CHAPTER XXXVIII

.

THE SPINE, THE SPINAL CORD, AND THE PERIPHERAL NERVES.

SYRINGOMYELIA.

The term _syringomyelia_ implies irregular dilatation of the central canal of the spinal cord, having a congenital origin, tending to relative increase later in life, with corresponding disturbance of function, the latter including paresthesiæ, loss of sensibility to heat and cold, more or less motor impairment and disturbances of nutrition, more noticeable in the region of the joints than elsewhere, the latter having been already considered in the chapter on the Joints. The dilatation is by no means regular, may occur in various regions of the cord, and attain a size permitting encroachment upon, and even atrophy of, the structures of the cord itself. When functional disturbance, especially paralytic, has become very pronounced a few surgeons have ventured to expose the cord by a laminectomy, and endeavored to make a more or less permanent opening with drainage of the dural cavity. Thus Keen has operated twice, Abbe once, and Munro three times, including twice on the same patient. Only in this last instance was any permanent relief obtained, and this was at the expense of a second operation. It is doubtful if any of the peculiar joint lesions of this disease will be in any way affected by operation for this purpose.

TUMORS OF THE SPINAL CORD.

Tumors of the spinal cord may be classified as follows (Krauss):

1. Tumors springing primarily from the envelopes of the cord: (_a_) Tumors of the vertebral column, and (_b_) tumors of the meninges, the latter including those arising from the external surface of the dura, or from the periosteum of the spinal canal, _i. e._, extradural tumors, and those from the inner surface of the dura and the other membranes, that is, intradural tumors.

2. Tumors developing in the cord proper, intramedullary. These are generally gliomas and do not present so much the symptoms of cord tumors as of syringomyelia.

Vertebral tumors may be carcinoma (secondary), endothelioma, sarcoma, osteosarcoma, as well as the non-malignant and cartilaginous or osseous tumors, and parasitic cysts, _i. e._, echinococcus. The sarcomas are the most common of all.

=Symptoms.=--The symptoms of tumor of the spinal cord depend upon the part involved and differ according as it involves the cervical, thoracic, or lumbar portions or the cauda equina. They are to be classed as _root symptoms_ and _cord symptoms_. _Root symptoms_ include pain, paresthesia, and hyperesthesia. The pain is usually persistent, burning, and severe, affecting one side or the other, if the tumor be laterally placed, or both sides if central. The pain follows the distribution of the spinal roots rather than the course of the intercostal nerves, _i. e._, is more horizontal and less oblique. These pains persist and have the characteristic feature of not presenting painful points on pressure. They are commonly referred to the abdomen, and may thus give rise to serious mistakes in diagnosis, _e. g._, they have been regarded as due to hepatic colic, dry pleurisy, appendicitis, etc. Pain may assume the girdle character, which is usually accentuated by movement, and is frequently accompanied by herpes zoster. The greater the involvement of the posterior roots the more painful the condition. When the anterior sensory roots are involved pain may be wanting and the disturbance assume a type of paresthesia, with final anesthesia, in which case the patient would at first complain of numbness and prickling sensations. There is sometimes noted a zone of hyperesthesia on the proximal side of the anesthetic area, or this zone, if not hyperesthetic, may be replaced by a condition of uncertainty of sensation.

The _cord symptoms_ are the reliable ones, varying according to the segment involved. The portions of the cord where lesions can be best localized are, for instance, the third to the fifth cervical, including the origin of the phrenic nerve; the fifth to the seventh cervical, where the posterior thoracic nerve comes off; the seventh to the eighth cervical and first thoracic segments, where originate the dilator nerves of the pupil. The upper border of the anesthetic area points to a lesion of the next or second higher spinal segment than the level really represents. The lowest level of the lesion corresponds to the highest level of the sensory disturbance. The level of the segment area of the skin of the back does not correspond to the level of the spinal segment involved, the latter being higher up. The point of greatest sensitiveness over the spine is in many cases a good guide to the segment involved, but is applicable only where the lesion is posteriorly placed. The absence of pain or tenderness along the spine means little or nothing, but their presence has great significance.

=Diagnosis.=--The diagnosis of a cord tumor covers, according to Krauss, a first or subjective period, indicative of irritation along the posterior roots, and is characterized by pain and paresthesia. This is followed in time by a second or objective period which points to invasion of the spinal cord, characterized mainly by weakness and later by paralysis, with disturbed tendon reflexes. Diagnosis early is extremely difficult, for pain and disturbances of sensation are produced in many ways.

=Treatment.=--The treatment of spinal-cord tumors is purely surgical and should be instituted promptly so soon as diagnosis has been made. Only in tumors of syphilitic origin will internal treatment be of any avail. The therapeutic test having been made, should it seem wise, and proved futile, the case should be regarded at once as surgical. According to Krauss’ statistics nearly 40 per cent. of all operated cases have resulted in recovery, while in 35 cases of sarcoma 8 have resulted in recovery and 6 in improvement. This is really a more gratifying statement than can be made with regard to brain tumors, and should be regarded as lending encouragement to surgical procedure.

