extremely serious and may hasten, or be the immediate cause of death. (See Fractures, p. 272.) Injury to or change in the vaso-motor nerves has been thought to be the cause also of changes sometimes observed in the lungs. In two cases elsewhere mentioned' I have known fracture of the cervical vertebræ to be followed by expectoration of blood coming from the lungs, and Blasius (following Moritz) describes a pulmonary congestion appearing promptly, marked at first by increased secretion, and rapidly causing death by oedema of the lungs, usually on the second or third day. Prognosis.-The injury is commonly deemed, and with good reason, one that places the life of the patient in great danger. Of the cases collected by Blasius the termination is noted in 278, and of these the injury caused death in 176 and was more or less completely recovered from in 102. These statistics, however, cannot properly be taken to indicate the actual percentage of mortality in such cases, because they are made up not from integral records but from published cases, and, as is well known, cases that survive are more frequently published than those that terminate fatally. Furthermore, as Blasius points out, the diagnosis is by no means certain in all of the recoveries, and in some of the fatal cases death may have been due to associated injuries. From these 278 cases Blasius took 159 in which the diagnosis was certain; of these 36 recovered and 123 died, a proportion of 22.6 per cent. of recoveries, or 1 in 4.4, which corresponds quite closely with that established by Gurlt, 19.6 per cent., for fractures of the vertebræ (see Fractures, p. 254). It is well worthy of note, also, that of these 36 recoveries the dislocation was completely reduced in 27 and partly reduced in 2, and that all these 29 and 5 of the remaining 7 were dislocations of the cervical vertebræ. In the fatal cases death usually followed promptly upon the receipt of the injury. Of 113 authentic cases 21 died within the first twentyfour hours, 31 on the second and third days, 17 between the fourth and seventh days, 14 in the second week, 5 in the third, 6 in the fourth, 3 in the fifth, 2 in the sixth week, and the remainder at periods varying from two and a half to five months. Death, especially in the cases in which it occurs promptly, is usually the consequence of the injury to the cord or of the inflammatory processes set up in it by the injury; but when this injury is situated in the lower portion of the cord life may be indefinitely prolonged, as in the case quoted above from Charles Bell, in which by complete lateral dislocation of the twelfth dorsal vertebra the cord was completely divided, and the patient, a child, died of croup thirteen months later. Simple compression of the cord involves less danger to life than its complete or partial division or crushing, and relief of the compression may be followed by restoration of function. If the compression takes place gradually, even to a very marked degree and at the upper end of the cord, as in several reported cases of cervical spinal caries, prolongation of life is still possible, and even marked and permanent compression at the level of the atlas and axis has, in two reported cases, not proved immediately fatal. In one of these, dislocation of the atlas forward from both the occiput and the axis with fracture of the odontoid process, the canal was reduced to a triangular slit two millimetres wide on one side and five on the other; the patient survived five months, being completely paralyzed during most of the time. In the other case, incomplete dislocation of the occiput from the atlas due to caries, the patient survived three months and died of tubercle of the brain. 2 If the dislocation remains unreduced the irregularities in the form and function of the column of course persist, and the irritation of the traumatism may lead to such ossification of the ligaments and bony ankylosis of adjoining vertebræ as will still further diminish the mobility of the column and increase the chance of the occurrence of fracture, as in a case mentioned by Ollivier d'Angers.3 If the dislocation is reduced the symptoms usually disappear promptly, but the paralysis may persist in whole or in part, and the case may even terminate fatally in consequence of the injury done to the cord or its envelopes. Treatment. This must be directed to the reduction of the dislocation, the prevention of its recurrence, and if reduction is impossible to the relief of the consequences of the displacement. The propriety of attempting reduction has been earnestly questioned, and many judicious surgeons have recommended that the attempt should be abstained from because of the possibility that it may add to the injury of the cord. Some (Nélaton) have suggested that the attempt should not be made unless the injury or its consequences have already placed the patient's life in imminent danger; while others (Porta) have sought to restrict the attempt to those cases in which the cord has not been injured and the existing dislocation can be borne without serious trouble or disability. The reason for the last advice probably lay in the belief that if the cord were already so injured by the traumatism as to give rise to noteworthy symptoms no good could be expected from reduction, a belief that is not in harmony with observed facts. The postponement of reduction until after the appearance of later symptoms due to