Imagens das páginas

proved by the fact that alkaline urine is obtained if a catheter be left continually in the bladder. When this is done no collection can take place in this receptacle, and the fluid is obtained as sent down from the kidney. The alkaline urine contains the triple phosphate, a salt which is well known to be formed in the kidney. The alkaline urine becomes, however, a source of irritation to the mucous membrane of the bladder, which falls into a state of chronic inflammation: adhesive mucus is then secreted, which, mixed with the triple phosphate, often constitutes a sort of alkaline glue at the bottom of the urinal. It is very probable that phosphate of lime may now be secreted by the bladder, increasing the alkalescence of the urine. These changes will readily be understood by those conversant with the morbid chemistry of this important excretion. We have not space to pursue the subject further, and we trust that at no distant period of time, the injuries of the spine will be treated of by one who is well able to do justice to any practical subject, we allude to Mr. Brodie. This distinguished surgeon has already favoured the profession with a paper on the primary effects of injuries of the head, but he yet owes us a debt which, importunate and clamorous though we may appear, we beg to remind him of-the sequence of that paper. In the mean time we correct Mr. Stafford on a point in which he has evinced some sins both of omission and commission.

Another symptom is torpor of the bowels, owing greatly, no doubt, to paralysis of their abdominal muscles, if not of their own: and flatulency, owing partly to the constipation, partly perhaps to diminution of the nervous influence by which the living gut controls the chemical decomposition of its contents. However this may be, the facts are as stated. Priapism is well known to be another occasional consequence of injuries of the spine. It has been attributed to concussion of the cerebellum, a gratuitous speculation.

The prognosis of concussion of the spine must depend on the seat of the injury, and its extent. The first is ascertained by inquiry and inspection, the second by the symptoms.

"The treatment of concussion of the spine must be adapted to the three different stages in which it presents itself to our notice. 1st. That immediately after the receipt of the injury; 2d. The inflammatory stage; 3d. That when the active symptoms have subsided. In the first stage, immediately after the receipt of the injury, the patient is usually so exhausted from the violence of the shock, that he is in a state of collapse. All that can be done at this time is, to place him on his back in a warm bed, and to administer stimulants, such as brandy, camphor, carbonate of ammonia, &c. until reaction commences. When reaction has taken place, antiphlogistic measures should be immediately resorted to. If the fever runs high, and the pulse be quick, full, and hard, the patient should lose blood from the arm. If, however, the symptoms are not sufficiently violent to demand very active treatment, he should be repeatedly cupped opposite the injury, purgatives also should be given, first to act briskly, then moderately upon the bowels. The feverish symptoms will be best allayed by the exhibition of antimonials combined with nitre, and small doses of saline purgatives. When the activity of the inflammation is diminished, blisters may be applied (and repeated as often as the preceding ones have healed) on each side of the spine, with the greatest advantage, until all inflammation has entirely subsided. During the treatment the patient should take nothing but farinaceous diet, and it is of the utmost consequence that the spine be kept as still as possible, for each movement, by increasing the inflammation, must necessarily diminish the pro

gress towards cure. To effect this, the double-inclined plane-bed, invented by Mr. Earle, will be found of the greatest service, as when the patient is placed on it there will be no necessity for him to be moved, either to perform the natural evacuations, or to have those means employed which are necessary to the restoration of his health.

In concussion of the spine, the muscles of the rectum are usually either so paralysed that they have no power to act, or that the fæces escape without their being able to control them; in the former case injections must be used. The bladder likewise is unable to expel its contents. A catheter in most cases must be passed at least twice in the day, or as often as a sufficient quantity of urine is secreted.

It often happens that patients who have had bad concussions of the spine recover to a certain point, and yet do not get quite well; that is to say, they have either an imperfect power of motion, or an imperfect sensation. It is difficult to say exactly from what this arises, but it is most probable owing to chronic inflammation, or to some alteration of structure of the medulla, in consequence of the injury. It should be treated, however, according to the symptoms. If pain still exists in the injured part, the means employed should be the same as in diseases of the spine. The patient should constantly lie upon his back, counter-irritants should be used, by repeated blisters, the moxa or issues, and the general health should be attended to. If, however, there is no pain, and there is reason to believe that the defective power arises rather from weakness than from any other circumstance, then stimulating the part will be the most likely means of restoring the lost powers, and the best means for this purpose will be friction on the spine and limbs, stimulating liniments, shampooing, electricity, and galvanism, and if the power of movement alone be defective, then the limbs affected should be made to undergo certain exercises calculated to restore them." 72.

