surface of the bone, and lead to an excavation in the bone that, while com- paratively small, is yet deep. It is remarkable that the carious process tends, with the very rarest possible exceptions, to progress towards the anterior sur- face of the bone, and not towards that surface that bounds the spinal canal. It will be seen that these cavities and excavations will var};- greatly in appearance. There may be a cavity deeply hidden in the bone. There may be a cavity near the surface, whose walls are formed partly by bone, partly by thickened periosteum and ligament. In other cases the anterior surface of the bone is laid bare, and thus are exposed erosions varying in extent and depth, or deeper and more cavernous losses of substance. As long as the destructive process is in any way active or progressive, so long will the walls of these cavities be lined by the granulation-tissue just alluded to. The con- tents of the cavities vary greatly according to the duration, and perhaps according also to the nature of the morbid process. In recent cases the con- tents may be laudable pus, or more usually curdy pus, made up of a thinnish opaque fluid, with flakes of a denser matter. Seldom, indeed, is the con- tained matter quite homogeneous. In less recent cases the contents may be thick or creamy, or still further inspissated so as to be caseous and firm. In any case there is usually mixed with the matter some bony debris that can be felt like grit when the contents of these cavities is passed between the finger and the thumb ; and in certain instances this debi^is may appear as actual and visible sequestra. Lastly, with regard to the extent of the disease in the vertebral column, regarded as a whole, the utmost diversity exists. As already remarked, only one body may be diseased, although, as a rule, many are attacked. The extent to which the individual centra are involved varies greatly. There may be merely a small cavity or excavation in each of the diseased vertebrae, or several of these bodies may be entirely destroyed, and no trace be left of them other than is provided by the undestroyed posterior segments. As a rule, the intervertebral cartilages are more or less extensively diseased, but cases are occasionally met with where extensive loss, of several contiguous vertebral bodies is associated with little or no appreciable destruction of the intervening disks. In the place of deep excavations in certain of the bones, there may be found a superficial erosion involving the anterior and lateral surfaces of a number of the bodies, and it is remarkable that when such erosions exist they are seldom limited to a small portion of the column. Some further observations will be made upon this subject in dealing with the deformity that forms so important a feature in the disease. Before leaving the matter of the osseous changes, it may be well to briefly discuss the nature of the process that leads to these changes. It is very gene- pott's disease of the spine. 521 rally allowed that the process is to be classed as a caries, but the great matter in dispute is, whether that caries is simple or tubercular. A vast amount has been written upon this subject, and a good deal of it to very little pur- pose. Many pathologists have insisted that there is a distinct tuberculosis of the spinal column, wdiile they have at the same time allowed that in many instances the process is non-tubcrcnlar. Most elaborate distinctions have been pointed out as serving to distinguish the simple from the tuber- cular caries : but these distinctions, falling short (as they have until quite recent time) of microscopic demonstration, are for the most part useless and delusive. It has been urged that in the tubercular process the cavities formed are peculiar in their de[>th, in their walls, and in their contents. The pres- ence of caseous collections has been considered absolute demonstration of tuberculosis, and little opaque specks have been pointed out in the inflamed bone as veritable tubercles. It is now known that tubercles in inflamed bone are bodies not to be criticized by the unaided eye, that the minute opaque specks are but altered inflammatory products, and that caseous matter by no means of necessity indicates a tubercular change. It is well known that tubercular action cannot be judged of merely by the destruction it effects, nor by the outline assumed by the excavations that it leaves. It is also well known that the simple factor of chronicity can so modify the inflammatory process as. to lead to a great diversity of appearances. The question then still remains, Is the pathological process in Pott's disease tubercular or not? If by "tubercle" be meant the "primitive or elementary tubercle" of Koster, the "tubercular follicle" of Charcot, or the "submiliary tubercle" of other authors, and if the presence of this body constitutes a tuberculosis, then is the caries in Pott's disease very often tubercular. In the fleshy granulations of the diseased bone, and in the altered soft parts that lie about it, genuine tubercles have been detected, and Lannelongue has quite recently demonstrated the manner in wdiich the carious action spreads by the development of tubercular tissue. It may, I think, be considered as distinctly proved that a local tuberculosis takes a part in at least some of the cases of Pott's disease, and, as far as I have been able to see, it probably takes a part in quite the majority of all cases. Unfortunately, a very grave and often most inappropriate clinical meaning has been attributed to local manifestations associated with tuber- cle. Any individual who presents tubercle in his body, is considered to be possessed with a very fatal ailment, and to be liable to death from the devel- opment of some more general and widespread form of tuberculosis. Into the nature of tubercle-producing processes I cannot now enter, but I have endeavored in the book already alluded to, to assign to them a somewhat more simple significance than they are usually credited with. As a matter of fact, the bulk of patients with Pott's disease, even if they do present tubercle in the spinal bones, do not die of general tuberculosis. Indeed, as far as my own experience goes, that form of death is tolerably unusual. Then again the fact must be recognized, that tubercle-producing processes may undergo spontaneous cure, and are, when quite local, susceptible to treatment. This has been fully demonstrated in the matter of scrofulous glands, which often present the most perfect forms of tubercle. I have endeavored elsewhere to show that tubercle is no neoplasm in any other sense than that it is an in- flammatory neoplasm, and that it is the outcome of a peculiar and distinctive inflanunator}' process. The main features of