SECT. CXVII.—ON THE VERTEBRÆ OF THE SPINE.
The vertebræ of the spine, when completely dislocated by accident, occasion instant death; for the spinal marrow undergoes extraordinary compression; and even when one of its nervous processes is compressed, it brings on dangerous symptoms. It often suffers sub-luxations, and when this takes place forwards it gets the name of repandation; when backwards, that of gibbosity; and when sideways, that of wry-neckedness. When there is a small sub-luxation of many vertebræ together, the distortion occasions a circular flexure of the spine, and in this case some are apt to be deceived, and take it for a complete dislocation of one spine, whereas a complete dislocation of one spinal vertebra does not produce a circular but an angular flexure of the spine, which is attended with more danger. When the dislocation is inwards, it cannot be reduced because no counter-pressure can be made on the belly. But those who imagine that they can effect anything in this case by stretching the patients upon a ladder, by apply cupping instruments, or administering sternutatories, or by producing coughing, or by inflation, are sufficiently exposed by Hippocrates. But since, often the breaking off of some of the small bones of the spine leaves a hollow appearance (as has been mentioned when treating of fractures), some have taken this for a dislocation forwards; and it being speedily healed, (for its callus is soon formed,) they have given out that a dislocation forwards is readily cured, although in fact it be wholly incurable, or difficult at least, to cure. For retention of the urine and fæces takes place, with coldness of the body; but this state is followed afterwards by an involuntary discharge of the excrements. These symptoms arise from the nerves and from muscular sympathy, and the patients soon die, more especially if the upper parts and the vertebræ of the neck be affected. But that gibbous state of the spine which mostly takes place from infancy, is a protracted affection and not speedily fatal; but, as Hippocrates has shown, it leads to disease and is incurable. But when this state occurs from an accident, the contrivances to remedy it with a ladder, suspending the patient erect, and inflation with a bladder, are altogether ridiculous. But the method of rectifying it, recommended by Hippocrates, will be alone sufficient. For, he says, a board, in length and breadth such as to contain the man, or a bench equal to it, is to be placed near a wall, being extended along the wall, and not more than a foot distant from it, and some robes are to be spread over it to prevent the body from being injured. Then the man, being bathed, is to be laid on his face along the board or bench, and a thong is to be twice passed round his breast by the armpits along the back; and the extremities of the thong are to be fastened to a pestle like a piece of wood erected on the floor at the extremity of the board or bench, and this to be given to a person standing behind the patient’s head to hold, so that when the lower parts are secured oppositely, and the upper pulled towards the head, extension may be made at the proper time. Then another thong being bound round both the feet above the ankles, and again another above the loins, so that its two ends may meet upon the haunch-bone, the extremities of these thongs are to be again united together, and bound to another pestle-like piece of wood resembling that already described; and this pestle, like the former, is to be erected near the extremity of the board or bench at his feet; and then we are to order the assistants to make counter-extension by these pieces of wood. Others effect this part of the operation by what are called aselli. They are axles turned upon an erect piece of wood, which is placed at each extremity of the large board or bench, at the feet and head of the patient, and the thongs are to be wrapped round them. While the extension is thus made, we press down the prominence of the back with the palms of the hands, and if necessary we may sit upon it without apprehension. If the spine is not thus made straight, and the patient can endure pressure, we may scoop out from the adjoining wall a furrow opposite the prominence of the back, so that the length of the furrow may not be greater than a cubit, and it must be in a situation neither much higher nor lower than the patient’s spine. But this furrow ought rather to be prepared beforehand, and on this account we directed the board at first to be placed near the wall. Then one extremity of a board is to be introduced into the furrow, while we press the other downward until it is clear that the spine is rectified. According to Hippocrates, extension alone without the board, and again the treatment with the board alone, is sufficient to accomplish the purpose. If this be true it will not be improper, in cases of dislocation anteriorly and laterally, to make the aforesaid extension without the compression. After the reduction, a thin piece of wood three fingers in breadth, and of such a length as to comprehend the dislocated part and some of the sound vertebræ, is to be wrapped round with a piece of linen or some flax, on account of its hardness, and applied to the spine with suitable bandages. And the patient must be kept upon a spare diet. If afterwards any remains of the protuberance are to be discovered, we must use relaxant and emollient applications, with the pressure by means of the plate. Some use a plate of lead.
