Chapter XXXI: Part 31

The changes which the bones, ligaments, and muscles undergo, vary, not only in the different species of club-foot, but in the different stages of the same case. The greatest alteration appears to exist on the part of the tarsal bones, which, although they are rarely completely dislocated, are generally somewhat separated from each other, twisted round their axis, variously distorted, atrophied, or marked by irregular spicula or exostoses. The calcaneum, cuboid, scaphoid, and astragalus, always suffer more than the other bones; which, however, as well as those of the metatarsus and of the toes, usually participate, more or less, in the deformity. The ligaments, in recent cases of club-foot, do not present any material changes, but in those of long standing, or in the higher grades of the affection, they are invariably stretched in the direction of extension, and relaxed in that of flexion. In some instances the original structures are partially replaced by bands of new formation, of a dense fibrous character—the volume and resistance of which vary according to the duration of the disease and the pressure of the parts which they serve to connect together. The muscles also are not much altered in the first instance, except that they deviate from their natural direction, and that, like the ligaments, they are elongated on the one hand and shortened on the other. In ancient cases the whole limb is always considerably wasted, and many of the muscles are remarkably thin and pale, or even transformed into soft, fatty bundles. The cellular substance is condensed and diminished in quantity; the adeps is absorbed; and even the vessels and nerves supplying the affected part are apparently reduced in volume. The skin of the foot, which receives the principal brunt of the pressure in standing and walking, is generally very much thickened and indurated, and large synovial bursæ are often formed beneath it, which are apt to inflame, and thus add to the suffering of the patient. Such is an outline of the more important changes experienced by the different textures in cases of club-foot: to enter more minutely into the subject would be foreign to the design of this article, the object of which is merely to present a general idea of the nature, causes, and treatment of this singular distortion.

The _treatment_ of this affection should be delayed as little as possible. The sooner, indeed, it is attended to, the more probable will be the chances of effectually removing it. This is equally true, both of the congenital and of the accidental form of the disease. The bones in early life and in recent malformations are much more easily restored to their normal position than in youth and manhood, or in cases of long standing; and the muscles also regain much sooner, as well as more completely, their original power. In the worst grades of the disease it is often exceedingly difficult, if the treatment be delayed until after the age of puberty, to accomplish a cure without great carving of the tendons, and the constant employment for months of various kinds of apparatus.

It is still a disputed point, whether, in the treatment of this affection, particularly in infants and young subjects, it is necessary, or even justifiable, to divide, as a preliminary step, the tendons of the muscles which are instrumental in keeping up the distortion. Without endeavouring to settle this question, for which the time has not perhaps yet arrived, I must express my conviction that the present rage for tenotomy is calculated to do a vast deal of harm, not only in individual cases, many of which do not require it, but, what is worse and more deeply to be lamented, in bringing discredit upon an operation, which, if judiciously performed, cannot fail to be of the greatest benefit. In most of the cases occurring in children under two or three years of age, division of the tendons is altogether unnecessary; indeed, one of our most distinguished orthopedic surgeons, Dr. Chase of Philadelphia, seems to trust almost entirely to the employment of apparatus, and to resort to tenotomy only in the worst grades of the disease. Whether this practice will ultimately be adopted by the profession generally, or the division of the tendons be restricted to particular cases, it would be premature to predict; but my opinion is, that much more cutting is now done than is necessary, or than would be done if the treatment of the disease were better understood than it appears to be.

Different kinds of apparatus are in vogue for the cure of this deformity, and it is therefore impossible to determine which is the best, or which should be employed to the exclusion of the others. Every practitioner seems to have his own notions on the subject, and to adopt such measures as whim, fancy, or caprice may dictate. Whatever apparatus be resorted to, the great caution to be observed, on the part of the surgeon, is, that the extension be made in a slow and gradual manner, that the skin be protected from friction and uneven pressure, and that the dressings be steadily retained during the night, as well as during the day, until several weeks after all deformity has disappeared. The object of these directions is self-evident, and too important to be neglected in our curative procedures. The time required for restoring the limb to its normal position must necessarily vary in different cases, and depend upon so many circumstances as to render it impossible to lay down any specific rule. From six weeks to four months, however, may be considered as a fair average, though occasionally a much longer period will elapse. The division of the tendons of the contracted muscles generally expedites the cure by several weeks.

In the operation for dividing the tendo-Achillis the patient may either lie on his abdomen or sit on a chair, and the heel is to be drawn downwards by an assistant with the left hand, the right being placed upon the plantar surface of the toes. The necessary tension being thus given to the part that is to be cut, the surgeon passes a narrow, straight, sharp-pointed bistoury through the skin, from one to two inches above the internal malleolus, flatwise between the tendon and the deep-seated structures. The knife is then pushed on until it reaches the opposite side of the tendon, when its edge is brought in contact with the anterior surface of the chord, which is now completely divided by steady pressure upon the handle of the instrument. The separation of the parts is indicated by an audible snap, and by the immediate cessation of the tense resistance of the tendo-Achillis. Scarcely a drop of blood is lost during the operation, which is almost unattended with pain, and is accomplished in a few seconds. A strip of adhesive plaster is applied over the little puncture, which generally heals by union by the first intention; and the limb, laid in an easy position, should be supported by a paste-board splint and a common roller. The apparatus for keeping up permanent extension may be advantageously employed in three or four days after the operation.