this inflammatory process are these : it is usually chronic, and is apt to be induced by very slight irritation, and to persist after the irritation that induced it has disappeared. The exudations in such a process are remarkable for their cellular character, and for the large size of 522 MALFORMATIONS AND DISEASES OF THE SPINE. some of their elements. Such exudations show also a remarkable tendency to resist absorption, and to linger in the tissues, the affected area becoming rapidly non-vascular. Among the common products of these inflammations are o'iant-cells, and, if a certain stage of the process be reached, tubercles. The tendency of the process is to degenerate, not to organize, and the degene- ration usually takes the form of. caseation. At the same time, these inflamma- tions have a tendency to extend locally and to infect adjacent parts, and their products present certain peculiar properties when inoculated upon animals. Lastly, the great feature of the process is this: it tends to commence in and to most persistently involve l^^mphatic tissue, and so actively is the marrow or lymph tissue of bone involved in the condition now under notice, that this at first consists essentially in an inflammation of marrow. This account will, I think, very fairly represent the nature of the process in many cases of Pott's malady of the spine. It must, however, be confessed that this condition is not met wdth in all instances. It is not to be expected in the caries that may follow after injury in a robust person free from any disposition to tubercle-producing inflammations. Such caries will usually be more active in its progress, will show less disposition to indiscriminate spreading, will be surrounded by a barrier of healthier action, and Avill show a less degene- rate condition of its products. On the whole, it will present a more favorable aspect of the disease, but, apart from such marked cases as these, it would be scarcely possible to diagnose the presence of tubercle with any certainty from naked eye appearances only. (2) The Changes in the Intervertebral Fihro-cartilages. — In most cases of Pott's disease, the intervertebral disks share in the destructive change. These bodies become softened and friable, show more or less extensive and often irregular losses of substance, and may be so entirely destroyed as to leave no trace. In cases where many vertebrse are attacked by a superficial erosion, a like ero- sion is generally to be seen on the front or sides of the corresponding disks, or in the centre of the disk a large cavity filled with more or less fluid matter may be discovered, that may be fairly compared to the cavities formed in the bone. There is generally a disproportion between the amount of destruction in the bones and that in the intervening cartilages. As a rule, the destruc- tion is most marked in the vertebral body, a condition to be explained pos- sibly by the fact that the mischief usually commences in the bone and then spreads to the articular disk. In this way the bone may be found extensively destroyed, and the cartilage thereby laid bare, and marked by a certain amount of softening of its parts, and by some irregular losses of substance. If the bodies of two or three adjacent vertebrae are entirely destroyed, there will be probably no trace of the disks that once intervened between them, although, in some cases, fragments may still be detected among the debris^ of such an outline as to faintly mark out the position of the lost centra. In exceptional cases the disease would appear to commence in the intervertebral fibro-car- tilages, and those bodies may not only present the greater amount of destruc- tion, but may exhibit the sole changes observed in the column. Broca^ gives the case of a young man, whose spine, after death, showed superficial erosion of all the dorsal vertebrae, with destruction, however, of no less than nine of the intervertebral articulations. In the place of the fibro-cartilages was a whitish, pap-like matter, and some bony debris^ derived probably from the rubbing together of the bared surfaces of bone. Chassaignac^ reported a case, also in an adult, where there was no trace of any intervertebral disks between the second, third, and fourth lumbar vertebrae. The bones appeared sound. 1 Gaz. Hebdom., p. 298. 1864. 2 Gaz. des Hopitaux, p. 156. 1858. POTT S DISEASE OF THE SPINE. 523 and were anchylosed together. An abscess had formed, but it was in procesa of cure. In an early volume of the Pathological Society's Transactions is an account of a case where the bodies of the six lower dorsal vertebne were carious on the surface, but where little or no trace of the corresponding disks was to be found. ^ Mr. Adams gives the case of a man, aged 43, who died of lumbar abscess. There was no deformity of the spine. The only lesion found in the column was due to the entire disappearance of the disk between the fourth and fifth lumbar vertebne. Between these bodies (which are described as a trifle " indurated") a gap existed that was exactly of the size and shape of the lost fibro-cartilage. The same observer records also a like case where the intervertebral cartilages between the tenth and eleventh dorsal and the third and fourth lumbar vertebne had been entirely destroyed, without any corre- sponding loss of substance in the adjacent bones. In this instance there was a psoas abscess, but no deformity of the back. Mr. Adams believes that the disease may, from first to last, be limited to the cartilages between the verte- bral bodies.^ Before dealing with the process of repair in Pott's disease, it will be neces- sary to give some account of two very conspicuous results of the process of destruction, viz., the deformity and the abscess. The Deformity. — When the destructive process has attained a certain magni- tude in the anterior segments of the vertebrae, a gap is produced that destroys the continuity of the column, as far, at least, as the part of it in front of the vertebral canal is concerned. It is obvious that the existence of such a gap would be incompatible with any great pressure upon the column, and, if the loss of substance were considerable, it would be scarcely compatible with the erect posture. What usually takes place in Pott's disease, therefore, is this : The column yields at the diseased point, it bends backward, the gap is elimi- nated by the approximation of the vertebra above the gap with the vertebra below, and in this way an angular projection of the posterior segments of the column is produced. It is needless to say that the development of this defor- mity is the most conspicuous feature in the disease. While this falling together of the vertebrae about the seat of the disease is essential to maintain any degree of