the persistence of the irritating conditions is as unwise, as fatal, as similar temporization in the treatment of fractures of the skull. If anything is to be done it should be done promptly, and yet it must be added that reduction has been successfully made in several cases as late as the eighth or ninth day after the accident, and in one after the lapse of two months, and was followed by the prompt or gradual disappearance of the paralysis. The attempt to discriminate, with reference to the question of attempting reduction, between cases in which the paralysis is due to simple compression of the cord and those in which it is due to its laceration or the effusion of blood within the canal is impracticable because of the impossibility of making a positive differential diagnosis between those conditions. The possibility that the attempt may cause the instant death of the 1 Costes: Schmidt's Jahrbuch, vol. 79, p. 208. 2 Darriste Bull. de la Soc. Anatomique, 1838, vol. 13, p. 144. patient, especially when the dislocation is in the upper part of the cervical spine, is a weighty factor in the problem but should not, in my judgment, deter the surgeon if the patient or his friends accept the risk. It should only stimulate him to make the most accurate possible diagnosis as regards the seat, direction, and mode of production of the dislocation, and most cautiously to select and execute the necessary manœuvres. The urgency of the symptoms may leave him but scant time for observation and reflection, and the history of the case may throw no light upon the mode of production, so that the general rule to return the dislocated part along the path by which it escaped from its position cannot be knowingly and deliberately followed. Under such circumstances the surgeon must trust to traction aided by such flexion and rotation of the column as his best scrutiny of the displacement and knowledge of the relations of the articular processes may suggest. Anæsthesia should be employed unless contraindicated by the condition of the heart or respiration. The return of the bone to its place is usually indicated by a distinct sound, and the rigidity which is usually present gives place to normal mobility. If the dislocation is comparatively slight, moderate lateral pressure may effect reduction, as in a remarkable case reported to Blasius' by Richter. A lad, eleven or twelve years old, consulted Richter because of deformity and stiffness of the neck caused by a fall. He found the spinous process of the third cervical vertebra slightly displaced to one side, and that pressure upon it caused pain. No paralysis. An attempt to reduce the dislocation by traction on the head failed, and the child was sent home to await another attempt. On the way, the child, who had heard and comprehended the diagnosis, stopped by a wall, leaned his head and shoulder against it, and pressed forcibly with his thumb against the opposite, convex side of his neck, and instantly reduced the dislocation. The story was confirmed by the child's companions, and the surgeon found at his visit the neck straight, normally movable, and free from pain. In another case quoted by Blasius a dislocation of the third cervical vertebra had remained unreduced in spite of several attempts; on the ninth day the patient fell out of bed, and reduction took place with an audible snap. After reduction has been made no other retentive measures than rest in bed are ordinarily required, but if there is reason to fear recurrence the parts may be immobilized by gypsum bandages or padded wire splints that embrace the entire trunk if the injury is situated below the shoulders, and the head and chest if it is in the cervical region. If reduction cannot be made immobilization is still necessary to favor the formation of firm adhesions and the solidification of the bones in their new relations; and in addition measures may be needed to combat the inflammatory processes set up by the traumatism and to meet the indications of other symptoms. Of the latter the most urgent is the acute hyperæmia of the lungs that has occasionally been observed, and this is most promptly and satisfactorily met by free venesection. The 1 Blasius: Loc. cit., vol. 104, p. 114. necessity of attention to the urinary bladder must not be overlooked, and although Hutchinson, in the paper above quoted, expresses the opinion that the disadvantages arising from the use of the catheter are greater than those following retention and relief by overflow, the contrary opinion is very generally held. Possibly it would be well to remove the urine by aspiration above the pubes twice a day for the first two or three days rather than by catheterization, in the hope of the early restoration of control. M. D. Harrison' speaks highly of the value of permanent antiseptic drainage of the bladder through a perineal incision in the treatment of "fracture-dislocations of the spine." Under its use he has seen not only the cystitis disappear, but also the bedsores heal and the paralysis diminish. DISLOCATIONS OF THE OCCIPUT AND CERVICAL VERTEBRÆ. Dislocations are far more frequent in this region than in others, a fact that is to be explained by its greater exposure to dislocating violence, by the anatomical relations which permit greater freedom of motion, and by the relative weakness of the connecting ligaments. The fifth cervical vetebra is the one most frequently dislocated. The anatomical