The interval between the divided extremities of the tendon is filled up with coagulating lymph, which is often poured out in considerable quantities. As in other situations, it becomes gradually organised, and is finally converted into a firm, dense substance, not unlike the original structure.

The tendon of the posterior tibial muscle may be cut most advantageously about two inches above and behind the internal malleolus. The operation is conducted upon the same principles as in the preceeding case, and the only particular caution to be observed is to avoid the posterior tibial artery and nerve, which might be endangered by carrying the knife too deeply. The most favourable situation for dividing the anterior tibial muscle, is where it passes over the ankle-joint: the long flexor of the great toe may be cut in the sole of the foot, where, when it interferes with the rectification of the limb, it forms a tense, prominent chord.—ED.]

The phalanges of the toes in general resemble those of the fingers in their diseased actions. _Exostosis_ of the extremity of the distal phalanx, however, has no analogy in the upper extremity; it is by no means an uncommon affection, and usually occurs in the great toe. The growth is generally globular and rough in its extremity, narrow at its origin, attached on the dorsal aspect, projecting obliquely upwards, and always of similar structure with the phalanx. Sometimes they are met with of a size nearly equal to that of the bone from which they spring, but the majority are considerably smaller. The only one I have met with springing from a small toe is here sketched. At first the patient complains merely of pain in the part while walking; soon the pain increases so as to impede progression very seriously; then the nail is found to be raised at its margin, and to cover a hard, unyielding, and tender swelling. The elevation of the nail increases, and the tumour becomes more apparent, covered by hardened cuticle, causing great uneasiness, and almost entirely preventing walking exercise.

It has been recommended to expose the tumour by incision, and remove it at its origin. This affords temporary relief, but the disease is generally in no long time reproduced, and the incision must either be repeated, or the phalanx amputated. The preferable practice, according to my experience, is to remove the phalanx at once. It is less tedious and painful than the incision, produces very little, if any, impediment to progression, and of course is quite effectual in eradicating this most annoying though apparently simple disease.

_Of Fractures._—Deformity, shortening, loss of power, unnatural motion on extending and moving the part, pain, and grating, mark solution of continuity in bone, or fracture. Swelling, with spasmodic of these symptoms may be wanting; there is little deformity, and no shortening, when one of two or more action of the muscles, soon takes place. One or several parallel bones is fractured. In fracture of the extremities, extrication of air into the cellular tissue, about the ends of the bone, is not unfrequent, though difficult to account for—giving rise to crepitation, superficial, and quite a distinct sensation from that imparted by the broken bone.

Bones become brittle as age increases, and fragility is also induced by certain disordered and debilitated states of the constitution. In some patients, the bones give way on very slight force being applied, after what may have been supposed a rheumatic attack; the thigh is broken by turning in bed, or by walking from the bed to a chair. In one instance, I had put up a fracture of the thigh with a long splint, and in three weeks afterwards the humerus was broken over the end of the splint during an attempt by the patient at change of posture. In many such cases union either does not take place, or is very imperfect.

In children, the bones frequently contain little earthy matter, bend easily, and often break partially on the convexity of the curve. Even at the age of twelve or thirteen, bending of the bones from injury sometimes occur to a great extent, as of the forearm from a fall on the palm of the hand; in adjusting the parts, a slight crackling is heard when they are brought nearly straight. Complete solution of continuity, though more rare, is occasionally met with in very young subjects.

Fractures are generally the result of great force applied directly to the shaft of a bone, or to its extremity; but they are also not unfrequently caused by twisting of the limb whilst the muscles are in a powerful action. Bones are broken transversely; but more frequently there is a degree of obliquity in the fracture, and the fragments are generally detached. A bone may be split longitudinally, as from a musket-ball striking its shaft in the centre; and fissures often extend from a cross break to a considerable extent, sometimes into joints.

Swelling is often rapid, from extravasation of blood; at other times it is slow, and of a serous character. At first it is soft and yielding, but after a time painful inflammatory tumescence supervenes, the violence and extent of which will depend on the severity of the injury, and very much also on the treatment to which the parts are subjected. If the bones be put as nearly as possible into their original position, and retained so, judiciously—the limb being laid in a comfortable and unconstrained posture, and the bandages, splints, &c., properly adapted—little or no pain or inflammatory swelling will occur; no more action ensues than is required for reparation of the injury. If, on the contrary, the bones are allowed to remain unreduced—perhaps after being well handled—their broken ends, laying among the soft parts, are pulled out by violent spasms, lacerations of the muscles and vessels is increased, effusion, swelling, and violent inflammatory action occur, the pain becomes excruciating, fever and delirium follow; there is an imminent risk of gangrene, and extensive suppuration among the muscles is almost inevitable. If the patient recover, the union is bad, and the limb deformed.