stability in the column, it at the same tirne serves probably to keep up and to aggravate the carious action. By this alteration in the configuration of the column, two diseased surfaces are brought in contact, and, more than that, are pressed together, and probably rubbed together. However injurious such approximation of parts may be, it is still very essential for the purpose of repair, and for the subsequent con- solidation of the weakened spine. The projection — as above observed — is angidar, and the apex of the angle usually corresponds to the posterior seg- ment of that vertebra in whose body the destruction has been the most exten- sive. There is some relation between the extent of the deformity and the amount of disease, although that relation is by no means a constant one. If only one or two vertebral bodies are lost, but are entirely lost, a sharp angle is produced; but, on the other hand, if many bones are involved, and none" of them to any great extent, a more rounded projection results, and a deformity more approaching a curve is produced. If the anterior segments of the column be examined at the seat of the deformity, very various conditions niay be met with, depending upon the nature and extent of the destruction. Stiveral vertebrae may be blended together in a confused mass, or tw^o ver- * Trans. Path. Soc, vol. iv. p. 7. London, 1853. « Ibid., vol. V. p. 241. London, 1854. 524 MALFORMATIONS AND DISEASES OF THE SPINE. tebr^fi partly destroyed, may be found so pressed together as to have dis- placed backwards some fragment of a third and intermediate body more extensively destroyed than themselves. Or the vertebrse, m fallmg m together to close up the gap, may have included a sequestrum of varymg dimensions that lies buried deeply in the angle of the deformity. Or, if the gap involve only the anterior half of the body of a vertebra, the posterior half may be found to have yielded to the superincumbent weight and to the inflammatory softenlno; that invades it, and to have brought about the typical disfigure- ment by^a bendino; or yielding of its parts. Further details as to the deformity in this disease will be reserved until the symptoms of the malady come to be considered. Abscess (Psoas Abscess ; Lumbar Abscess ; Iliac Abscess, etc.)— An abscess usuallv presents itself externally at some time in the course of Pott's disease of the"^ spine. There are cases, however, where the malady runs its entire course and ends in anchylosis and cure, and yet no abscess makes its appear- ance. Such cases are not infrequent, but they cannot be regarded as any evi- dence of the existence of angular deformity without abscess. Probably m all these cases an abscess has existed at some stage of the disease. This abscess, as the cure has advanced, has itself undergone cure; its contents have become inspissated and caseous, or even calcareous; its walls have become shrunken and inert ; and but meagre traces of a once large collection of matter have persisted. I am not aware of any specimen that can of itself oflter an un- doubted example of spinal caries without abscess, and although the matter may still be regarded as unproven, it is probable that m all instances some suppurative collection is formed. The importance of the abscess m Pott s malady cannot be exaggerated. It usually forms the most troublesome feature in the history of the case, and, more than that, it is directly or indirectly the most common cause of death in those who are afflicted with the disease, i propose to deal first with the mode of formation of the abscess, and secondly with the various forms of the abscess as determined by position, etc. ^ Formation of the Abscess.— Lsinne]onQ^ue^ has described this process m con- siderable detail, and his account agrees in its general points with that most usually ffiven by pathologists. He speaks of the granulations m the bone as penetrating the periosteum, and as spreading the disease m the parts outside that membrane. He speaks of the soft parts around as becoming inflamed and involved in the process, and as presenting granulation-tissue akm to that which has been developed in the bone. Indeed, he urges that the morbid pro- cess in the bone and in the soft parts outside it are identical, and are modited only by diversity of structure and opportunities for extension and develop- ^ The debris and suppurative matters that result from the caries in the bone are first included, perhaps, within bony walls, and then within walls formed partly by the diseased bone and partly by the inflamed sott parts about it. l^astly, if the purulent collection acquires any magnitude, the wall that bounds it is derived practically from the soft parts alone, and the share taken by the bone in its limits becomes very insignificant. As the disease is m the anterior seo-raents of the column, the abscess appears upon the front surtace ot tne spme, not usually immediately in front-on account of the resistance ottered by the anterior common ligament— but a little to one side of the body ot the diseased vertebra. The collection will at first be small and sessile. As it increases, it tends to gravitate, and so move downwards on the spine. In this I Abces froids et tuberculose osseuse. Paris, 1881. pott's disease of the spine. 525 way it becomes pedunculated, and its fundus, or most dependent part, acquires dimensions quite out of proportion, often, to the size of its attachment. The abscess when in this condition has been aptly compared by Follin and Duplay to a leech, gorged with blood, hanging on to the column. The direc- tion the purulent collection tends to take — viz., a direction downwards along the front of the column — is to .be explained by gravity, by the less resistance oiFered in this position, and by the decided resistance offered to the progress of the abscess by the structures at the posterior part of the spine. The path- ology of such an abscess is identical with the pathology of like abscesses else- where. It will be obvious that the abscess will at first occupy the hollow or angle produced by the deformity, and this circumstance will explain the fact that large collections of pus may form in front of the dorsal spine, in this disease. Without any injurious pressure been exercised upon the lungs. The contents of the cyst vary. When small, the pus is usually curdy, and con- tains flaky matters with, possibly, some bony debris. When of large size, the matter may still present a curd-like appearance, although more usually it is tolerably thick and homogeneous. Varieties of the Abscess. — There are cases where the abscess may remain closely adherent to the seat of disease at the spine, and after attaining a cer- tain size may cease to grow. To such collections the name of vertebral abscess