The operative details will be discussed later in this chapter.

THE PERIPHERAL NERVES.

The remarks made concerning the surgical affections of and operations upon nerves contained in the previous chapter, pertaining to the cranial nerves, will apply equally well to the peripheral nervous system.

_Constant pressure_ as well as contusions of nerves will cause more or less paralysis. The surgeon occasionally sees manifestations of this kind in the so-called “crutch paralysis,” due to pressure upon the brachial plexus by the use of crutches, and in another form so generally associated with administration of an anesthetic as to be called “ether paralysis.” It is another form of pressure paralysis due to indifference in letting the arm, for instance, hang over the edge of an operating table during anesthesia or operation. It does not call for operation so much as for electricity, massage, and similar measures. Extreme consequences of nerve and vessel injury are portrayed in Fig. 410.

_Tumors of nerves_ are both benign and malignant, the former assuming the fibromatous type oftener than any other, and frequently involving more than one nerve trunk, attaining also considerable size and impairing or destroying function by pressure. In addition to the true fibroma of nerve sheaths we have the peculiar type of _fibromas of nerve stumps_ seen after amputations, and the multiple neuromas, again largely of the fibromatous type, which involve many and in rare instances nearly all the peripheral nerves. Cases are on record where as many as 1600 small and large tumors have been found, strung like beads upon wires, along all the peripheral nerves throughout the body. Another variety of fibromas of nerves involves those of the skin and produces small _painful subcutaneous nodules_, although these may attain a considerable size. Within the past few years there has been a much better familiarity with that form of growth known as _plexiform neuroma_, in which entire nerve trunks are involved, so that they become elongated, thickened, and tortuous, and resemble a varicose condition of the veins. The plexiform neuromas are found in any part of the body; they produce little or no pain, but lead to disturbances of function, as well as to peculiar irregular swellings that may be mistaken for lymphangioma, and which are often accompanied by pigmentation of and growth of hair upon the overlying skin. (See chapter on Tumors.)

For the various purposes already mentioned different nerve trunks and plexuses are made accessible for operation by the following methods.

=The Brachial Plexus.=--The brachial plexus is reached through an incision similar to that for ligation of the subclavian artery. After opening the deep fascia the nerves are sought and found behind the subclavian vein and lying around the artery. This plexus is stretched especially for the relief of choreiform spasm or painful nervous affections. The various nerves of the upper extremity, after leaving the brachial plexus, are made accessible to operations for grafting or suture as below. (See Fig 406.)

=The Median Nerve.=--The median nerve lies in front of the brachial artery and is exposed through an incision as if the artery were to be tied in its course. It may also be found on the inner side of the tendon of the palmaris longus, where it lies beneath the deep fascia.

=The Ulnar Nerve.=--The ulnar nerve is reached through practically the same incision as the median, when it is sought in the middle of the arm, but is farther back. It lies near the surface, just behind the inner condyle, between it and the olecranon, and at the wrist it is on the radial side of the tendon of the flexor carpi ulnaris.

[Illustration: FIG. 410

Gangrene (mummification) of arm resulting from injury to nerves and vessels. (Preindlsberger.)]

=The Musculospiral Nerve.=--The musculospiral nerve is found between the heads of the triceps, where it lies in the groove which winds obliquely around the humerus.

=The Radial Nerve.=--The radial nerve lies to the outer side of the radial artery, three inches above the wrist. Should any of the nerves of the arm or forearm have been cut by an accident which has produced an incised wound they should be sought for in the wound if fresh, and in the neighborhood of the scar if older, and should be reunited by suture, as already described.

=The Great Sciatic Nerve.=--In the lower extremity it is the great sciatic nerve which is usually made the subject of operation. An incision midway between the great trochanter and the tuberosity of the ischium, by which the lower border of the gluteus muscle is exposed, will enable the surgeon to identify the biceps, to divide the deep fascia, and find the sciatic nerve at the outer border of the muscle. It is sought for the purpose of nerve stretching, and it may be pulled completely out of the wound, while the entire weight of the limb may be suspended by it.

=The Tibial Nerve.=--The tibial nerves may be exposed through incisions identical with those indicated for ligation of the tibial arteries.

=The Anterior Crural Nerve.=--The anterior crural nerve lies in Scarpa’s triangle, near Poupart’s ligament, on the outer side of the femoral artery.

Tetanus should be treated by injecting antitoxin into the main nerve trunks, as well as into the spinal canal. The individual nerve trunks of the brachial plexus may be exposed in the upper arm, where the point of the hypodermic syringe needle may be inserted into their substance. The same expedient may be employed with the sciatic or anterior crural trunks, through the incisions just described. The same measures may be used in cocainizing the nerve trunks, as suggested by Crile and others, and described in the chapter on Alterations of Blood Pressure (p. 181).

Abbe has suggested to treat certain cases of inveterate neuralgia of the peripheral nerves by an intraspinal division of the posterior nerve roots.