A fracture is said to be _simple_, where there is no wound of the superimposed integuments. The external parts may be bruised, or the deep structure much injured, with laceration of the vessels and rapid and great swelling; or there may be little or no injury of the soft parts. Great danger may exist without division of the integuments; these, yielding under the force, may remain entire, whilst by great and direct violence the bone is comminuted, the muscles broken up, and the vessels and nerves torn,—the limb is infiltrated with blood, and must become gangrenous as soon as reaction takes place. But usually these untoward circumstances do not exist in simple fractures, the soft parts being but slightly injured.

Fracture is _compound_ when the integuments are divided by the external force, so as to expose the broken bone. But the wound may not penetrate to the bone; and then the accident is termed fracture with wound, not compound fracture. The soft parts are often divided by the sharp end of the bone; this is frequently the case in oblique fracture, occasioned by a fall from a height, the lower fractured extremity being pushed forcibly upwards. The muscles are usually much injured. The wound is either large or small, lacerated or clean.

Fracture, simple or compound, is _comminuted_ when the bone is divided at the broken point into fragments, either small and loose, or large and adherent to the covering of the bone and other soft parts.

Fracture may be _complicated_ with wound or displacement of a neighbouring joint, and with laceration of large bloodvessels and nerves.

Union of divided bones, as of soft parts, is preceded by incited circulation in the part, and effusion of organisable matter. The extent of action is regulated by that of the injury, whether inflicted by accident or by operation. If the soft parts have not been much bruised, if the bone and its covering are merely separated and slightly displaced, and then speedily put in contact, the incited action and the effusion are limited to the divided parts. There is no irregularity afterwards at the point of fracture, the new matter that is not required being absorbed soon after deposition; the bone is smooth and even as before. The deposit of new matter under the periosteum and into the medullary canal is here well exhibited. By this means only is the bone kept together for a very considerable period; afterwards the broken ends are united, and the temporary callus absorbed. If, on the contrary, there is much displacement, and if that is not entirely removed, intense action ensues both in the soft and hard parts, there is great effusion of new matter, or callus, soft and yielding at first, but gradually becoming hard and dense—bony particles being deposited from the vessels ramifying in the extremities, or in the attached fragments, of the old bone. When detached portions of callus are found lying in the soft parts, a piece of old bone which retained its vitality has generally formed the matrix of the deposit. When the ends of bones have been badly placed, and meet each other at an angle or curve, occasionally osseous deposit seems to form in the concavity. This increases in size, unites with the portions of the shaft, and forms a sort of bridge uniting them. This by M. Gulliver has been termed accidental callus.

In badly reduced fracture the swelling is great and hard. The callus is exuberant, much being required for the union of the fractured ends that overlap, and are perhaps far from being in contact; the vascular action and accompanying effusion are great, according to the necessity for them. The bone at the united part is enlarged to perhaps double its original thickness, or even to a greater size. After some time, the ends of the old bone, and part of the new deposit, are rounded off by absorption of the protuberances, and the part becomes more shapely. The canal of the bone and the cancellated texture is again restored. The accompanying sketch of a section of the humerus shows a double fracture. The superior one near the neck, where there is still some thickening, had been well adapted, and the canal is quite perfect. In the other and more recent there is considerable overlapping. The portion of outer osseous shell projecting into the medullary canal would in the end have been removed by the absorbents, and the deformity much diminished.

When the ends of the bone are not well placed, or when they are moved occasionally whilst the uniting medium is still soft, there is danger of a false joint being formed—the callus either giving way, or being all along imperfect, and the extremities at the soft part becoming smooth and moveable on each other; or incited action may run high and terminate in suppuration, with death or ulceration of portions of the bone.

Fragments are sometimes entirely detached at the time of the accident, and perish at once; or are so slightly connected with the shaft that they lose their vitality on the first accession of inflammation, become surrounded by purulent matter, part from their slight attachments, and come towards the surface. Or the shaft itself may be so bruised by the violence of the injury as to be incapable of resisting incited action, though slight. By malpractice, such untoward consequences as the preceding, and many others beside, are frequently induced.

The uniting medium of separated bones remains soft for some time, as was already observed; and often, whether from the state of the constitution, or the circumstances connected with the fracture, the parts remain long moveable. Pregnancy is said to prevent union; but I have often seen fractures in pregnant women unite as speedily and firmly as if the patients had been in that state, and otherwise in robust health; profuse uterine or vaginal discharges, or determination to particular parts or organs, will certainly retard union.

In ordinary cases, the limb, if not lying altogether straight, can be moulded into a proper form after the lapse of eight or ten days from the time of injury, without the patient suffering any great degree of pain, without the process of union being at all interrupted, or the cure protracted; even at the late period of five or six weeks, badly united fractures may sometimes be much improved by gradual pressure and change of position. A gentleman fell from his horse, and sustained simple fracture of both bones of the leg, near the middle. It had been laid and retained on its side. I saw him exactly six weeks after the injury; the leg was much curved forwards, and the foot turned outwards. The limb was placed on the heel, and a long splint, with a foot-piece, applied on the outside; by attention to its position, and by gradually tightening of the bandages, it soon became quite handsome. Care should be taken not to allow the patient to rest too soon on the fractured limb; for though quite straight, symmetrical, and of the proper length, when the retentive apparatus is discontinued, it may become short and deformed in a few days from even slight weight being put upon it.