may be given. It is obvious that they could not be detected during life; that they would indicate but a comparatively slight or non-progressive form of the disease, and that they might afford examples of resolution or spontaneous cure. More usually, however, the abscess increases, and advancing towards the sur- face ultimately discharges itself from some part of the exterior of the body. Considerable variety is shown in the direction or route whereby these sup- purative collections reach the surface, and this variety in routes has led to some variety in names. The situation of the bone-disease will obviously m.odify to some considerable extent the point at which the abscess will ulti- mately present itself. If the disease be in the cervical spine, the abscess usually discharges itself at some point about the sides or back of the neck, although it may in rare cases present itself behind the pharynx (post-pharyngeal abscess), or open into the gullet or trachea, or pass down into the thorax, or wander to the anterior part of the neck. If the disease be in the dorsal region, the suppu- ration will usually follow the course of the psoas muscle, and thus reach the groin (psoas abscess). Or it may incline back^vards and discharge itself in the loin (lumbar abscess); or it may extend no lower down than the iliac fossa (iliac abscess) ; or it may pass that district and reach the gluteal region, or the perineum (gluteal abscess, etc.). Even w^hen all these routes are exhausted, the abscess may still present itself in other and more unusual situations. When the mischief is in the lumbar spine, the abscess most commonly points in the lumbar or iliac regions, or may follow the course of the psoas muscle, or present itself in one of the less usual situations to be hereafter described. It will be most convenient to give a very brief description of each of these varieties of abscess depending upon Pott's disease. Psoas Abscess. — This form of abscess is most usually met with in disease of the lower dorsal or upper lumbar region ; but it may occur with spinal caries in any part of the dorso-lumbar portion of the column. If the abscess commences in the dorsal region, the collection is placed ()ehind the pleura, and gravitates along the front of the vertebrae until it reaches the diaphragm. It may pass through the diaphragm, either by creep- ing along by the side of the aorta, or by making for itself a passage through that partition by inflammatory absorption. Its subsequent course has been 526 MALFORMATIONS AND DISEASES OF THE SPINE. very ably described by Mr. Shaw.^ "When the abscess," he writes, "has perforated the diaphragm and gained its abdominal side, it comes into relation with the heads of the psoas muscle. That muscle arises by one set of fibres from the sides of the bodies of the vertebrae, by another from the roots of the transverse processes ; and stretched across both orifices in front are the liga- menta arcuata. As the abscess, therefore, travels downwards, it has to pass throuo-h a narrow strait ; it is prevented from enlarging on the forepart by the resistance of the ligatnenta arcuata, and at the back by that of the spine and lowest rib ; hence, in order to proceed, it has to force its way in the line of the psoas muscle. That, however, can only be done by penetrating into its interior. It accomplishes this, in the first place, by inserting its most advanced part, like a wedo-e, between the two orifices ; it then splits and distends the fibres, so as to form a cavity for the reception of the pus ; the muscular fibres become incorporated with the walls of the abscess, and the psoas at length is con- verted, more or less thoroughly, into an abscess. But the muscle, charged wdth pus, does not expand equally in every direction. The fascia iliaca forms a kind of sheath for it ; and this being particularly strong on the inner side, and united firmly to the brim of the true pelvis, prevents the growth of the abscess invv ardly. On the outer side, however, the connections are loose ; and there enlargement takes place freely. The abscess now chiefiy occu- pies the hollow between the united fibres of the iliacus mternus and psoas muscles on the inside, and the crest of the ilium on the outside. When the advanced part reaches the level of Poupart's ligament, a certain retardation occurs ; and then a bulging will be observed along the line of the flexure of the groin. The abscess now perforates the abdominal walls. ...... and the opening is invariably at one place, namely, behind Poupart's ligament, between the united tendons of the iliacus and psoas muscles and the anterior inferior spinous process of the ilium. The situation corresponds to- the point of iunction of the outer with the middle third of Poupart's ligament ' i he abscess then descends a certain way down the thigh, and opens usually about the insertion of the psoas. n -, . j By this process, the entire psoas muscle may be destroyed and converted into a mere bag of pus, but, no matter how complete the destruction, the branches of the lumbar plexus that traverse the muscle remain intact, and lie, dissected out, across the purulent cavity. This cavity is generally very irreo-ular in its dimensions. Where it passes the diaphragm and the abdo- minal walls, it is usually narrowed into a small " neck," and there are many cases where the continuity between parts of the abscess-cavity has been destroyed by a temporary or permanent closure of the " neck" situate at the abdominal parietes. ^ • • xi • • The part of the abscess-cyst just above the perforation m the parietes is usually of considerable dimensions, and like dimensions may also be attained by the abscess in the thigh. On reaching the limb, the pus may leave the psoas, and extend iiidefinitely about the front of the thigh, forming a large collection of matter, or it may proceed down the limb and point at almost any part ot the extremity. Erichsen, indeed, cites a case where an abscess, which took origin in disease of the dorsal vertebrse, opened by the side of the tendo Achillis. Sometimes the abscess cavity bifurcates high up, and the pus descends m both psoas muscles, forming a double psoas abscess ; and the same condition may 'be met with where two abscesses form, one on either side, and descend independently towards the pelvis. Pus from disease of the lumbar vertebrae may enter the psoas muscle at any part of its length, and lead to the forma- tion of a definite psoas abscess. 1 Holmes's System of Surgery, 2d ed., vol. iv. page 119. 2 Science and Art of Surgery, 6th ed., vol. ii. 242. pott's disease of the spine. 