Commentary. Our author’s account of dislocations of the spine is entirely condensed from Hippocrates’s work ‘De Articulis,’ and the commentary of Galen on the same. The description of the methods of reduction is so plain, that we need not take up time in illustrating it. It will be remarked that he makes mention of a mode of reducing these dislocations by means of axles or aselli. In the days of Hippocrates they were acquainted with only three of the mechanical powers, namely, the lever, the wedge, and the axis in peritrochio. The last mentioned is called by him asellus. (See De Fracturis cum Comment. Galeni.) Hippocrates makes mention of a mode of reducing dislocations of the spine, by succussion in a ladder, but expresses himself unfavorably of it as being a procedure which none but charlatans would practice. He speaks with becoming contempt of those who have recourse to ostentatious modes of performance ad captandum vulgus.
Celsus states very decidedly the fatal nature of dislocations of the uppermost vertebræ. Even those below the diaphragm are designated as highly dangerous. They happen either forwards or backwards. Those above the diaphragm occasion paralysis of the hands, vomitings, contractions of the tendons, difficulty of breathing, pain, and relaxation of the ears. Those below the diaphragm produce paralysis of the lower extremities, suppression of urine, or an involuntary discharge of it. Even these cases, he adds, prove fatal within three days. He says, that Hippocrates’s mode of reduction by counter-extension and pressure on the part with the heel, applies only to cases of incomplete luxation.
Oribasius describes the method of reduction by means of a machine, as mentioned by our author. It will readily be understood that the whole process consisted in making counter-extension upwards and downwards, and pressing upon the part which projects with a piece of wood. (De Machinamentis.)
Albucasis explains the nature of the accident and the methods of reduction in much the same terms as our author. The patient is to be laid upon a board or bench of sufficient length, spread with some soft thing to prevent him from being hurt. Then a pole or piece of wood is to be fastened at each extremity of the bench; and a rope or swathe, being carried round the patient’s body by the armpits and above his head, is to be fastened to the upper pole, which is not to be fixed firm in the ground; and another rope is to be brought round below the part affected, and fastened to the pole at his feet. Powerful counter-extension may be thus made, while the surgeon presses upon the protruded part with his hand and pushes it into its place. If these means do not succeed, he directs us to fasten a piece of wood into a hole in the wall opposite the protuberant part of the patient’s back and to press down with it. Other methods are also described by him. After reduction he directs us to apply a splint with bandages, as recommended by our author.
Avicenna describes all the methods of reduction here mentioned; and in the Latin edition of his works there are plates to illustrate his descriptions. Judging from our own experience of such cases, however, we would say that such contrivances can seldom be required to reduce these dislocations, as there is much less difficulty in the reduction than in keeping the parts in place afterwards.
Haly Abbas copies the description given by Hippocrates of the mode of reduction. After the parts are restored to their place, he recommends us to apply a board (tabula lignea) three fingers broad, and of such a length as to comprehend the dislocated vertebræ and some of the adjoining ones; and to bind it firmly on to prevent a recurrence of the displacement.
The ancients were well acquainted with the curvature of the spine occasioning paralysis of the lower extremities. Alsaharavius remarks that it occurs most frequently in childhood, and arises from an inflammation or collection of humours between the vertebræ. Sometimes, he adds, it is occasioned by a gross flatus. This is the disease called spina ventosa. When connected with a collection of blood in the part, he recommends bleeding, clysters, and various emollient applications. When it arises from flatulence he prescribes the hermodactylus. If the usual means do not succeed he approves of the actual cautery. (Pract. xxviii, 9.)
But no ancient author has treated so fully of curvature of the spine as Rhases. He states that it occurs most frequently in childhood, and often proves fatal by occasioning pressure on the thoracic viscera. The disease, he says, may arise from a fall, a blow, an abscess, or a gross flatus contained in the vertebræ. In cases of paralysis of the lower extremities connected with this disease, he approves of applying the actual cautery to the back. (Cont. i.) He states correctly that dislocations of the upper vertebræ often prove suddenly fatal. He directs the surgeon to keep them reduced with a splint extending the whole length of the spine. (Cont. xxix.) On the spina ventosa or gibbositas, see further Serapion (v, 26.) For the cure of it, he recommends first discutient plasters, and if these do not succeed he advises recourse to the actual cautery. (v, 27.)