The period at which firm union takes place varies; the process is more rapid in young people than in those advanced in life, and will depend more on the extent of the injury, and its vicinity to the centre of the circulation than on the size of the broken bone. The requisite length of confinement is regulated by these circumstances, and by the use to which the part is to be afterwards put; the lower limbs require longer time for consolidation than the upper.

In the treatment of fracture, as in solution of continuity in the soft parts, great advantage is gained by placing the disjoined parts as nearly in their original position as possible, retaining them so, and allowing of no motion. These indications ought to be accomplished very soon after the accident; many evils are thus prevented—the further laceration of the soft parts, the inflammatory effusion into all the tissues, and the consequent startings and spasms of the muscles. This cannot be too much insisted on. There is much folly and absurdity in allowing a broken limb to lie unrestrained—leaving the ends of the bones displaced, the one riding over the other—whilst attempts are being made to keep down the inflammation, by applying leeches, cold lotions, or large poultices—all perfectly ineffectual so long as the palpable cause of incited action remains unheeded. The circumstances which kindle and keep up inflammation should always be understood; they are easily discovered in fracture, and when understood should never be lost sight of. If the parts be replaced there will seldom be inflammation; if they remain displaced, the inflammation is so great that it is impossible to subdue it by any means short of removal of the cause. There is also an impossibility,—not to mention the patient’s sufferings,—of reducing bones to a good position some weeks after the accident. Such practice has been extensively followed and recommended by some, even modern writers; they set about reducing a fracture at a period after the accident, at which, by proper treatment, union would have been completed, or at least far advanced. The confinement and suffering of the patient are increased threefold, and after all the cure is bad, and there is a risk of false joint.

In all fractures, whether simple or compound, comminuted or complicated, if an attempt is to be made to save the limb, let reduction be immediate; coaptation and retention of the separated parts cannot be made too soon. A neglected case may be met with, in which the intensity of inflammatory action in all the tissues may forbid immediate interference. But even though inflammatory action has taken place to some extent, there are no surer means of arresting it than removal of its cause—the irregular ends of the bones being taken away from among the soft parts—provided it can be done without violence or increase of tension. Reduction is facilitated by proper position of the limb, by relaxation of certain sets of muscles. Extension and counter-extension are made, and but very little force is required; the surgeon extends the limb with one hand, and resists with the other; when the system is excited, and the muscles act spasmodically, an assistant may be required to steady the limb, and to resist the extending power which the surgeon employs. Then the position of the limb and of the patient, when long confinement is required, must be considered, and rendered as easy as possible, though at the same time secure. The apparatus for retaining the bones in the right position must be varied according to circumstances.

In compound fractures, when the wound is so small and clean that adhesion readily takes place, the cure is as rapid as in the simplest form of accident; but when the soft parts are much lacerated, the breach in them must be repaired by granulation; there will be profuse discharge from the wound, with risk of deep suppuration, and union of the bone will be slow. To accomplish reduction, long and sharp pieces of bone may require to be removed by means either of the saw or of the forceps, or else the wound must be dilated; both proceedings may be necessary in some cases. Detached portions of bone, and foreign bodies, if any, must be taken away; and the edge of the wound may be approximated when a reasonable chance of adhesion exists. The limb must then be properly placed and secured. Inflammatory action, should it threaten, must be kept down, but bleeding and purging are to be employed with caution. The action and its consequences are moderated by one or two depletions, but these must not be had recourse to without due consideration of circumstances; strength is required to effect the action necessary for union, and to withstand the subsequent suppurations, though these may be prevented or at least moderated by timely depletion. Abscesses are to be opened early, the parts are fomented, and then perhaps poulticed. The limb must all along be kept in a correct position, dead portions of bone must be removed when detached, and the strength supported by generous diet and wine. Opiates are of great use in alleviating the pains and twitchings in the limb. Poulticing is to be continued only for a short time; in many cases it may be altogether superseded by fomentations; and the latter should be used only when abscess is threatened, or when the patient is much pained at one or more parts of the limb. Support and gentle pressure are indispensable soon after evacuation of the matter, when no fresh collection is threatened.

