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Fractures of the Spine

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The spinal column may be broken by indirect or direct violence. A heavy weight, such as a sack of flour, falling on a man's neck and shoulders may break the back some distance down. Again, a man has been known to be sitting on the branch of a tree when it broke and allowed Lim to fall to the ground in the sitting posture, fracture of the spine high up resulting. These are cases of indirect violence. Direct violence has many instances, a very com mon one being that of a miner whose back is broken by the fall of a mass of coal or earth as lie lay, or was crawling along, face down wards. The break is generally transversely through the bodies and arches of the vertebrae. The accident may be a simple one or very grave. Spinous processes may be broken off merely, or vertebrae twisted round or otherwise displaced, with nothing further of any conse quence, recovery taking place with some de formity but nothing worse.

In the majority of cases, however, the spinal cord is seriously injured, and the symptoms vary according to the degree and position of the injury.

Signs.--At first the person suffers from severe nervous shock, which may produce collapse, shown by pallor, coldness, feeble pulse, vomit ing. There may be unconsciousness. When the shock passes off, pain is complained of at thd seat of injury, especially on movement. There is swelling over the painful part, and irregular projections and depressions can be felt. But the important signs depend on the site of the injury.

(1) When the in julw is below the dorsal vertebrce (p. 60), in the lumbar region, the legs and lower parts of the trunk are motionless and insensible. At first there will be great costiveness; and afterwards the stools will pass without the patient's will or knowledge. Owing to loss of power over the bladder the urine will be re kilned, requiring to be regularly withdrawn by means of an instrument. At a later period, if the urine is not regularly withdrawn, the water constantly .dribbles away because of over-dis tension of the bladder. In a few days the urine will become offensive, smelling strongly of am monia.

The person may live two or tbree weeks, or even a month.

(2) If the fracture be lower down in the back than the second lumbar vertebra (p. 60) power and sensation may not be I, st, and recovery may be expected to take place. This is because the spinal cord ends at the level of the second lum bar vertebra, and only appendages of it are con tinued further down the spinal canal.

(3) If the fracture be higher up, in the dorsal region, besides the symptoms mentioned under (1), breathing will be imperfect, and may be further impeded by attendant fracture of the ribs. Death is likely to result in about 5 or 6, or at most 10 or 15 days.

(4) When the injury is still higher, at the lower part of the neck, palsy of the arms is added, and the breathing is still more laboured. The 1 atient

cannot survive beyond a day or two.

(5) If the injury be above the fourth vertebra of the neck (p. 60) death will be instantaneous, be cause respiration is impossible.

When, as in injury below the dorsal verte brae, the sufferer has survived for several days, or a week or two, there is great trouble owing to the involuntary passing of stools, the dif ficulty of keeping him clean, and the retain ing of the urine. Bed-sores are a continual source of annoyance. They form roost com monly over the prominent parts of the hip-bones and over the projecting process—trochanter an the outer side of the thigh-bone. They begin to show themselves about the fourth, or even as early as the second, day. Their formation may be detected by the white, sodden appearance of the skin, which afterwards becomes brown, then black in the centre, after which the skin comes away in shreds. The sores form with great rapidity and sap the patient's strength.

Treatment.—First of all great care must be taken to guard against moving the spine while the patient is being carried home, undressed, and put to bed. He ought to be carried home on a stretcher of some kind, and kept from roll ing about on the stretcher by bundles of cloth ing, &c. The clothes should be cut of to avoid movement; and the person ought to be laid fiat on his back on an appropriate bed. The best bed for the purpose would be a water-bed. If a water-bed is not to be obtained then a bed with a bottom of boards, and one or two firm but elastic hair-mattresses is best. Bed-pans and other similar conveniences ought to be at hand, so that moving the patient is not neces sary. Mackintosh cloth, covered with a sheet, ought to be under the the patient's hips. Water pillows, feather-pillows, or pillows of other kinds, covered with oil-silk, are also necessary for equalizing the pressure on different parts of the body, to prevent, as far as possible, the forma tion of bed-sores. The urine must be drawn off by a catheter (see CATHETER) twice in twenty four hours. In fact, as soon as the patient has been got to bed the catheter ought to be passed. The bowels may require to be moved by injec tion. To prevent bed-sores to the utmost ex tent cleanliness and dryness are absolutely ne cessary, and avoiding pressure by the use of pillows. When the sores have formed they should be cleaned with carbolic acid lotion (1 of acid to 60 of water). This lotion should also be applied to the sore by cotton-wool, which ought to be covered with gutta-percha cloth, and re tained by straps of adhesive plaster. As to diet, easily digested food is necessary, milk, beef-tea, and similar fluid nourishment. It is to be re membered that exhaustion is often extreme, and requires guarding against. Indigestion is liable to afflict the sufferer. This is to be relieved by acid tonics (see APPENDIX OF PRESCRIPTIONS).