CASE OF A FRACTURED STERNUM.

JOHN OATES, aged 38, by trade a cabinet-maker, being in company with ſome friends at a Tavern, and drink⯑ing freely, a diſpute aroſe, which termi⯑nated in blows, and he was unfortunately thrown down with ſuch violence on the edge of a chair, as to cauſe a fracture of the Sternum, about four inches above the enſiform cartilage.

Being carried home, a neighbouring Apothecary was ſent for, who ordered ſome draughts to be taken, and a volatile liniment to embrocate the part. Symptoms, how⯑ever, ſoon became alarming, great pain and difficulty in reſpiration, cough, and oppreſſion on the lungs. Theſe complaints were ſuffered to increaſe, without any means being uſed to alleviate them, for the ſpace of one week. He often ſpoke with cer⯑tainty of his breaſt being broken, and ſaid he could ‘"feel the bones jar againſt each other."’

Obtaining no relief, and being poſitively told that his complaint was only a bruiſe, he diſmiſſed his Apothecary, and applied to the NEW FINSBURY DISPENSARY, on Tueſday, the 23d January, 1787. He was immediately viſited by DR. SKEETE [9]and myſelf, with MR. HAIGHTON, who happened to call on me that morning. On examination, we perceived that a fracture had taken place as deſcribed above, but how much of the bone was depreſſed, or how deep the depreſſion might be, we could not readily aſcertain, owing to an inflam⯑mation which occupied the inferior and middle part of the Sternum, and which ſeemed haſtily advancing to ſuppuration. His pulſe was hard and full, the cough frequent, and attended with ſuch diſtreſs and anxiety to the patient, that he ſaid he ſhould be perfectly well if the cough could be ſtopped; for at that time he could plainly feel the broken edges of the bone grate on each other, the irritation of which was al⯑moſt inſupportable, and prevented his taking any reſt.

He was immediately blooded to the quantity of ſixteen ounces, which was much inflamed, a laxative mixture ordered to be taken occaſionally, an emulſion of Sperm. Ceti, cum Sal. Nitri, and Tinct. Thebaic. every three hours; and every other means uſed to obviate the effects which we imagined would be the conſequences of ſuch an acci⯑dent. On the day following, the pulſe was rather ſofter, and the reſpiration not quite ſo laborious; ten ounces more of blood were taken from him, which had the ſame inflammatory appearance; the inflam⯑mation on the Sternum was more circum⯑ſcribed, and evidently ſhewed that ſome pus was already formed. The laxative medicine was ordered to be repeated, and thirty drops of Tinct. Thebaic to be taken at night.

Symptoms continued much the ſame till Saturday, the 27th of January, when Mr. COOPER, Surgeon to Guy's Hoſpital, fa⯑voured me with his company, and was of opinion that the abſceſs on the Sternum ſhould be immediately opened. About ſix ounces of pus were diſcharged. On paſſing my finger to the bottom of the wound, I expected to have diſcovered the broken portion of bone, but did not, probably owing to the parts having become thickened in conſequence of the preceding inflamma⯑tion. The fracture, however, was evident to one ſenſe, though not to the other; for on the patient deſiring us to place our ear on the wound, we could hear the edges of the bone grate on each other at every in⯑ſpiration. The pulſe being ſtill full, it was thought neceſſary to draw ſix ounces more of blood. He had no reſt this night, the [12]cough being inceſſant. On Sunday, the 28th, the countenance appeared much de⯑jected, the ſkin hot, but the pulſe calm; I ordered the opiate to be increaſed to ſeventy drops of Tinct. Thebaic, and ap⯑plied a bandage, or rather a girt, (ſuch as I uſe in fractures of the ribs, and which is made to buckle to what degree of tight⯑neſs may be requiſite) in hopes of being able to confine the motion of the Sternum, and thereby prevent the irritation which the fracture produced. I intended to have ap⯑plied this bandage when I firſt viſited him, but it was thought that if much preſſure was thrown on the ribs, it might probably cauſe the inferior broken part of the bone to protrude through the inflamed integu⯑ments, and be productive of much danger; the bandage was therefore deferred till the abſceſs was opened, and the bone not being [13]evident to the touch, we had leſs to fear from the application of a moderate preſſure.

He experienced much relief in conſe⯑quence of the bandage being applied, the cough was greatly abated, the opiate pro⯑cured a ſound ſleep, and the bone was not troubleſome in inſpiration; the pulſe was perfectly calm, and the wound diſcharged a healthy pus. He was now ordered ſome mutton broth, having hitherto been confined to water-gruel.

