securely incased in its canal formed by the bony arches and stout ligaments of the vertebræ and further protected by its covering of dura mater and free suspension within the cerebrospinal fluid. Fracture of a vertebral body with displacement of the fragments frequently produces more or less contusion of the cord. If the contusion involves the entire thickness of the cord, the most prominent symptom will be loss of motion and sensation in the region over which the injured segment presides, and we have: Paralysis of the rectum and bladder; paraplegia of the lower extremities if the injury is in the thoracic portion above the lumbar enlargement; motor and sensory paralysis of the trunk and upper extremities, marked disturbance of the respiration, sometimes excessive elevation of the body-temperature, if the injury is in the lower cervical portion; early death from injury to the respiratory center, if the lesion occupies the upper cervical portion.

In addition, motor paralysis in the distribution of the sciatic nerve is observed in injuries involving the lumbar enlargement (at the level of the spinous process of the twelfth thoracic vertebra); paralysis of rectum and bladder; impairment of sexual power; local anesthesia of the anal and perineal region, of the genitalia, and of the posterior aspect of the thigh, when the lesion is below the third lumbar vertebra. In this localization the cauda equina alone is affected. The condition of the reflexes is variable; as a rule, they are obliterated when the entire cord is injured by contusion or other analogous compression. If the injury is slight, they may be unchanged or even exaggerated.1

The diagnosis of fracture of the body of a vertebra in very severe cases can hardly be mistaken. If the degree of injury is known, if the kyphosis is readily recognizable and the symptoms of transverse lesion of the cord are present, the diagnosis is assured. But nervous phenomena

1 For further details see the instructive monograph of Trapp (Deutsche Zeitschr. f. Chir., vol. XLV, p. 434).

need not necessarily be present in fracture of the body of a vertebra, and we must insist that the spinal cord and nerve-trunks escape injury in many cases. A glance at the fracture in the upper thoracic portion of the vertebral column represented on Plate 19 (Fig. 1 a) shows that the cord at this point is quite intact.

In these cases the force is only a moderate one and the kyphosis is less distinctly marked. To detect the latter, careful examination, especially by inspection, is necessary; the least deviations from the normal curvature of the vertebral column, such as accentuation of the curve, the presence of a prominence at the seat of injury, and flattening of the adjacent portion, must be looked for. If the examination is made some little

time after the injury, functional disturbances, local pain on pressure, and pain elicited at the suspected spot by sudden pressure on the head in the direction of the vertebral column, are valuable diagnostic data. Ability to stand or walk, or even to do light work, does not absolutely exclude fracture of the vertebra, especially a compression-fracture. If grave symptoms develop later on, they are due to loosening of the impaction at the seat of fracture and to alterations in the fragments, such as occur in every variety of fracture.

The prognosis depends on the character of the accessory injuries and their consequences. As far as the fracture itself is concerned, it may heal by bony union, and many patients live on undisturbed and are able to do more or less work, provided only the spinal cord has not been injured. If, on the other hand, the symptoms of cordlesion are present, the case immediately becomes very grave. Even if myelitis is warded off, other dangers threaten. Bladder paralysis, as a rule, calls for the use of the catheter several times a day, and while perfect asepsis should always be insisted upon and is not impossible of attainment, there is nevertheless great danger in actual practice of cystitis developing through infection by the catheter and resulting in septic pyelonephritis which eventually ends the patient's life.

Fig. 29.-Patient with fracture of a cervical vertebra as he lies on the surgical bed. sling (jury-mast) is attached to the head.

Glisson's

Otto Knüppel, twenty years of age, was severely injured on the 5th of August, 1895, by a fall
on the head from a horizontal bar. He was admitted to the clinic on the same day with a fracture
of the sixth and seventh cervical vertebræ. There were pain on pressure and ecchymosis at the seat
of fracture. At first the upper extremities were not involved, but motor, sensory, and reflex
paralysis was present from the level of the fourth rib downward. Retention of urine and feces
marked and persistent priapism; pulse 60; temperature 39.9° C. (104° F.); sensorium not involved.
Later partial motor and sensory paralysis appeared in the upper extremities. The catheter had to
be used regularly. Soon cystitis developed and the patient was threatened with bed-sores.
from pyelonephritis on the 1st of October, 1895.

Death