The injury is often so great as at once to demand removal of the limb. There is no alternative, when, from laceration of the soft parts, superficial, deep, or both—comminution of the bone to a great extent—rupture of large vessels—and opening of joints—either gangrene or an overpowering suppuration are rendered not only probable but almost certain. The period at which the operation is to be undertaken requires judicious selection. Some patients are not affected constitutionally even by great and violent injury, such as dreadful laceration of the limbs; whilst others, even after slight wounds, are seized with delirium, tremors, vomiting, lowness of spirits, depressed circulation, paleness of the surface, and appear on the eve either of rapid sinking or of immediate dissolution. In the first class of patients immediate amputation may be had recourse to with safety and advantage. In the second, the patient must be reassured, and stimulated both by external and internal means; in short, reaction must be brought about, and then let the surgeon operate. If he amputate before this, his patient will most probably die on the table, or very soon after his removal from it; reaction will never take place, and sinking of the vital powers be accelerated by the ill judged interference. A greater or less time is required for the occurrence of reaction in different individuals; the usual period is from two to six hours. Commencement of it is a sufficient warrant for operation; the surgeon must not delay till inflammatory fever has been lighted up, for then he will interfere with great disadvantage. He must then subdue the inordinate action as much as possible, and wait for the suppurative stage. When the patient has become hectic from profuse and long continued discharge, when, perhaps, no union has taken place—then also the limb must be removed. In civil practice, patients as often recover from secondary as from primary amputation. But according to the experience of military surgeons, the result is otherwise—many recover after primary and few after secondary; much may depend on the accommodation of the patient afterwards. A great deal must necessarily be left to the judgment, discretion, and conscientiousness of the surgeon.

_Fractures of the cranium_ were treated of as connected with disturbance of the important organ which it protects.

The _bones of the face_ are occasionally broken and displaced. The frontal sinus is sometimes opened by fracture of the external plate. No small degree of force is required to effect this injury:—I recollect an instance of it, with opening into the sinus, occasioned by an attempt at suicide; the man had struck his forehead violently with a large stone, wishing to knock his head to pieces. The integuments are generally divided, and, during expiration, blood, sometimes frothy, is poured out through the opening. When there is no wound of the integument, emphysema of the forehead and eyebrows has resulted from disruption of the bones that compose this cavity, or others connected with the nostrils.

The _ossa nasi_ are fractured and displaced by direct violence. They may be broken and comminuted without much displacement, or separated from their connections and depressed without much fracture. Even slight cases are generally attended with laceration of the Schneiderian membrane, and with profuse hemorrhage from the nostrils. The soft parts over the bones are thin and tense, and consequently in many cases divided. Great swelling is apt to ensue, at first either bloody or œdematous. Inflammatory swelling to a great extent, both externally and internally, is to be dreaded and guarded against. Abscess of the Schneiderian membrane, frequently of the septum narium, occurs from slight injuries, if neglected; and, if not actively and properly treated, may terminate in loss of substance and consequent deformity of the features.

The existence of fracture of the ossa nasi is very readily ascertained; the part is distorted, being either uniformly depressed, or hollow at some points, and abruptly prominent and sharp at others. With the view of remedying deformity produced by displacement, and preventing the bad consequences already spoken of, the bones must be restored to their original position. They are to be raised by means of a strong probe or director, covered with lint, and introduced high into the cavity. Whilst, by means of this instrument, pressure outwards is made, the fingers of the surgeon are applied externally, so as to mould the organ into a proper shape. Unless force be again applied to the part, there is no risk of subsequent displacement; no apparatus is required to preserve the bones in situ.

In compound fracture the detached spiculæ are to be picked out, and the wound cleansed of blood and extraneous bodies; its edges are to be brought neatly together, and retained by one or more stitches, with slips of unirritating plaster. Inflammatory symptoms are to be warded off and combated by purgatives, antimonials, local abstraction of blood, and fomentations. Formation of matter in the nasal cavity is to be prevented, by scarification of the swollen membrane that fills the nostrils and precludes the passage of air; and if matter has been allowed to collect, it must be early discharged.

Opening into the frontal sinus, whether the result of accident or of exfoliation, may sometimes be closed by paring the edges of the integuments and bringing them together, or by covering the deficiency with a flap borrowed from a neighbouring part. Such measures should not be resorted to, in the case of opening from accident, till after all inordinate action has subsided, otherwise adhesion will fail.

Cases of fracture of the _superior maxilla_, _os malæ_, and _zygoma_, have been met with. Great displacement cannot occur, nor is any peculiarity of treatment required. If the fracture is compound, loose portions of bone may require removal.

The _inferior maxilla_ is exposed to violence, but from its construction and consistence is capable of resisting a great degree of force. It may be broken at various points; the usual site of fracture is where the canine or the first small molar tooth is implanted; but it not unfrequently gives way at the symphysis, or near the angle. The alveolar processes are often detached, with loosening of one or more teeth. The fracture is frequently compound; being produced by a direct blow, as the kick of a horse. The bone sometimes breaks at a part not struck, as at the symphysis from a blow near the angle. The accident is easily recognised; in fact, the patient, if sensible, has himself discovered fracture before he applies for assistance. There is distortion of the part, and the broken extremities, when moved, are felt grating on each other; there is discharge of blood, perhaps of teeth, from the mouth; and in compound fracture the ends of the bone are visible. At the symphysis the parts are not much displaced; they are more so when the fracture is in the site of the first molar. In the latter situation it is occasionally difficult to replace the bone, and retain it in its proper position.

The face swells to a greater or less extent, according to the severity of injury done to the soft parts, and the time which has elapsed before reduction. The parts within the mouth swell; often there is great infiltration of the loose cellular tissue under the tongue. Sometimes extensive abscess forms, showing itself in the mouth or under the chin.