527 Pus may leave the psoas muscle at almost any point, and lead to abscess in some other situation. Lumbar Abscess, — This abscess usually has its origin from some disease of the lumbar spine. The pus, guided by the fasciae of the part, passes along the posterior abdominal wall, in front of the quadratus lumborum muscle, and having reached the edge of that muscle, becomes superficial in the space bounded by the external oblique and latissimus dorsi muscles, the iliac crest, and the last rib ; or the pus may pierce the quadratus, or proceed along its inner parts, and ultimately point behind, at the outer edge of the sacro-lum- balis muscle. A lumbar abscess may, however, be but an offshoot from a psoas abscess, or it may proceed from disease in the dorsal spine where the purulent collection has avoided the psoas entirely, and has proceeded direct to the lumbar region. Pus in this region also may avoid the fasciae, and, escaping into the loose subperitoneal connective tissue, may set up a peri- nephritic or a pericsecal abscess. The term iliac abscess is applied to a purulent collection in the iliac fossa, and such an abscess may be due to disease in either the lumbar or the dorsal spine. It may be merely an offshoot from a psoas abscess, or a psoas abscess may leave the muscle at the pelvic brim, and, entering the iliac fossa, con- tinue to develop there. In other cases the pus may be directed to the iliac region by the aorta and common and external iliac arteries, or, in the case of lumbar disease, the matter may gravitate directly to this region. Gluteal abscess is not common, and pus may reach this region in many ways. An iliac abscess may increase considerably, and in time mount up over the crest of the ilium, and so reach the gluteal region. Or pus may be conducted to the great sacro-sciatic notch by the common and internal iliac arteries, and may escape from that notch, either above or below the pyriformis muscle. In other cases, the matter may appear to simply gravitate to the floor of the pelvis and escape at any convenient spot. It may especially follow the great sciatic nerve, and, pursuing the course of that nerve, the abscess may reach as far even as the ham.^ Lastly, the matter may pass towards the middle line, and may point in the perineum or ischio-rectal fossa. Some idea of the relative frequency of these abscesses in spinal disease, may be gained from the folio w^ing table by M. Michel : — ^ He gives the following as the result of an examination of 48 cases of Pott's disease iiccompanied by abscess : — In 39 of the cases the abscess was about the pelvis. In 6 it was in the neck, and in 3 it was found in the dorsal region. Of the 39 abscesses about the pelvis — 13 were about the groin, 14 occupied the iliac fossae and the upper and inner, or outer, part of the corresponding thigh, 1 appeared by the anterior superior spine of the ilium, 7 were in the lumbar region, , 3 in the gluteal region, and 1 in the perineum. Of the 6 about the neck — 1 was in the supra-clavicular fossa. 3 presented at the sides of the neck, and 2 were post-pharyngeal. , The 3 abscesses in the dorsal region appeared near the middle line, and by the sides of the diseased vertebrj3e. > FoUin and Duplay, op. cit., tome Hi. p. 666. 1868-9. 2 Diet. Eucyclop. des Sc. Med., Art. Rachis. Paris, 1874. 528 MALFORMATIONS AND DISEASES OF THE SPINE. Rare Forms of Spinal Abscess.— {1) In disease of the dorsal spine the pus inay proceed more or less directly backwards, and present itself by the sides of the corresponding spinous processes. (2) In disease of the same region the matter may pass forwards beneath the pleura and along the intercostal spaces, and thus reach the anterior mediastinum. Here it may be discharged by the side of the sternum. If the collection occupy the precordial region it may receive pulsations from the heart. (3) Mr. W. Adams has recorded a case that I believe to be unique, where the pus pursued an upward direction. The case was that of a lad, aged 12, with disease of the last two dorsal and upper two lumbar vertebrae. There was angnlar deformity. The abscess took at once an upward course,' and opened opposite the spine of the seventh cervical ver- tebra. (4) Mr. Shaw^ has recorded a case where the abscess follow^ed the course of the inguinal canal, and, presenting at the external^ ring, closely resembled a hernia. He cites, also, a like case recorded by Sir B. Brodie.^ (5) Broca^ has recorded a case where a psoas abscess opened into the hip- joint, having effected an entry through the anterior part of the capsule. (6) Leudet* notes an instance of the abscess opening into the spinal canal. (7) Several cases have been put on record where the abscess opened into the lung, and, in some of these instances, fragments of carious bone were expectorated.* In M. Michel's monoo;raph, above alluded to, a case is quoted where the abscess opened both into the lungs and also into the oesophagus. (8) In many instances a collection of pus derived from some spinal mischief may open nito the intestinal canal ; and usually, if not always, into the colon.- There may be an opening into the gut and one also through the skin, so that Avhile pus passes from the rectum, some fecal matter may also escape through the cuta- neous aperture. I have seen an example of this condition, and several cases have been recorded. Lallemand^ has given the account of a man, aged 19, who developed an abscess in the ischio-rectal fossa. This ultimately became a fistula in ano. When subjected to operation, a number of pieces of necrosed bone were encountered. It was then discovered that the man had " a delor- mity" of the lumbar spine. It was supposed that in this case the abscess was spinal, and the pieces of bone derived'from the vertebrae, but the evidence as to vertebral caries was very scanty, and the body was not exammed after death. (9) A spinal abscess may discharge its contents by the urmary bladder ; an account of a case presenting this complication is recorded by ^^The matter of implication of the spinal cord in Pott's disease will be con- sidered with the " symptoms of the malady." II. The Period of Eepair.— While destructive changes are going on in the anterior segments of the column, a process of repair is to be observed about the posterior segments. An adhesive form of inflammation appears to be excited about these parts. The periosteum covering the spinous and other processes becomes inflamed, a like change takes place m the ligaments that pass between the various portions of the posterior vertebral segments, and m this change the adjacent connective tissue has also a share. In this way the laminae, and the transverse and spinous processes that correspond to the dis- eased portion of the spine, become matted together by inflammatory material. As the change advances, the products of the inflammation organize, and the adhesion between the various parts concerned becomes much more intimate and 1 jjj^ p ]^23 ^ C)n Diseases of the Joints, p. 267. 