DIAGNOSIS. - Except the deformity and crepitus, any or all of the above symptoms may be caused by injury to or disease of the cord without any fracture of the spine. Hence the diagnosis is generally obscure; but no manipulation should be undertaken for the purpose of elucidating it, for fear of precipitating a fatal issue. Fracture and dislocation are usually associated, and their differen tiation is of no clinical importance.
In estimating the location of the in jury, it must be remembered that the pressure symptoms may be due as well to haemorrhage or inflammation as to the displaced bone, and also that it may take twenty-four to forty-eight hours for the paralytic symptoms to appear at their distinctive level. Hence the local symp toms of pain, tenderness, and deformity are much better guides to the level of the lesion than the paralytic and anaes thetic symptoms.
ETIOLOGY.—Indirect violence by caus ing an excessive bending of the spine is the common cause of fracture. Such violence may be applied by a fall of the subject himself or by some heavy body falling upon him. Less frequently mus cular violence produces a fracture of the spine, the usual location of such fract ures being the cervical region and the usual cause a sudden jerking backward of the head: as to avoid striking the bottom when diving in shallow water.
- The crushing force which causes the fracture is very likely to cause a simultaneous dislocation.
The bodies of the vertebrae are the parts most affected, except in the cervical region, where the transverse and articu lar processes are more frequently in jured. Direct violence occasionally tears away the spinous process. There is no regularity about the fractures, how ever, every conceivable variety having been observed. The upper fragment is usually displaced forward. on the lower one and the cord is compressed, rarely torn across, between the two. Subdural haemorrhage or secondary meningitis may give rise to still further compression. The nerves that make their exit at that particular segment are usually torn, as are the attached muscles and ligaments.
PROGNOSIS.—Fractures of the Lower Three Lumbar Vertebrx.—In fractures of this region only the cauda equina is liable to compression, and its individual components can usually slip aside from any obtunding fragment, and thus there will be no pressure symptoms. Under appropriate treatment the bones unite and the patient may recover entirely or with a weak back, or with paralysis or pain from pressure in some of the nerves.
Fractures Above the Second Lumbar.— The prognosis as regards life and death varies with the amount of damage done to the cord. If the cord is permanently damaged, the patient may continue to live as long as two months, only to die finally of exhaustion or of septic infec tion from bed-sores or catheterization. Death may be instantaneous from shock or from involvement of the phrenic nerve in the laceration. In fractures high up in the cervical region, even of the atlas and axis, death is not always instanta neous, but the least movement or jolt may be enough to bring fatal pressure to bear on the cord.
—In all manipulations the greatest care must be exercised to avoid the production of farther displace ment. The patient must be kept upon a water-bed, catheterization must be con ducted with every precaution, and the bladder irrigated daily with a saturated watery solution of boric acid, or, if cys titis supervenes, with a 1 to 4000 solu tion of nitrate of silver. Pressure must be taken off spots where bed-sores threaten, and, if they occur, they must be kept clean and dry by antiseptic pow ders. Nor must the patient's general vitality be neglected. As long as there is any hope of recovery electricity and massage to the paralyzed muscles are ad vantageous, and the strictest cleanliness must be insisted upon. The curative measures are mechanical and operative.
Mechanical Treatment. — This origi nally consisted in traction upon the head and feet by two assistants while the surgeon endeavored to reduce the fract ure by direct manipulation. More re cently suspension and the application of a plaster jacket, as for Pott's disease, has afforded some good results, and a similar treatment is that of Dr. Woodbury's, who applied the jacket to a child upon whom traction was being made while it lay face down upon a hammock of cheese-cloth. Dr. Stimson advocates suspension along a plank, the plaster being applied while pressure is main tained on the protuberance.
Operation.—The so-called laminec tomy is done through a long vertical in cision with its centre over the fractured vertebra;. The bone is bared and the spinous processes of three or four of the vertebrae removed. Then with Rongeur forceps the laminm are divided on either side as close as possible to the transverse processes. The dura is then exposed and if distended with pus or blood it is incised and drained. Otherwise it is gently retracted and the bodies of the vertebras are palpated. Any unevenness in them is removed, the straightening of the whole column attempted, and the wound closed without drainage, unless hrnmorrhage or suppuration demand it.
The results of operation have been so unsatisfactory even at the hands of its most earnest advocates, and the effect of traction and the plaster jacket so mani festly advantageous, that the mechanical method is the treatment of election even though operation has occasionally dis closed and remedied pathological condi tions upon which no manipulation could have exercised a beneficial influence.
Fracture of Nasal Bones.—The nasal bones, cartilages, and septum may each and all be fractured. Such fractures may be followed by tedious suppuration, facial emphysema, plugging of the lacry mal canal, and, as the displacement is always backward, some formity is inevitable, unless they are re placed.
DIAGNOSIS.-By endeavoring to move the upper and lower parts of the nose laterally upon each other, false motion and crepitus will thus be elicited.