1011. If the dislocation of an oblique process be left alone, the pain gradually subsides, and the patient has no other inconvenience than an unnatural position of the neck and restricted motion of the head. It is, therefore, held most advisable by some (DESAULT, BOYER, RICHERAND, and DUPUYTREN) to leave this dislocation alone, because in attempting to reduce it, the spinal marrow may easily be so torn as to cause sudden death (a). This opinion is, however, grounded especially upon an imperfect reason, and various cases are known, in which the reduction of this dislocation has been followed with happy result. SEIFERT (6) has refuted the reasons against undertaking the reduction of this dislocation, and has frequently performed it successfully. The patient should be placed on a low seat, or sitting on the ground, and his shoulders firmly held back by an assistant. The Surgeon then grasps the head, with one hand beneath the chin and the other beneath the occiput, makes extension first in the direction of the dislocation, then in the longitudinal axis of the neck, and when this seems to have been sufficiently made, he twists the head strongly towards the dislocated side. Still the more pressing is the necessity for reduction in dislocation of both oblique processes of the neck vertebræ, and that this may be effected, with care, the observation of WALTHER proves. The patient is to be put in a horizontal position, held up by three assistants, one of whom makes counter-extension on the pelvis, a second draws the shoulders back, and when the trunk is thus properly fixed, a third assistant grasps the head and makes extension, first in the direction of the dislocation, afterwards in the natural longitudinal axis of the neck, that is, he first pulls the head pretty forcibly back by gradually lengthening the neck, and then turns it backwards. But when the extension in this direction has attained a certain extent, the head must be brought into its naturally straight position, by undiminished and still successively increasing extension. GUÉRIN (c) reduced a seventh months' dislocation of the second vertebra of the neck upon the third. 1012. Dislocation of the oblique processes of the back vertebræ cannot happen, nor dislocation of the bodies of neck-vertebræ, on account of the breadth of their joint-surfaces, the quantity and thickness of their ligaments, the strength of the muscles surrounding them, and the slight motion with which each vertebra is endowed. Only when the bodies of the vertebræ are broken can they be dislocated; but then so great violence operates that symptoms of pressure and concussion of the spinal marrow accompany it. All the cases described as dislocations of the back and loin vertebra, are fractures of those bones, or simple concussion, or some other injury of the spinal marrow. In consequence of the form and connexions of the bodies of the vertebra, every dislocation must cause death. DUPUYTREN has collected several cases in which dislocation was accompanied with fracture; in one case separation of the bodies of the vertebræ occurred from tearing of the intervertebral substance, without any fracture. In all these cases death followed the simultaneous injury of the spinal marrow. From what has been said, it may be collected, how those cases are to be thought of, in which, with some projection observable after the operation of violence upon the spine, the patient cannot sit upright, and so on, it has been supposed that by laying the body over a tub or any round body, the common dislocation could be reduced. BOYER has also observed on this point, that in violent bending of the spine, the upper and (a) PETIT-RADEL, Dictionnaire de Chirurgie; in Encyclopédie Méthodique. (b) Ueber die prognostische Bedentung thera peutische Behandlung der Halswirbel verrenkun- interspinous ligaments of the spinous processes, and the hinder so-called yellow ligaments may be torn. If the tearing be confined to the interspinous and to the upper ligaments, the patient may recover after a longer or shorter period of rest; but tearing of the yellow ligaments causes palsy and death (a). 1013. The ligaments of single vertebræ may be partially or completely torn through, without dislocation, but the injury of the spinal marrow therewith connected may cause death suddenly or subsequently; and to such cases all that has been said in relation to fractures of the spine applies. In every case of distortion and tearing of the ligaments of the spine, only a strict antiphlogistic treatment, with continual rest, and subsequently, frequent purgatives to prevent the destructive subsequent diseases, may be employed. III.