differences between the articulations of the atlas with the occiput and axis and those of the other vertebræ are such that a separate description of the injury at the upper end of this region is necessary. DISLOCATIONS OF THE OCCIPUT (FROM THE ATLAS). The articulations between the occiput and the condyles of the occipital bone are formed on each side by a long, oval articular surface on the atlas, which is concave both from before backward and from side to side; the long axis of which runs from in front outward and backward and the outer margin of each is higher than the inner margin, so that each articular surface looks upward, inward, and backward, and together they constitute a cup-shaped socket into which the rounded condyles of the occipital bone fit, and upon which they have a motion only of flexion and extension. In addition to the ligaments uniting the two bones there are other and strong ones within the canal which directly unite the posterior surface and apex of the odontoid process with the occipital bone and thus aid in opposing the separation of the atlas from the latter. The dislocation was formerly deemed quite a common one, and to this opinion succeeded another more in harmony with the anatomical conditions of the joint but still erroneous, namely, that it had never occurred. There are, however, three observations which positively demonstrate the occurrence of the injury, those of Costes,2 Bouisson, and Milner.* 1 Harrison: Liverpool Med. Chir. Journ., July, 1887. 3 2 Costes: Schmidt's Jahrbuch, vol. 79, p. 208, and Malgaigne: Des Luxations, p. 329. Both these accounts are abstracts of the original report in the Journal de Bordeaux, August, 1852, and they differ materially from each other in some points. In the account here given I have in the main followed the former, since Malgaigne's appears to have been taken from an abstract, not from the original paper. Bouisson: Schmidt's Jahrbuch, vol. 82, p. 216, from Revue Méd. Chirurg. de Paris, vol. 2, p. 355. 4 Milner St. Bartholomew Hosp. Rep., vol. 10, p. 314. In the former a lad fifteen years old was thrown down and beaten upon the back of the neck, by which the atlas was displaced forward from its articulations with both the occipital bone and the axis, and the odontoid process of the latter was broken off. The patient's head remained inclined forward, and movements of the neck were difficult. A few days later hyperæsthesia and paralysis of motion appeared, and persisted, without treatment, for four months; then the right arm and leg became painful and he was taken to the hospital. The pulse was feeble and slightly quickened; at the posterior part of the neck was a firm swelling projecting a little on the right side which subsequently proved to be the posterior part of the axis, and the chin was turned to the left and so depressed as almost to touch the chest. He died thirty-six days after admission to the hospital. At the autopsy the skull was found dislocated backward from the atlas, the articular surfaces being completely separated on the right side, while on the left the anterior and inner part of the articular surface of the condyle was still in contact with the posterior part of that of the atlas. At the same time the atlas was tilted forward, rotated to the left in front and to the right behind, and displaced forward upon the axis; the odontoid process was broken off at the base and reunited by fibrous tissue in an almost horizontal position with the body of the axis. The posterior arch of the atlas was so closely approximated to the body of the axis that the interval between them was reduced to a triangular slit five mm. wide on the left side and two mm. on the right. In the second case, Bouisson's, a lad sixteen years old was thrown down upon his face and instantly killed by the fall of a heavily laden cart, the edge of which pressed upon the upper part of the back of his neck. The right condyle of the occipital bone was displaced backward from the corresponding articular surface of the atlas for a distance of two centimetres, with rupture of the capsular ligaments; on the left side the ligaments were torn but the articular surfaces were not displaced from each other. The posterior occipito-atlantoid and the right alar and occipito-odontoid ligaments were torn, and the muscles of the neck were extensively lacerated and contused. A large extravasation of blood extended upward from the spinal canal between the dura mater and cerebellum, and the medulla was greatly compressed but not torn. In Milner's case a man thirty-eight years old fell from a height of seventy feet and was taken up dead. The head was freely movable, and capable of being so displaced to either side that the top of the spinal column would form a projecting tumor in the neck. There was found "complete dislocation of the occipital bone from the atlas and axis, all the ligaments on both sides which connected them with the occiput were completely torn across." The posterior arch of the atlas was broken off transversely where it joins the lateral masses. The odontoid process was cracked longitudinally, but there was no displacement between the atlas and the axis. The medulla oblongata and the vertebral arteries were divided. In connection with these may be mentioned several other cases of which the histories are so defective that the exact nature of the lesion remains in doubt. Some of them are given in the article by Bouisson |