We would not recommend practitioners to be so much alarmed about the stage of collapse. It is with injuries of the spine, as with those of the brain, in this particular. If the injury is remediable the collapse is very seldom, very seldom indeed, so profound as to inspire serious and just alarm, or require stimulants which may afterwards be injurious. If the injury is so severe as to occasion a collapse that will prove fatal, that injury will kill in spite of all our cordials. We would not be mistaken. We do not affirm that patients never sink from collapse independent of lesions which must necessarily be mortal, but we affirm that they very rarely do so, and we confess that we never saw an instance of the kind. But we do say, that for collapse as it usually presents itself, no stimulating treatment is necessary. Warmth and the bed are all that are required, and if more active measures are unnecessary they are likely to be injurious. Mr. Stafford relates two cases; we shall take one. Previous to this we shall give the cadaveric appearances in those who die from concussion of the spine.

"The parts exterior to the osseous canal are much contused, and sometimes blood is found extravasated in the cellular membrane. The membranes of the medulla spinalis are in a high state of vascularity, opposite to the point where the blow took place, and occasionally one or more of them are ruptured. There is also more or less blood, either coagulated or not, between the dura mater and osseous canal, the dura mater and arachnoid membrane, the arachnoid membrane and pia mater, and sometimes between all at the same time. When the patient dies immediately after the accident, the medulla spinalis is generally of its natural colour and texture, but now and then it is rather redder, and if minutely examined through a magnifying glass, the capillaries ramifying upon it

may be seen injected with blood. When the death of the patient has been delayed, it is not uncommon to find it of a yellowish red colour, and of a softer consistence, and in some cases where there has been much inflammation, it is rendered into a more fluid state at the part where the concussion took place. Occasionally it is observed that the inflammation of the injured portion has extended itself along its own substance to the brain, as well as along its membranes, to those of that organ, and in this case there is a quantity of fluid found in the vertebral canal." 79.

We cannot look upon the foregoing chapter on concussion, as either displaying all that is known on the subject of concussion of the spine, or even as evincing method and precision. After injuries of the spine we meet with two series or orders of symptoms; the one immediately consecutive to the injury, and expressive of its charater and extent, the other arising after a certain interval, and dependent on chronic inflammatory action set up in the medulla, its membranes, or even in the spinal column. These have not been well separated and discriminated by Mr. Stafford. But to pass to one of the cases.

Case. James Liddy, æt. 30, admitted into St. Bartholomew's Hospital Feb. 5th, 1830.

About the middle of January, after throwing himself from a wall 12 feet high, he immediately found a sensation of chilliness, pricking, and partial inability to move the right leg; he was likewise unable to make water or retain his fæces. Previously to his admission he had taken some medicines, which had been of no service. On his admission, he complained of considerable pain in the lumbar region, increased by tapping the spinous processes, and pain along the anterior and upper part of the thigh, in the inguinal and hypogastric regions, with some swelling in the groin. He was cupped and twice blistered, with such relief, that on the 13th he was able to leave the hospital. On the 20th he returned, with considerable uneasiness in the leg, thigh, and hip, with disposition to sickness and thirst. He was bled to 16 ozs. took laudanum in an effervescing draught, was blistered and cupped. After this treatment there remained but slight uneasiness in the right thigh and knee, with an inability to rest the heel on the ground. On the 9th March, a moxa was made in the lumbar region, and soon afterwards he voluntarily left the hospital. After this Mr. Stafford has made some mistake in the dates. It seems that he was again in the hospital, and left it in September, with the action of the bladder still imperfect, and a slight pain in the thighs. He now pursued his occupation-that of a corn-porter, when he soon became worse. In December, apparently, he returned, with complete incontinence of urine, some difficulty in retaining his motions, pain on pressure in the lumbar region, and also along the inner side of the thighs, with great tenderness on pressure. His general health was good, but he did not sleep well. He was put on milk diet, ordered to keep the horizontal posture, two moxas were applied to the lumbar region, and some physic given. The dribbling of urine, and feeling as if he wished to void it, continuing, a catheter was passed, and about a pint of healthy urine drawn off; there was a slight stricture about three inches from the orifice of the urethra. He was ordered to wear an elastic gum catheter plugged, and to have the water drawn off every four hours. On the 6th Dec. two moxas were again applied. On the 10th, he complained of great increase of pain in the thighs,

extending also to the calves of the legs. Eighteen leeches were applied to the thighs with much relief. On the 18th, the pain in the legs was very severe, and the same application was made to them with some success. On the 1st of January, a blister was applied, with good effect, to the left calf for pain there. He could now bear pressure on the spine without pain, but complained of cold and shivering. On the 1st February he was in good health, but did not sleep well; the urine was passed three or four times daily, but only at the water-closet, and he always felt a desire to pass more; he introduced the elastic catheter every evening, and drew off half-a-pint of healthy urine; there was no difficulty in retaining the fæces. In this state he left the hospital, with the moxas not yet healed.


Under this head we find nothing very new or instructive, but some cases are related which are worthy of extraction, for facts are the matériel of medical science. In order to shew that fracture of the spinous processes of the vertebræ is frequently recovered from, we have two cases related.


