9795 50% Choicest Norway Cod Liver Oil with the Soluble Phosphates. PHILLIP'S EMULSION. Pancreatized. THE CHAS. H. PHUNME HEMICAL CO., 128 PEARL ST., NEW YORK. THE SOUTHERN 07 PRACTITIONER * AN INDEPENDENT MONTHLY JOURNAL DEVOTED TO MEDICINE AND SURGERY SUBSCRIPTION PRICE, ONE DOLLAR PER YEAR The location of fractures of the spine may be anywhere in its extent. They occur more frequently in the cervical region, and are more serious here than at any other site; although, as is well known, prognosis of a fracture of the spine is never good. These fractures may be produced either by a direct or an indirect force. The direct force producing them usually fractures the spinous processes and the arches of the vertebræ. However, when the force is of sufficient intensity, further injury may be done at the same time to the bones. When an indirect force produces a fracture, it is capable not only of injuring the spinous processes, the transverse processes, and the arches, but frequently produces crushing of the bodies of the bones. Accompanying any Read at Meeting of Nashville Academy of Medicine, November 22, 1904. fracture there may or may not be a diclocation of the vertebræ, complete or incomplete, but such dislocation is not an uncommon complication. We are all aware that the nerves given off from the spinal cord arise from the cord higher up than their point of exit from the canal. The lower down the nerve the longer the distance traversed by it within the canal. Therefore, in determining what vertebra is injured, we must always take into consideration the fact that the nerve showing the symptoms arises from a point above its exit, as stated above. The eight cervical nerves come from points within the cord between the first and the sixth cervical vertebræ. The first six dorsal nerves come from the cord between the seventh cervical and the fourth dorsal vertebræ. The remaining dorsal nerves arise between the fourth and the tenth dorsal vertebræ, while the lumbar and sacral nerves arise between the tenth dorsal and the second lumbar vertebræ. After having thus arisen, these nerves travel down along the cord within the canal to their respective points of exit. A fracture or a fracture with dislocation produces its symptoms not by the traumatism that may have been done to the bones and soft parts, constituting and surrounding the spinal column, but to the fact that the lesion has been produced in the cord, or in the nerve proceeding from the cord, either within the canal or at the point of exit, or to the fact that this injury has produced a condition which causes the pressure on these structures. The injury may be a complete laceration or transverse section of the cord produced by the bony structures under pressure, or it may be a partial laceration of the cord produced in a like manner, or again there may be no visible crushing of the cord at all, and yet a sufficient pressure produced upon it to suspend its function. Furthermore, pressure may be brought about by hemorrhage within the dura, or secondarily by inflammation, which causes swelling around the cord. The point I wish to make clear is, that the function of the cord, although it is not always completely destroyed, yet may be so destroyed that it is impossible to determine whether we have a complete lesion, a partial lesion, or simple pressure of a marked degree on the cord. Assuming the above statements to be correct, then from the symptoms, however marked they may be, it is easy to see how one could fail to determine exactly the condition present. The symptoms are paraplegia extending up to the level of the exit of the nerves from the canal, whose centers lie at the point of fracture. If this paralysis is not complete, sensation is more easily elicited than motion. Besides this, different sensory symptoms manifest themselves in the region paralyzed; and at the border line between the paralyzed parts and those that are not, there is frequently present a marked hyperesthesia. If the function of the cord is completely suspended, especially in cases in which crushing has taken place, all reflexes in the paraplegic area are obliterated. However, if the cord does not suffer complete suspension in its function, the reflexes are simply subdued for a while, and later on may become excessive in their activity. The patient suffers from paralysis of the bladder and the rectum, and loses control both of his urine and his fæces. Priapism is likely to occur, especially in fractures of the cervical region. Neuralgic pains, tonic and clonic spasms and fibrillary twitching of the skeletal muscles, in other words, symptoms of irritation are at times. present in these patients below the point of fracture. If the fracture occurs in the lower cervical or upper dorsal region, an intractable mydriasis may be present, owing to the fact that the nerve center which controls the size of the pupil curiously lies in this part of the cord. In the lower cervical region the breathing is disturbed, and complete crushing of the cord or suspension of its function at the level of the third cervical vertebræ means suspended respiration, and therefore the death of the patient. The nerves of sensation and motion are not the only ones involved in this distress. Vasomotor nerves come in to play their part; the color of the skin changes, in one region there is blanching, in another there is reddening. An excessive rise of the body temperature occurs in cervical injuries. This temperature sometimes reaches 106°F. Albert reports a case in which the patient perspired freely in the upper uninjured portion of his body, while that portion suffering from paralysis was perfectly dry. Consequental on the injury, as purely secondary symptoms, we have the development of cystitis, due to retention, and the appearance of bed sores, which, although they vibrate back and forth, spreading at one time, at another time attempting to heal, but usually disappointing the surgeon by enlarging again before the healing is complete. Whatever may be the interest attached to the symptomatology of fractures of the spine, the fact still remains and needs to be impressed again that we are unable, from evidence derived from an examination of the region injured or from that produced by the symptoms following the paralysis, to determine the all-important point as to whether the cord has been completely lacerated, or not. Those patients who have suffered from a complete transverse separation have been doomed by our forefathers, and are yet doomed by the majority of surgeons, as hopeless cases, and the only thing that has been done or is now considered capable of being done, as a rule, is to ease them into their graves as gently as possible. But it is well for us to stop and ask ourselves this question: Have not our forefathers eased, and do we not likewise ease many patients into their graves, who show the symptoms produced by complete separation of the cord, and yet, in fact, have not that complete separation? If this is possible, then it behooves us as honest medical men to study exhaustively the conditions that confront us before we continue in the same old beaten paths. Almost invariably our text-books and our current literature teach us that in these cases there are two methods open before us. In one of them we use purely palliative treatment, and await the death of the patient; in another advice is given never to open the skin and attempt to relieve the condition by an operation, for they claim that the dangers produced by this operative procedure and the possibility of complications resulting from it, so increase the danger that an operation is worse than valueless. Therefore, they say put the patient in the best possible position, make him comfortable and reduce the parts to their normal position by making extension and counter extension, and by the use of whatever mechanical device the surgeon may see fit. The chief danger, they must admit, of going into the spinal column is in |