8 Bull, de laSoc'. Anat., tome xxvi. p. 406. * Ibid, tome xxviii. p. 253. 5 See cases by Triquet (ibid., tome xxii. p. 450) and DeviUe (ibid., tome xxvni. p. 139), also case by Shaw (loc. cit., p. 125). _ • « Arch. Gen. de Med., tome vii. p. 474. Ifc35. ' Loc. cit., p. 1^5. pott's disease of the spine. 529 strong. If at this stage the specimen be macerated, the bones in the posterior segment will be found to present here and there irregular bony outgrowths, the result of periostitis, but there will be no direct or indirect bony union' between any two adjacent vertebrae. As the process of repair advances, ossi- fication occurs in the fibrous material that has been formed, the periosteal new growths assume a greater magnitude, adjacent vertebrae become locked together by the contact of stalactitic processes, and in certain cases the posterior segments of several of the vertebrae about the seat of disease may be firmly blended by a true anchylosis. This process of repair in the posterior segments of the column appears early in the course of the malady, and is seldom absent in any but the most severe cases. Evidences of it may be trifling, but they are usually to be noted. The importance of this process cannot be exaggerated. By the time that the disease has so far advanced in the anterior part of the spine as to destroy, perhaps, several successive bodies, the process in the posterior segments will probably have brought about such consolidation of the column as to prevent that gross bending or breaking of the weakened spine that, without such con- solidation, would be almost inevitable. With regard to the reparative processes in the anterior portions of the column, it must be remembered that the parts lost in Pott's disease are never replaced, and that in no case — after either slight or severe destruction— can the spine ever quite return to its normal condition. If the gap formed by the loss of tissue be considerable, the vertebrse, in falling together to produce the defor- mity, lessen the dimensions of the cavity and help to expel its contents. Bony surfaces above and below the seat of disease are thus brought too;ether.* If the process of cure at once advances, the granulations that cover the exposed bone develop into fibrous tissue, and with this material the cavity in time becomes more or less entirely filled. In certain instances, some portion of the fibrous tissue may ossify, and a more or less complete union of true bone ensue. ^ This true anchylosis, however, is of rare occurrence. If an abscess exists, Its contents become more or less absorbed, what was once pus becomes putty-like or caseous matter, the cyst shrinks, its walls become greatly thick- ened and more fibrous, and by clinging close about the seat of the disease serve to bridge over any gap that may have formed, and to still further strengthen the weakened part. In some cases the absorption of the abscess- contents would appear to be very complete ; and in other instances the puru- lent matter, alter becoming caseous, may finally undergo a calcareous meta- morphosis. The portion of the column that has experienced loss of substance IS strengthened also by a thickening of the periosteum, and by a develop- ment ot much fibrous tissue in such soft parts as are in the immediate vicinity. By the blending of these altered parts with the remnants of the abscess-wall, a very substantial support may be afiPorded. In addition to these means of immobilizing the spine, the ^ap may be bridged over by stalactitic processes of bone formed by the vertebra that im- mediately encroach upon the gap. Sometimes these bridges of bone may serve t^ fuse the vertebrae together by a true osseous anchylosis, while in other cases they may give support to the part by merely becoming locked together. Ihese masses of new bone are seen most often about the sides of the ver- tebral bodies, and appear sometimes as if derived from the anterior common ligament. When the loss of substance is limited to a mere surface-erosion on the bone the deficiency is supplied by a fibrous formation, although in some very rare cases, Follin and Duplay assert that the excavation may be covered in by a plate ot new bone formed from the adjacent sound bone and periosteum.* VOL. IV. — 34 * Op. cit., tome iii. p. 666. 530 MALFORMATIONS AND DISEASES OF THE SPINE. Where the intervertebral disks are alone destroyed,^ and in some cases where the loss of bone is very limited, the vertebrfB on either side ot the gap may become fused together by a true, central, bony anchylosis^^ in addition, posiibly, to union by%ony processes at their j^nphery. M. MicheP alludes [o a case where the •fibro-cartilages between all the lower cervical vertebree had been lost, and where the bodies concerned had become welded together bv firm, but irregular, new bone. .... If sequestra have formed they may be ehmmated, or if they remain in situ they will be usually encysted and hidden from view. The tissue that incloses them may be either fibrous or bony, although it more usual y belongs to the softer structure. Cloquet^ records a case m which the last two dorsal and two upper lumbar vertebra were necrosed, apparently en masse but in which the entire sequestra were firmly inclosed in a solid, fusiform cyst of bone. By this means the solidity of the spine had been mamtained. Lastly, it must be remembered that the longer the disease has lasted, the less can the vertebral column look to the spinal muscles for support. From long continued disuse these muscles waste, and become degenerate, and by their feebleness add an additional source of weakness to the already debili- tated column. Symptoms of Pott's Disease.— The symptoms of Pott's disease of the spine vary considerably, both in their comparative frequency and in their intense- ness They vary also in the order and time of their appeara,nce, and will obviously be influenced by the locality of the mischief m the column. They can be most conveniently considered under the following distmct heads : (1), Rigidity of the spine. (2) Local pain. (3) The spmal deformity. (4) The abscess. (6) The cord and nerve symptoms. (6) The gait and general aspect. (7) Some general symptoms. (1) RiqidUy of the Spme.