The bone is to be brought to its former shape by pressure of the fingers on the outside, and of the thumbs placed within the mouth on the corners of the teeth. Motion is prevented, and the parts are retained in their proper situation, by a wedge of cork or wood interposed on each side of the jaw, and grooved so as to receive the teeth both above and below. The wedges are placed with their thick ends anteriorly, and are retained by the lower jaw being firmly bound towards the upper; sufficient space for the introduction of food must be left between the wedges at the fore part of the mouth. Pasteboard or leather is applied externally, cut so as to fit exactly the fractured bone; it is previously softened in warm water, that it may adapt itself to the shape of the parts, and form a case over them; a thin layer of tow or wadding is placed between it and the skin, and the whole is retained by a roller, which is preferable to split cloths. The patient should not talk, or in any way attempt motion of the injured bone, and the food given should not require mastication. Inflammation is to be kept down by the usual means, and abscesses, if they form, must be early evacuated. Detached teeth and splinters of the jaw are to be extracted at the first; if teeth loosen much during the cure, they should be considered as foreign bodies, and removed, otherwise they will keep up the discharge, and tend to prevent union.[61] From three to six weeks is generally sufficient time for consolidation of the fracture. In severe cases union may be prevented by necrosis of part of the bone; or, though the bone unite, the external wounds may not heal, and the discharge may continue till the dead portions separate and are discharged.

_Fracture of the Spinal Column_ is attended with alarming symptoms, and often terminates fatally, from the pernicious effects necessarily produced on the spinal chord, either immediately or consecutively, when the bones forming the column are disjoined to any great extent. The injury is effected by great violence—by the body being projected and alighting awkwardly—by a fall on the breech from a height, the head and trunk being bent forcibly forwards—by direct blows on the spine.

Displacement of the bones forming the spine, seldom takes place without fracture to a greater or less extent. Pure dislocation of the spine, from the rupture of ligaments and fibro-cartilage, is a very rare accident; few cases of it are on record, and in them the injury was in the cervical region; I have only met with two instances of complete and pure dislocation. The ligaments are of great strength, and the bones yield sooner than they do; and in the greater number of severe injuries of joints this is the case more or less.

A very well marked specimen of luxation, without the slightest fracture of the fourth from the fifth cervical vertebra is delineated on the next page. The injury was occasioned by the person falling backwards over a high paling, on which he was sitting, and alighting on the back of the head: along with the proper ligaments, the spinal chord is seen to be torn. The patient, of course, did not survive many days, being almost perfectly paralysed.

In general, either the bodies or the processes of the vertebræ are broken, and sometimes comminuted; occasionally the bodies are broken entirely through, with considerable displacement, the upper or lower end, as may be, projecting. There is twisting or bending of the trunk or neck, the articulating processes on one side only being displaced, whilst the ligaments on the other remain pretty entire. In some cases, either the spinous processes, or the articular, are separated without yielding of the bodies of the vertebræ, or of the interposed substance; then there is bending of the trunk forwards.

The symptoms vary according to the site of the injury, and the extent of violence inflicted on the spinal chord. This important organ may suffer concussion without fracture or displacement of the bones; its functions may be consequently more or less disturbed, and paralysis occasioned of those parts that are supplied with nerves from below the injured point. Without fracture, too, vessels may give way within the canal, and by compression from effused fluid urgent symptoms will be produced.

The power of motion may be lost whilst sensation is retained, and _vice versâ_; but in general both are either impaired or destroyed. In one case that came under my care, there was power of motion in one limb and no sensation, whilst in the other there was no motion but the usual sensation.

Patients may recover from the effects of a severe blow on the spinal column and consequent concussion of the chord, but very frequently they do not. Changes may take place at a late period in the chord or its membranes, in consequence of the injury—as thickening of the coverings—bloody, serous, or lymphatic purulent effusion—disorganisation and softening of the medullary matter. Inflammation of the membranes, or of the chord itself, may supervene, either very soon after the accident, or long afterwards; its intensity and period of accession will depend on the extent of the injury, and on the treatment. The muscles act spasmodically, the circulation is excited, the sensorium and nervous system are disordered, delirium ensues, and is followed by paralysis and coma.

In some cases of displacement, even to no small extent, the spinal chord escapes being bruised, torn, or compressed; no bad symptoms may ensue; or paralysis to a greater or less degree occurs and gradually goes off, probably occasioned by bloody effusion, which is afterwards absorbed. This I have witnessed in several instances—in a boy who fell from a high rock—in a woman who fell from a window; both lighted on the breech, and the trunk was bent forwards. The lad remained stout, but his trunk was somewhat deformed by an excurvation; the woman recovered perfectly. In these cases there was evidently laceration of the interspinal ligaments, though probably not of the ligamenta subflava, for the spinal chord must be stretched or otherwise injured when these are torn.