-OF DISLOCATION OF THE PELVIC BONES. (Luxatio Ossium Pelvis, Lat.; Verrenkung der Beckenknochen, Germ.; Luxation des Os du Bassin, Fr.) CREVE, Von den Krankheiten des weiblichen Beckens. Berlin, 1795. 4to. p. 137. 1014. The broad surfaces of the articulations of the pelvic bones, and the great strength of their ligaments, render their separation impossible under natural circumstances, except when acted upon by extraordinarily great violence. The rump-bone may be dislocated inwards, and the hipbone, upwards. These dislocations are never complete; the effects of violence, however, usually act upon the intestines of the pelvic cavity and upon the spinal marrow, and inflammation and tearing of these intestines and effusion of blood, and so on, in the pelvic cavity, ensue; also, palsy of the lower limbs, of the bladder, and rectum; and not unfrequently is fracture of the pelvic bones present. The treatment of these dangerous injuries must be precisely the same as has been mentioned (par. 615) for fractures of the pelvic bones. One case shows that a dislocation of the hip-bone upwards may be produced by a fall from a great height, without symptoms of concussion of the spinal marrow or injury of the pelvic intestines. The share-bone and the spine of the hip-bone of the left side were higher; the left limb was shorter than the other, but the distance from the trochanter to the spine of the hip-bone and to the knee, was the same as on the other side; flexion and extension of the thigh were accompanied with severe pain in the symphysis pubis and sacro-iliaca, with which frequently the whole hip-bone moved. The extension caused only severe pain, without bringing the limb to its natural length. The treatment in this case consisted in strict quiet, and the employment of proper antiphlogistic remedies. When the patient began to walk, he gradually, by the weight of his body, recovered the proper position of the hip-bone (b). 1015. Great as must be the violence to produce a separation of the hipbone, if its articular connexions have their natural degree of strength, just as easily can it be produced if these connexions be lax and yielding. Such is the case in loosening and swelling of the ligaments of the pelvis during pregnancy. Wherefore also frequently from the extension which these bones suffer during delivery, or if the woman get about soon after her downlying, a pretty smart pain is suffered in one or both joints of the pelvic bones, which recurs at every movement, and is accompanied at first with the sensation of a tearing, and subsequently, distinct crepitation is felt in the pelvic joints. The gait of the patient is then difficult, and on examination, the position of the two hip-bones is not found alike, the one being more or less high than the other. A similar swelling, loosening and laxity of the joint ligaments of the pelvic bones often arises from an internal diseased condition, in which slight violence is sufficient to produce a separation of the pelvic bones. 1016. The principal indication in these cases is, to fix the pelvis as steadily as possible and prevent every movement; for which purpose, a belly bandage, or a leathern girdle, is to be applied sufficiently tight around the hips; by this the pain is often instantaneously got rid of, and the patient's movements much improved. How far the laxity of the ligaments, depending on general causes, may be relieved by friction, purging, and the like, must depend on the circumstances of the individual case. 1017. The coccyx may by violence be driven inwards, or by difficult labour be thrust outwards, giving rise to fixed pain, increased by motion of the lower limbs, but especially in going to stool; frequently it becomes severe and pulsating, when suppuration takes place. The ligaments are not torn in this so-called dislocation of the coccyx, it therefore recovers its natural position; the employment of the hand for its replacement, by the introduction of the finger into the rectum, or by its application externally is therefore superfluous. The treatment consists merely in rest, antiphlogistic treatment, and the local application of remedies to effect dispersion and get rid of the inflammatory symptoms. If suppuration take place, a speedy outlet must be afforded to the pus, or otherwise considerable destruction of the loose cellular tissue is produced. IV. OF DISLOCATION OF THE RIBS AND THEIR CARTILAGES. (Luxatio Costarum, earumque Cartilaginum, Lat.; Verrenkung der Rippen und ihrer Knorpel, Germ.; Luxation des Côtes et de leurs cartilages, Fr.) 1018. Dislocations of the hinder end of the ribs have been totally denied by many writers, but admitted by others, who have mentioned a threefold kind of separation, inwards, upwards, and downwards, and complete and incomplete dislocation. So long as the examination of corpses had not shown the