-A rigidity of that part of the vertebral column which is the seat of the disease is usually the earliest sign of Pott s malady, and Ts, apart from this fact, a feature of great importance. This rigidity is, when of early occurrence, due to contraction of the muscles of the back, and is nature's mode of endeavoring to keep the inflamed parts at rest. It is exact y to be compared to that rigidity of inflamed joints that is to be especially observed when disease commences in the articular ends of the bones. At a later period of the vertebral disease, this symptom is also due to the permanent rigidity of the posterior segments of the spine, and to those v-anous conditions that lead to a false or true anchylosis of the diseased portion of the co "mn. In advanced cases, where the muscles have become flaccid and atrophied, this latter condition is probably the sole cause of the symptom. To fully appre- ciate this early evidence of spinal caries, it is well to make one's self familiar with the degree of mobility permitted in the norma column m children and Tdults of various ages. In examining a young child, it is most convenient to have t placed flat upon its face, and then, on lifting up the lower limbs and moving them (together with the pelvis) in various directions, with the unoc- cupied^ and plated upon the back, any rigidity of the column can be soon estLated. In Pott's malady, the portion of the «P"^e which is the seat of the disease, appears to move in a piece, and will permit of little oi no bend- nj o ro a ion'^in any direction. In adults this feature can be investigated n^the same manner, if an assistant moves the lower lin>bs and pelvis, and also by making the patient stoop and lean first to the one side and then to the other! or attempt any series of movements that will test the mobility of the spinal column. . Loc. cit., p. 478. ' Ga^- des Hop., 1858, p. 108. pott's disease of the spine. 531 (2) Local Pam.— The symptom of pain, localized at the seat of disease, is of very uncertain occurrence, and is, perhaps, more often absent than present. For diagnostic purposes it is of no value. On this point, Mr. Fisher well observes that " local pain in the back is much more frequently met v^ith when no disease of the spine exists than when the vertebrae are affected. In many cases no pain is complained of in the back, at the seat of disease, throughout the whole course of the ailment, and in other instances it is scarcely severe enough to draw comment from the patient. This local pain, when present, is usually deep seated, dull, uncertain in its duration, and worse at nio-ht and on vigorous movement. It is often much aggravated by any motion that Jars the spine, and may be found to be made worse when the spine is per- cussed. Mr. Howard Marsh, speaking of this symptom, says that the pai n may be felt either at the affected spot or below it, but very rarely above it.^ The pain, when present, is usually most obvious at the earlier stages of the disease, iuid ceases to be noticed when the spinal column has become more consoli- dated. It was the custom in less recent times to attach much importance to this local pain, and its recognition was accomplished in doubtful cases by pressing a hot sponge along the spine. This method of investigation has, however, been long proved to be useless. The pain to which reference is now made is due to inflammation of the bones, and proceeds, probably, directly from those tissues. It must be clearly distinguished from the severe, parox- ysmal, and often agonizing pain that sometimes radiates from the back, and is due to some nerve-irritation. In some cases, where the mischief is acute, there may be swelling and heat about the affected part of the spine. Such symptoms, however, are extremely uncommon. (3)^ The Spinal Defonnity.— This deformity, the so-called "angular curva- ture," is the most conspicuous symptom in Pott's disease. The method by which it is produced has been already detailed in the paragraph on the path- ology of the disease. In many cases it is the first symptom noticed ; and, indeed, in hospital practice it is unusual for a patient to be brought for treat- ment at a stage of the disease antecedent to the occurrence of the deformity. The deformity makes itself evident at an earlier period in some parts of the «pine than it does in others, and the conspicuousness of the "curvature" is greatly influenced by its site. The deviation of the column is seen earliest when the dorsal region is attacked, the explanation being that the dorsal spine has already a normal curvature backwards. The spinous processes also, in this region, are of great length, and are soon rendered' prominent by being separated" somewhat from one another. In the lumbar region the deformity is very slow to appear, owing to the fact that the normal curve in this part of the column is directly forwards; and, moreover, there must be considerable destruction of the vertebral bodies before it can make itself evident. In the cervical reo-ion no regular deformity is produced. In this region the muscles are better able to support and balance the diseased segments, with the result that, as the destructive process advances, the head simply subsides vertically towards the trunk, and the column becomes shortened. In some cases— either from un- equal destruction of the bones, or from unusual muscular action— the cervical spine acquires a slight lateral deviation to one or other side. In any case, the marked rigidity of the column is very conspicuous. ' It will thus be seen that the deformity in Pott's disease will be most con- spicuous, and will reach its greatest degree of development, when situate in » Op. cit., p, 12. 2 British Medical Journal, vol. i. p. 913. 1881. 532 MALFORMATIONS AND DISEASES OF THE SPINE. the dorsal re^^ion. It must not be supposed, however, that an " angular curvature" of necessity appears in all cases of Pott's disease below the cervi- cal reo-ion. In some cases— especially in lumbar disease— no delormity ap- nears throughout the whole progress of the malady ; but at the same time it must be confessed, that the absence of distort on m dorsal disease is very unusual. Bouvier endeavored to construct a table to show the relative fre- quency of deformity in the various segments of the spine, with the following results : — ' Out of 101 instances of Pott's disease there were _ 10 cases of lower cervical disease, 3 with deformity, 7 with none. 55 " dorsal " 45 " 10 " 36 " lumbar " 20 " 16 " These statistics are, however, of but slight val^ie, inasmuch as the duration of the disease is not given in the various cases. And it may not be unrea- sonable to suggest tlmt in some of the cases credited with no deformity, an " ano-ular curvature" may have in time developed. , ^ , . , , The deformity itself consists in a bending backwards of the column m the antero-posterior plane of the body, and its great feature is this: it is angular Ind median. The extent and prominence of the " curvature'' will depend not only upmi the seat of the mischief, but upon the amount of bone lost m the anterior segments. A sharp and abrupt angle will usually indicate a severe but limfted loss of bony tissue, while a more extensive and more rounded deformity will