The chord is more or less injured in the majority of cases of fractured spine. If the injury occurs high in the cervical region, immediate death ensues, from compression or laceration of the medulla oblongata. Respiration is arrested by compression or destruction of the chord above the origin of the phrenic and other respiratory nerves. If the chord is injured in the middle of the cervical region, there is paralysis of the upper and lower extremities, with distention of the bowels, and inability to void the urine; the lower bowels have become insensible to the stimulus of distention from want of nervous influence, and the sphincter ani is paralysed. The bladder becomes distended, and then incontinence of urine follows; and frequently there is priapism. The quality of the urine is changed, the secretion of mucus from the bladder is vitiated and increased. Slow inflammation of that organ is induced, the urine becomes bloody and mixed with ropy mucus; lymph is deposited on the lining membrane.

Bruises of the loins often lay the foundation for degeneration and abscess of the kidney, with many of the symptoms of calculus vesicæ, attended with red tongue and hectic, ultimately terminating fatally.

The effects of concussion of the spine are frequently developed long after the infliction of the injury. There is formication, numbness, and difficulty of regulating the motions, in one or more limbs. Still the muscles are not shrunk, nor unable to perform powerful movements; but the patient cannot put his hand or foot to the place he wishes, and cannot support the weight of the body without assistance. Sensation in the limbs is lost to a greater or less degree, their heat is diminished, and it is found difficult to preserve their temperature equable. The symptoms increase till the limbs become totally useless. Along with the lower limbs the bladder is affected, though not always. The urine is not voided with force, and incontinence occurs from distention. Sometimes excitement of the viscus follows; the secretions from its surface are increased, and often mixed with blood. Yet patients survive long under such circumstances, digestion and the other important functions are well performed, and the intellect is unimpaired.

Prognosis in injuries of the spine is unfavourable, as well as in disease of the chord, whether the result of injury or not.

From the treatment much need not be expected; but still no chance is to be thrown away, even in the most unfavourable cases. The attention must be directed towards alleviation of the symptoms. The comfort of the patient must be looked to in regard to the situation of the injured bones and other parts, even where there is reason to believe that the chord is lacerated or completely divided, and that there is no chance of recovery. In less severe cases, by placing the injured parts in their proper position, and retaining them by splints placed along the sides of the spinous processes;—by keeping down inflammatory action, palliating all the symptoms as much as possible, and attending to the state of the bladder if necessary—unlooked for recoveries have taken place.

It has been proposed to treat the spine, in cases of severe and alarming fracture, in the same manner as the cranium—by trephining; and some have recommended this in almost all kinds of injuries. I allude to the practice only to condemn it. The spinal chord is generally displaced and compressed by the lower portion of the fractured body of the bones. One cannot easily comprehend what an operation is to effect in such cases. Further notice of this proceeding is unnecessary, seeing that, as far as I know, it has been unanimously discarded by the profession from amongst the list of surgical operations.

When the patient has borne up against the shock of the injury, and the more immediate consequences, and when partial loss of sensation and motion has supervened, great benefit is obtained from counter-irritation, by blisters, issues, or moxa. But these are not advisable, but to a certainty injurious, till after time has been allowed for subsidence of the immediate effects—for union of the divided parts, and disappearance of acutely excited vascular action. The endermoid application of strychnine is also efficacious in many cases where the injury has been slight—as in the following. A young man was struck on the back of the neck with a leaden plummet. The immediate effects were loss of power and sensation in the whole body. The use of the upper limbs was regained gradually and completely; and when he applied to me, the remaining symptoms were diminished sensation and irregular muscular action in the lower limbs. The mode of progression was very remarkable; supported on the points of the toes and assisted by a staff, he made two or three quick steps as if running, and then suddenly stopped, a few more rapid steps and another abrupt halt, and so on. A succession of small blisters was applied along the sides of the spine in the dorsal and lumbar regions, On the raw surface strychnine was sprinkled, commencing with half a grain daily, and gradually advancing to a grain and a half. He made a perfect recovery in less than three weeks.

In another patient, in whom sensation in one limb without motion, and in the other motion without sensation, remained after severe injury of the spine by a fall from a high window, complete recovery was obtained by the internal use of strychnine, and repeated application of the moxa.

Slow degenerations of the spinal chord are not easily combated with success. Considerable changes of structure have taken place, as shown by the symptoms, before the patient becomes alarmed and applies for relief. He has had a feeling of distention about the lower part of the bowels, and voids his urine with some difficulty; perhaps he suspects stricture of the urethra as the cause. He lifts his feet awkwardly, sets them down clumsily, and all of a piece; his knees totter, there is no feeling about his buttocks, and a numbness round the anus. At length he is for the first time alarmed by incontinence of urine having supervened, or by the limbs having sunk under the weight of the trunk, and by his coming to the ground with violence. The remedial means are local abstraction of blood from over the seat of the disease, followed by friction and counter-irritation. Strychnine may be tried in some cases. But it is indeed seldom that the progress of the case is satisfactory.