existence of these dislocations, it was doubtful whether the common dislocation were not fracture of the hinder end of the ribs; examination, however, has proved the possibility of the dislocation of the ribs. B. COOPER (a) mentions a case of WEBSTER'S, in which a man who had died of fever, was, on dissection, found to have the head of the seventh rib drawn upon the front of the corresponding dorsal vertebra and anchylosed to it. Some years previously he had had a sudden and violent fall from his horse, for which the ordinary treatment of frac tured ribs had been had recourse.to. DONNE (b) showed from the examination of the body of a child of eleven years old, a complete dislocation of the tenth, and a partial one of the eleventh rib; FIMICANE one of the eleventh and twelfth rib; HANKEL (c) a dislocation of the eleventh rib. 1019. Dislocation of the ribs is only produced by the direct operation of external violence. It occurs most frequently at the eleventh and twelfth ribs, because their front end has no point of support, the transverse process is less projecting, and the costo-transverse joint, together with the interosseous costo-transverse ligament are deficient. Dislocation of the rib may be distinguished by its greater mobility, when the finger is run along it, and which is still more perceptible the nearer it approaches (a) His Edition of A. COOPER'S Dislocations, p. 520. (b) Gazette Médicale de Paris, 1841, No. 26. (c) Ib., 1834, p. 187. the hinder end; by a particular rustling, (which is not to be confused with that from fractured rib or from emphysema,) which is perceived on the movements of the body and ribs by the practitioner, or by the patient himself; by a yielding of the parts covering the hinder end of the rib; by a depression where the head of the rib should be found, and by motion of the hind end on pressure of the front end. It is accompanied with cough, difficult respiration, severe pain, and other symptoms, as in fractured ribs (par. 627.) 1020. To effect reduction, the patient should be placed with his chest upon a firm pillow, so that the front end of the dislocated rib may be pressed backwards, and then the vertebra above and below the dislocation is to be pressed down. The rib must be kept in place, by a thick compress placed at the front end and upon the spinal column, and properly fastened with a chest bandage. If the object cannot be thus attained, it has even been advised to open the cavity of the chest, and with the finger or with a hook to bring the rib into its place. No one should be seduced to such a practice. It is most proper in every case to proceed, as in fracture of the ribs, to prevent the motions of the chest, with a broad bandage, and to counteract the other symptoms by proper means. 1021. The cartilages of the upper false and lower true ribs may be separated in violent bending backwards of the body, in which the ligaments are torn where the under cartilage overlaps the upper. At this part projection and depression are observed, the patient feels pain, and the breathing is somewhat disturbed. The natural position of the cartilage can be restored, if the patient inspire deeply and bends backwards, whilst some pressure is made on the projecting cartilage. The treatment is the same as in fracture of this cartilage (par. 629.) ASTLEY COOPER (a) has noticed dislocation of the cartilage most frequently at the sixth, seventh, and eighth rib, from the breast-bone and the end of the rib, not unfrequently in children, as consequent on general weakness. V. OF DISLOCATIONS OF THE COLLAR-BONE. (Luxatio Claviculæ, Lat.; Verrenkung des Schlüsselbeines, Germ.; Luxation de la Clavicule, Fr.) 1022. Dislocation of the Collar-bone is much more rare than fracture, and may be of the sternal end or the scapular end of the bone. 1023. It is generally held that the sternal end of the collar-bone may be dislocated forwards, backwards, and upwards. In this dislocation, if the separation of the joint-surfaces be only rather considerable, the tendinous strengthening fibres, the interclavicular ligament, and perhaps frequently the fibres of the sterno-mastoid muscles seem to be torn. In dislocation forwards, which is the most common, and depends on violent pressing backwards or inwards of the shoulders, a projection is observed on the fore and upper part of the breast-bone, which subsides when the shoulder is pressed outwards; the shoulder stands deeper and more inwards; the head is inclined towards the ailing side; the movement of the arm is interfered with and painful; if the shoulder be raised, the prominence subsides; if the shoulder be depressed, the prominence rises up towards the neck. The dislocation is frequently incomplete, the front only of the capsule being