From this time to Monday the ſixth of February, the ſymptoms indicated much danger; he ſweated profuſely, coughed in⯑ceſſantly, and what he expectorated was often tinged with blood. He took liberally of a decoction of Bark with Elixir of Vitriol, drank warm milk every morning, and uſed ſuch nouriſhing articles of diet as [14]were directed by DR. SKEETE. This plan ſeemed to ſucceed, for from the 6th to 12th of February, the ſweats were much diminiſhed, and the cough leſs frequent; but the wound diſcharged a foetid ichor in great abundance, which proceeded from a ſinus extending above, and for ſome ſpace round the ſuperior part of the wound. We were now of opinion that this ichorous diſ⯑charge might proceed from the edges of the broken bone, if ſo, it became adviſe⯑able to make a further opening, to endea⯑vour to reach the foundation of the miſ⯑chief, and then purſue ſuch a courſe as might be indicated from examining the condition of the parts.

This, however, was delayed till Saturday, the 17th of February, as for ſome days we pleaſed ourſelves with the idea that the [15]parts would unite independent of our in⯑terference, eſpecially as the diſcharge from the wound became thicker; (DR. SKEETE having added Gum Myrrh to the decoction of Bark) but we were unhappily diſap⯑pointed in our expectations; and as no time was to be loſt, I informed him of the plan which (on conſultation) we intended to follow, viz. to make an inciſion down to the bone, to examine its condition, and, if neceſſary, to remove whatever part of it might, in our opinion, be an obſtacle to a perfect union. He readily aſſented to what⯑ever might be judged expedient for his relief; not on his own account, having ſuffered ſo much that life was become a burden, but for the ſake of his wife and five infant children, whoſe ſubſiſtence de⯑pended ſolely on his labour. I made an inciſion from about an inch above the edge [16]of the old wound, and continued it to the bottom, the knife grated on the bone, and the inferior part became evident to the touch, tho' covered externally with a ſmooth granulation. It now appeared that the fracture was not immediately on the centre of the Sternum, but more inclined to the right ſide of it; that portion to which the ribs are united was firmly attached to them, and in conſequence of the inciſion, the fractured part had ſeparated from its ſitua⯑tion, and expoſed the cavity of the mediaſti⯑num. I paſſed my finger into the cavity, and felt the parts apparently carious on each ſide. We now could only conjecture that a large exfoliation would enſue; but, in all proba⯑bility, the conſequence of this operation might prove fatal, either by the pus lodging in the cavity of the mediaſtinum, or by cauſing that irritation often conſequent to [17]the expoſure of cavities. Theory certainly juſtified us in theſe concluſions, but practice has happily convinced us that notwith⯑ſtanding theſe diſcouragements, there was ſtill a method left to prevent what we had ſo much reaſon to fear. The bone, tho' broken, was not denuded, both the ſuperior and inferior portions were covered with granulations; it then became an object to endeavour to promote a union of thoſe parts by incarnation, ſimilar to what occurs in compound fractures, in which light it might now certainly be conſidered.

I muſt here obſerve, that on the day fol⯑lowing, I found him much better, he be⯑came eaſier after the operation, coughed but little, and ſlept the greateſt part of the night without taking the opiate; this was the firſt natural ſleep he had enjoyed ſince [18]the accident happened, for the opiates only ſerved to palliate the cough, without pro⯑curing any refreſhing ſleep, altho' he gene⯑rally took one hundred drops of Tinct. Thebaic; the expectoration alſo appeared more frothy, and he had no difficulty in diſcharging it from the lungs. This amend⯑ment was but temporary, for from the 17th to the 24th of February, the opiates were again obliged to be given. Our attempts to procure a union of the parts proved abortive, and the inferior edge of the bone protruded through the wound at every in⯑ſpiration, and conſequently expoſed the cavity of the mediaſtinum. There ſeemed no proſpect of any exfoliation, I therefore omitted the former bandage, as it appeared to have no power to anſwer the intention we had in view, and paſſed a common roller round the inferior part of the Sternum; [19]the preſſure of this brought the lower por⯑tion in contact with the upper, and we had the pleaſure of ſeeing a union effected in a few days. The ſweats from this time totally ceaſed, and the cough was not troubleſome. I removed him to Iſlington, for the benefit of the air, there the cough entirely left him, and he ſlept without taking the opiate.

When he attempted a deep inſpiration, he felt a ſmall preſſure on the fractured part, and alſo on the right ſide of the wound; which ſide was evidently enlarged, and felt as if the cartilages of the ribs had received ſome injury from the fall. He complained that the air was too ſharp for him, and (to uſe his own expreſſion) ‘"felt like vinegar in his noſtrils;"’ indeed this was ſo much the caſe, that if he ſtood at the [20]window when open, or attempted to walk out, the air inſtantly cauſed him to ſneeze violently, which gave great pain to the fractured part. I was therefore obliged to remove him from Iſlington, where he only continued four days; and for two or three nights after he returned home, the cough again became violent, ſo that I was under the neceſſity of repeating the opiates. As the wound healed, the cough abated, and his only complaint was that of great weak⯑neſs, and a total inability to uſe his arms with any freedom of motion. He could ſtoop to buckle his ſhoe, could take up any weight, but was utterly unable to perform any lateral motion.