_Fracture of the Clavicle._—This bone is liable to be broken by indirect violence, as by falls on the point of the shoulder, from horseback, or from the top of a carriage; or by a fall with a carriage, the person being inside—of this accident I have met with three or four instances. It may also be broken by direct violence, as by a blow on the bone, or by the person striking it against a hard substance in a fall. It generally gives way about the middle. The fracture, when occasioned by force applied to the acromial extremity, is usually oblique; transverse when the force is applied to the shaft of the bone. The displacement is in most cases great; but when the fracture is at the bend near the scapular extremity,—a not very uncommon accident,—disjunction of the fractured extremities is prevented by the attachments of the conoid and trapezoid ligaments. In ordinary cases, that fractured extremity projects which is attached to the sternum, whilst the scapular portion is depressed and carried inwards. In short, the scapular portion is displaced, the sternal is nearly in situ; though, from the depression of the former, the prominence of the latter appears to arise from displacement. The arm falls forwards and downwards.

The fracture is sometimes compound. The wound is generally small, and occasioned by the projection of the sternal portion; or the integument may be divided by the external force.

The nature of the accident is readily recognised. The deformity is very apparent. There is swelling, from extravasated blood, over the bone; the shoulder is unnaturally approximated to the chest, and depressed. The motions of the extremity, those above the shoulder, are impaired. Crepitation is felt on raising the arm, and carrying it backwards so as to bring the fractured surfaces into contact.

When the patient is seen immediately after the accident, the bones are to be placed in apposition, and retained, without delay, and before inflammatory swelling has come on. No complicated apparatus is required. A pad, firm, though of soft material, and large enough to fill the arm-pit completely, is rolled in a shawl and placed in the axilla; it is retained by tying the shawl over the opposite shoulder, a soft pad being interposed between the knot and the skin to prevent excoriation, and is farther secured by tying the ends under the axilla of the uninjured extremity, which should also be protected by a small cushion. A few turns of a roller, or a handkerchief, are placed round the arm and chest, so as to secure and fix the limb; so the retentive apparatus is completed. The shoulder is thus raised, and removed from its unnatural position; and the fractured extremities of the clavicle, previously placed in accurate contact, are prevented from being again displaced. The elbow and forearm should be supported by a sling, otherwise the unsupported weight of the limb dragging on the shoulder will cause considerable pain, and subsequent displacement will be apt to occur. In order to prevent swelling, it is sometimes advisable to support by a bandage the hand and forearm. The apparatus should be looked to occasionally, adjusted and tightened; and the cushions should be replaced by fresh ones, to prevent excoriation and uneasiness. The bone will be found to lie quite smooth, to remain of its proper length, to unite, generally within twenty days, and that without any unseemly exuberance of callus. No evaporating lotions are necessary. No compresses or splints need be applied over the bone. If the patient be bruised in other parts, and become feverish, it may be requisite to abstract blood and exhibit antimonials, purgatives, &c. But all inflammation, arising from the fracture, subsides on the accomplishment of reduction, adaptation, and retention of the portions. If the fracture be compound, the edges of the wound should be brought together and retained, so as to favour immediate union.

The _body of the scapula_ is broken, generally by a severe injury of the chest, as by a hard and heavy body passing over it. There is little or no displacement; and the accident is not easily detected, more especially after swelling has taken place.

It is sufficient to restrain motion; and this is effected by passing a bandage round the chest, over the scapula, and round the arm.

The _acromion process_ may be broken off; but the accident is rather uncommon. The fracture is produced by direct violence—a blow or a fall on that point. The spine of the bone also is sometimes broken by a like cause. Portions of the acromion may be separated along with the ligaments connecting the clavicle to it, in the accident of dislocation of the scapular extremity of that bone. The acromion is occasionally broken into fragments by heavy falls on the point of the shoulder.

There is a slight appearance of flattening of the shoulder at first, and then great swelling. Crepitation is felt by pressing gently and alternately with the points of the fingers over the fractured part.

The arm requires to be raised and supported by a sling.

_Fracture of the Ribs._—One rib, or more, may be broken by injuries in various ways—by blows of the fist—falls on hard bodies—pressure on the chest by heavy bodies passing over or falling upon it. They generally give way anteriorly to the angles, at the most convex point; but sometimes near the spine or the sternum. At the same time they may be partially luxated at either of the extremities. The fracture is generally transverse; occasionally, and rarely, oblique. Sharp portions are seldom detached. The skin is sometimes divided, but more frequently the pleura and lungs are torn by the spiculæ projecting internally; hence effusion into the chest, and emphysema of the subcutaneous cellular tissue near the fracture, take place. The emphysema, if permitted, extends over the greater part of the chest, and even farther.

Fracture of the ribs is attended with pain, particularly during full inspiration; and if the injury is severe, the patient is incapable, without great pain and exertion, of accomplishing full inspiration. He uses his handkerchief, sneezes, and coughs, with the utmost difficulty. Crepitation is felt by the patient, and is easily detected by the surgeon, by placing the hand on the suspected point, and desiring the patient to attempt full inspiration so as to grate the surfaces on each other. Motions of the trunk, and often of the upper extremities also, are attended with aggravation of the symptoms. In some cases attentive examination is necessary to discover crepitus—in certain situations, and when perhaps one rib only has given way, especially if some time have elapsed betwixt the infliction of the injury and the application of the patient for relief.