torn, and the bone but little projecting. In disloca (a) Above cited, p. 537. tion upwards, the distance between the two sternal ends of the collar-bones is diminished, and the dislocated end is higher than that of the opposite side. Dislocation backwards, the possibility of which is admitted by most persons, though by others in a manner doubted, but which has been proved by a case of PELLIEUX'S (a), may be caused by violence which thrusts the shoulder forwards, or acts immediately upon the sternal end of the collar-bone from before backwards. Its symptoms are a depression in place of a projection, at the inner end of the collar-bone, only at the opposite end there is decided position and direction of the bone from within outwards, and from behind forwards, severe pain in the region of the collar-bone, and upon the whole side of the neck to the very base of the lower jaw, the mastoid process and occipital protuberance, on sudden movement of the arm, especially in certain opposition to overcome it, as well as with pressure of the hand; on motion, a dull rustling is perceptible to the patient, as of rubbing the two surfaces of the bone together; some pain on rotating the head, hence a degree of stiff neck, so that the head, neck, and chest move together if the patient look sideways; incapability of the patient raising himself from the bed, except by putting an object before him to serve as a point of resistance; lastly, slight pain in swallowing. As the greater number of writers on this dislocation state that, in it, the wind-pipe and gullet, the vessels and nerves are compressed, and severe symptoms are thereby produced, neither of which was observed by PELLIEUX in his case, and the assumption of which depends only on a short notice of DUVERNEY'S (b), and a case related by ASTLEY COOPER, in which dislocation in the second way occurred, therefore PELLIEUX gives a superficial and a deep dislocation of the sternal end of the collar-bone, taking for the former, the symptoms above described, but for the latter, which can scarcely occur but from direct severe violence upon the collar-bone, and with complete tearing away of the m. sterno mastoideus, the more important symptoms of pressure on the wind-pipe and gullet, and on the vessels and nerves of the neck. But this statement is unsupported by any reason; for in the case related by A. COOPER, (p. 401,) there occurred, during great curvature of the spine, a gradual dislocation of the sternal end of the clavicle backwards, in which, for the purpose of relieving the severe symptoms of impeded swallowing, the dislocated end of the collar-bone was removed. [In September 1835, there was admitted into St. Thomas's Hospital, under TYRRELL, a case of compound dislocation of the collar-bone, backwards, which I saw. It had been caused by an earth slip of twelve feet in height, burying him, whilst employed in preparing for the Southampton railroad, and driving the sharp end of a pickaxe, with which he was working, into his chest. He reached the hospital three hours after the accident; and on examination, the cellular tissue below the right collar-bone and on the upper part of the breast-bone was found emphysematous. The collar-bone was distinctly dislocated backwards at its sternal end, and there was a wound in the skin opposite the junction of the second rib with its cartilage. When the finger was introduced into this aperture, the great pectoral muscle was found completely scraped from its clavicular attachment, and the finger could pass as far outwards as the coracoid process of the blade-bone, and inwards, it followed the collar-boue to the windpipe, on the right and fore-part of which it rested, slightly sunk behind the upper piece of the breast-bone, so that it somewhat interfered with respiration and deglutition. The interarticular cartilage seemed to remain in its proper place, except a small portion which had been torn off with the bone; the extreme inner end of the collar-bone could not, however, be distinctly felt; no wound of the intercostal muscles could be ascertained. The pickaxe had probably first passed upwards and outwards, then turned inwards, torn off the pectoral muscle from its origin, and having dislocated the bone, passed inwards above the breast-bone in those directions in which the finger could move; probably it had wounded the pleura and right lung, which appeared the only way of accounting for the emphysema. According to his own account, it would seem as if the handle of the ool had penetrated, for he says, the handle was standing upright and he fell forward (a) Memoire sur la Luxation de l'extrémité sternale de la Clavicule en arrière; in Revue Médicale, 1834, August, p. 161. (b) Traité des Maladies des Os, vol. i. p. 201. |