probably indicate a slight degree of destruction of mai^ vertebra.. In some cases the bending of the column may be so severe that the two parts of the spine form a right angle with one another, oi the anterioi surface of the vertebra above the excavation may rest on the upper s rface of the vertebra below it. When the disease is of long standing, the Zminence of the deformity may be increased by the wasting that occurs in ?he muscles of the back. In certain cases there may be some slight latera deviation of the spine in addition to the antero-posterior displacement This S on would Appear to be met with only in the lumbar and dorso-lumbar ?eS s! a°d is due either to unequal destruction ot the vertebm, or to un- 3 muscular action. In all cases compensatory curves are formed both above a"d below the seat of the deformity. It is only by means of such coni- Ttensation that the patient can retain the erect posture. These curves aie E St s en when the'disease is situate in the dorsal . spine -dj;!! obviously vary in degree according to the extent of the original detormity. Income cases of Pott's malady involving the lumbar region, where the destruction oi ?he bodies has been sudden and severe, no compensation is possible : the erect Sturf cannot be maintained, the column falls forwards, and the patient can onlv nroa-ress when upon his hands and feet, or knees. , „„ ?n eS all instances the deformity develops slowly, but cases have been recorded in which the "angular curvature" appeared with comparative sud- denness In such cases-of Which Michel gives examples-the deformitj^ha. nsuallv aBpeared during some unwonted or forced movement, a,nd has been Te o a gFvTng wav oflome of the supports furnished to the diseased parts Jr to frXre ff the posterior segments of the column at ^^e seat^ I)elr,ech Nekton, and Louis all record instances where this sudden toimation o^^^tC "curve'' has been associated with sudden paraplegia. The rapidity itl whieh the deformity develops depends to some extent ,"Pon the pat-^^^^^ movements and upon the non-observance of rest. Shaw,^ howevei, lecoios a else Xre no increase of the spinal deviation occurred during a period of fourteen yeai", ahhough the patiLit was engaged all the while in the work ■ Quoted by Michel, loc. cit. ' Loc. cit., page 114. pott's disease of the spine. 533 of a blacksmith. At the end of the period mentioned, an abscess appeared. Like examples have been put on record by others. It is important also to note that the deformity may commence and may increase while the hori- zontal position is being observed. Such cases show that the weight of the column above the seat of disease is by no means the only factor in producing the angular deviation, but that the abdominal muscles may also be active agents. in that direction. (4) The Abscess. — The chief points in connection with this symptom have already been dealt with in considering the pathology of the disease ; and some further tacts will be noted in dealing with the matter of diagnosis. So variable is the evolution of the symptoms of Pott's disease, that the spinal ab- scess may be the very first evidence of the malady, and, on the other hand, this affection may run its entire course, and end in anchylosis and cure, with- out any trace of abscess having been observed. The absence of abscess is, however, quite the exception. As to the period of the disease at which this symptom should become evident, nothing posi- tive can be said. It may appear before any deformity is obvious ; it may be the very earliest symptom ; it may not appear until the disease has existed for many years. Many cases are recorded where the abscess did not appear for ten, fifteen, twenty, or more years after the commencement of the disease, the patient having in the mean time apparently made a perfect recovery. It is probable that all such cases are examples of what Sir James Paget^ has called "residual abscess," that is* to say, an abscess taking its origin from the residues or relicts of past suppuration. The patient has caries of certain vertebrae, and an abscess is formed at the seat of disease, but does not tend to reach the surface of the body. In time a process of cure takes place, the wall of the abscess shrinks, its contents become more or less absorbed, and . perhaps no trace is left but some small collection of caseous matter. As long as the patient's health remains good, and as long as no injury or unusual circumstance tends to irritate the part, so long does this residuum of a past inflammation remain inert. But when these untoward conditions are pro- vided, the ill-disposed material acts as an injurious foreign body, and an ab- scess that perhaps reaches the surface is the result. As to the influence of local and general conditions upon the formation of the abscess, something a little more definite can be said. As may be surmised, the more acute and rapid is the spinal mischief, the more certain and the earlier IS an abscess likely to appear. Moreover, a general condition of ill-health is apt to affect the formation of the abscess in a like injurious manner. The same may be said of neglect of treatment, of persistence in movement and exercise, and of direct injury to the diseased parts. In opposition to these general statements, however, numerous exceptions have been recorded. Mr. Fisher mentions the case of a gentleman who had presented a projection of the spine for more than two years, no abscess appearing until the end of that period, although the patient had during the whole time indulged in the usual athletic pursuits of young men. Then again, an abscess may be asso- ciated with a form of Pott's disease that has assumed a very chronic course, has given little or no trouble, and has led to but trifling deformity. On the other hand, instances are recorded of an absence of external abscess, though the^disease is accompanied with severe deformity and paraplegia. The general features of the abscesses that accompany Pott's maladv are identical with those of cold abscess in general, and require no especial descrip- tion. Lannelongue^ has shown that the surface-temperature over these col- ^ Clinical Lectures and Essays. London, 1877. Loo. cit., page 171. 534 MALFORMATIONS AND DISEASES OF THE SPINE. lections is hmhev than that of the corresponding surface on the other side of the body. He quotes the case of a child, aged 7i years with a lumbar de- formity and a large psoas abscess at the upper part of the lelt thigh. This abscess showed an absolute absence of any of the common signs ot inflamma. tion and was indeed a typical cold abscess, yet the temperature noted was as On one occasion. On another occasion, o r, / OQO follows : „ • -11 H7° G (9d°.7 F.) 37°. 5 (99°. 3 F.) Temperature in axilla, . . • ; iiol)llo A\