Case 1. "In the month of December, 1820, a soldier, belonging to the North Gloucester Militia, was at work in an excavated stone pit, when the roof gave way, and fell upon his back. He was immediately dragged by his fellow-workmen from the stones and mould which were upon him, and was carried home. He was examined, and it was found that the spinous point of the first lumbar vertebra was not in a regular line with the others; it was depressed, and fractured. The man had complete paraplegia below the injury, and the bladder and the rectum were also paralysed. When reaction was established he was bled largely, and powerful doses of purgative medicines were administered, in every form and dose, together with the employment of purgative clysters, but with no effect, until the eighth day, when the torpor of the bowels was overcome. was now unable to retain the fæces, and they made their escape involuntarily. His bladder also still remained paralysed, and it was necessary to relieve it constantly by the catheter. He continued in this state for three months ; at about which time sensation began to return, with pricking and shooting pains in the limbs, and shortly afterwards he perceived he could move his legs slightly backwards and forwards. In six months both these powers had so increased that he could walk with crutches, and in twelve he could go about without any support, and all that he suffered from was weakness in the limbs. The bladder and rectum gained their power also, in the same ratio as the other paralyzed limbs. When I last saw him, the parts over the injury were much thickened and consolidated. It is probable that there was more injury in this case than fracture of the spinous process; but this can only be proved by the examination of the parts after death.

Case 2. A man was admitted into St. Bartholomew's Hospital for an injury of the back, but he had no symptoms whatever of concussion of the spine. There was, however, an irregularity of the lower spinous processes of the dorsal vertebræ, and it was found that the tenth was flattened and depressed. The part was cupped and fomented, and aperients administered. In a month he went away quite well." 86.

Sir Astley Cooper has shewn that Nature is capable of repairing fractures of the vertebræ as of other bones, in fact, there can be little doubt that the fracture itself is of comparatively little moment; it is the implication of an organ so important as the medulla, which confers upon it the seriousness and

danger which attend it. Mr. Stafford gives the brief particulars of two cases, calculated, in a high degree, to teach caution and gentleness in the handling of patients who have suffered from fracture of the spine.

Case 1. "July 25th.-A man having received a kick from a horse, upon the back of his neck, became instantly paralyzed in all parts of the body below the injury. He was immediately carried to St. Bartholomew's Hospital, and in about twelve hours after the accident delirium came on. The surgeon desired that the head might be shaved, in order that the proper remedies might be employed. In doing this, the barber turned the head a little on one side; the patient instantly fell from under his hand, and expired. Upon examination it was found he had fractured the third cervical vertebra, and that the sharp point of the fracture had pressed upon and wounded the medulla.

Case 2. A man fell from a great height, and broke his neck. An officious nurse, in moving him up, as she thought to relieve him, let his head fall backward. He instantly expired. He had fractured the second cervical vertebra.

Both of these cases occurred to my own knowledge, and from them it may be seen how necessary it is to keep the spine quite motionless, and more particularly when the accident happens in the neck. As soon as the patient receives the injury, he ought to be placed on one of the double-inclined plane beds, upon his back, and he should never, if possible, be moved, until there is sufficient reason to believe the fracture is united." 95.

We pass over some cases of fractured spine, and merely insert the morbid appearances observed after these injuries.

"When only simple fracture of the spine takes place, the morbid appearances are generally the same as in concussion; but if there is a complication of injuries, such as depression of the bone, &c. or there is dislocation of the vertebræ from one another, then it is found that compression, contusion, or either total or partial laceration of the medulla spinalis, may be produced. When the medulla is compressed, it does not always follow that there should be any difference from concussion in the morbid appearances, although most generally it is found that either some of the membranes are torn, or there is an extravasation of blood in the canal, and the medulla itself is much redder than usual. When the medulla spinalis is contused, it is usually found to be soft and disorganised; being occasionally streaked in its external substance with coagulated blood, and in one instance, mentioned by Sir E. Home, a clot of blood was found in its centre.

The membranes may be ecchymosed, ruptured, or have coagulated blood between them. If long after the injury, the medulla may be changed both in colour and structure, being in the one of a yellowish, red, or grey, and in the other much softened. Laceration of the medulla almost always occurs when there is fracture with dislocation, or when there is dislocation alone, and it may happen even under any circumstances, when there is displacement; the medulla, in these cases, may either be partially or wholly lacerated, and generally its membranes are torn, and blood is effused in the vertebral canal." 107.

The fourth chapter treats of dislocations of the spine. These are so rare, that Sir A. Cooper never saw an instance of the accident. When dislocation does occur, it is, from obvious reasons, more likely to take place in the neck than in any other part: elsewhere, indeed, it may be looked on as impossible. The most usual seat is between the atlas and dentata. J. L. Petit relates a case, which is also quoted by Boyer, where the only son of a tradesman went into his neighbour's shop, and playing with his infant son, lifted him from the ground, by putting one hand under his chin and the other on the back part of the head, by which he dislocated his neck, and the child

« AnteriorContinuar »