March. During this month, he was perfectly free from complaint; had taken Pulv. Cort. Peruv. 3. ter die. The [21]enlargement related to have been on the right ſide of the wound was much leſſened, but an abſceſs formed on that ſide imme⯑diately on the breaſt, which broke on Friday, the 30th of March. It appeared quite ſuperficial, and to have had no con⯑nection with the original injury.

April. The wound on the Sternum was now healed to about the ſize of a ſix-pence, and from this a vaſt diſcharge was daily evacuated; ſuſpecting ſome ſinus, I paſſed the probe, and found one, which extended about two inches on the right ſide between the two inferior cartilages, directly above that enlargement already mentioned. This ſinus was laid open, and continued diſcharg⯑ing till the beginning of Auguſt, when it was propoſed to apply a cauſtic on the part; the action of which laid bare the [22]fractured portions of the bone, the ſuperior edge greatly depreſſed, and the intermediate ſpace filled with a kind of membranous ſubſtance, which had prevented an oſſific union of the parts. It was now curious to obſerve the proceſs which nature was daily executing, in order to fill up the vacuity; at every dreſſing ſome new excitement was perceived; increaſed vaſcularity^* in the living portions of bone, by which the carious [23]part became more ſeparated, and granu⯑lations ariſing from the ſurrounding ſoft parts. On the 10th of October, the exfo⯑liation from the inferior part took place, the portion of bone was but ſmall, healthy granulations being ſubſtituted in its place.

We now aſſiſted him with an elaſtic truſs, which proved of ſo much ſervice as to enable him again to follow his buſineſs of a cabinet-maker. This truſs makes an equal preſſure on each ſide of the breaſt, and ſupports the ſternum in ſuch a manner, that if he takes it off, he ſays, he feels ‘"as if his inſide was falling in pieces."’ With⯑out it, he is incapable of performing any lateral motion.

The wound now healed, without any in⯑terruption, and was perfectly cicatrized on the 23d of October.

The following obſervations are ſuch as will naturally ſuggeſt themſelves on an at⯑tentive conſideration of the above facts.

Firſt, That the caſe was attended with conſiderable danger, throughout the greater part of its progreſs; but from very different, and even oppoſite circumſtances, at different periods. In the beginning, the ſymptoms of inflammation in the Thorax ſeemed to be ſo general and violent, that without the free uſe of the lancet, aſſiſted by dilution and the antiphlogiſtic regimen, it is pro⯑bable that a fatal termination would ſpeedily have enſued; but the only method by which this could be prevented, doubtleſs aſſiſted in inducing that ſtate of debility and hectic under which the patient was afterwards in danger of ſinking, and which required the liberal exhibition of Bark, Elixir of Vitriol, [25]Myrrh, and ſuch nouriſhing articles of diet as were judiciouſly preſcribed by Dr. Skeete. The ſame thing happens in many caſes of diſeaſe which fall under the care of the Surgeon; and the preſent inſtance is a ſtrong illuſtration of the neceſſity of a particular attention being required to the ſtate of the conſtitution, as well as to the condition of the diſeaſed part.

Secondly, It may appear extraordinary, that notwithſtanding the frequent expoſure of the cavity of the Mediaſtinum, which ſeemed to take place when the broken edges of the bone were ſeparated, during the alternate motions of inſpiration and expi⯑ration, that this expoſure was not followed by any repeated attack of inflammation, or by any effuſion of pus into the cavities of the Thorax, tho' we had more than once ſufficient reaſons to apprehend ſuch effects, [26]eſpecially when the expectoration aſſumed a purulent and bloody appearance, with ſymptoms of hectic. The event therefore ſeems to prove that ſuch adheſions muſt have taken place between the Lungs and Pleura in the neighbourhood of the injured part, as compleatly to have prevented any ſuch effect.

Thirdly, After ſome months, the treatment was almoſt entirely confined to the part; the healing of the wound being prevented by the ſtate of the bone underneath, as has been already mentioned.

Fourthly, That the loſs of ſubſtance which the Sternum has ſuſtained, is at preſent ſupplied by granulation only; and whether nature will in this caſe, as in many others, reſtore the part to its original ſtate, by a bony depoſition, time alone will be able to diſcover.