There has been added to the standard operations on nerves another measure. This consists of _grafting_ by means of foreign material; using a section of nerve trunk removed freshly from some animal, or inserting catgut loops between nerve ends which shall serve as trellises upon which the growing nerve tissue may arrange itself. Powers, of Denver, has, for instance, reported the implantation of four inches of the great sciatic nerve of a dog into the external popliteal of a man. The results seemed to be good so far as sensation was concerned, but negative as regards motion. Probably no method of nerve grafting will give so good results as the utilization of a part of the nerve itself to be operated upon, by partially detaching and turning back a portion of its central end and uniting it to a similar flap made from the other end. Various operators have made use of different materials for the purpose of forming a tube around the nerve ends, and thus excluding other tissues. For this purpose cargile membrane is perhaps as serviceable as any. When all other measures fail the method by long catgut sutures may be adopted.

DISLOCATION OF NERVES.

A few of the nerve trunks may be displaced by injury in such a way that they are liable to subsequent redislocation. The condition is recognized by the mobility of the nerve trunk under the skin, by peculiar sensations when the trunk is irritated, and often by tingling sensations referred to its distribution. The condition is most common in connection with the ulnar nerve, just behind the inner condyle. Should nothing else give relief the trunk should be cut down upon and retained in place by suture or by fixation of other structures around it.

WOUNDS OF THE SPINE AND CORD.

=Penetrating Wounds.=--Penetrating wounds of the spine occur both in military and in civil practice. Sometimes the vertebræ alone are injured; occasionally the spinal canal will be opened, with little injury to the bone, only the cartilage suffering. All such injuries are serious in proportion as the cord itself may be injured. Such injuries may be direct or indirect. Should a large vessel have been divided the cord may suffer from pressure of clot, and should this injury occur high in the spine, death may be caused by pressure. The severity of such an injury is generally estimated by phenomena pertaining to the nerve supply of parts below the wound. Should anything indicate partial or complete division of the cord, or that a single nerve trunk has been divided, then an operation is indicated for relief of symptoms, and for nerve or cord suture except in those instances where destruction seems to be too complete to warrant it.

=Gunshot Injuries.=--Gunshot injuries vary from small punctures and penetrating wounds to extensive laceration. The lower the injury the lower the mortality, other things being equal. Such injury to the cervical region generally proves quickly fatal. The symptoms here are not essentially different, save that the bullet may have done still more harm by passing beyond the cord, and that to the signs of a penetrating wound may be added those of a traumatic hemothorax or some other serious complication. It is necessary to distinguish between mere stiffness of the back and disinclination to use certain groups of muscles and absolute loss of motility. The former may indicate contusion and the latter severance or pressure. After some perforations cerebrospinal fluid will escape. In one instance I opened a spinal canal for perforating gunshot wound with complete paralysis, and found not only that the bullet had divided the cord but had passed through the vertebra into the lung beyond. A very curious phenomenon presented in this case is that when the passage was well opened air passed backward and forward through the spinal wound, the patient thus partly breathing through his back.

[Illustration: PLATE XLVI

Intraspinal Hemorrhage, mostly Subdural, with Minute Subpial Ecchymoses.]

The effect of _pressure from hemorrhage_ is practically the same whether it be intradural or extradural, or occurring within the structure of the cord itself. The presence of blood in the spinal canal is known as _hematorrhachis_, and when occurring within the cord itself is termed _hematomyelia_. The typical symptoms of sensory and motor paralysis, which serious pressure upon the cord always produces, occur when produced by mere presence of fluid more slowly than when due to the introduction of a foreign body or to comminution of the bone. Diagnosis is then much facilitated if by the personal history it can be learned that there was an interval after the reception of the injury and before the occurrence of paralysis, during which the patient had reasonable use of the parts later paralyzed. This interval may be one of but a few minutes’ duration or may have extended over several hours.

When, on the other hand, such an interval lasting several days has been noted, then the intraspinal lesion must be either one of acute degeneration or of suppurative character. (See Plate XLVI.)

The question of _operation in spinal hemorrhages_ will frequently be raised, and is to be decided in part by the intensity of the symptoms and in part by the character of the injury. Incomplete paralysis would indicate a lesser degree of pressure and justify a hope that the outpoured blood may be resorbed. This hope may be further encouraged should symptoms improve. On the other hand symptoms of complete paralysis, indicating serious and extensive pressure upon the cord, would justify a laminectomy, and make it even more encouraging than though it were done for a crushing injury. The more serious cases, then, of spinal hemorrhage would seem to justify exploration.

Until very recently it has been held that a complete cross-division of the spinal cord must necessarily be followed by a hopeless paralytic condition, plus the changes due to ascending degeneration of the upper segment. The results of laboratory experiments have made this quite plain, and therefore it was a startling innovation in surgery when Harte could report an experience contradicting all that we had learned to believe in this regard. In spite, then, of the fact that experimental suture of the cord after its division had not been successful in animals we are now confronted by three more or less successful cases reported by American surgeons, Estes, Harte, and Fowler, where the spinal cord was sutured after division, with at least

## partial recovery of function. In Harte’s case the operation was done

three hours after injury; in Fowler’s case ten days had elapsed. Fowler used chromicized catgut sutures in the cord itself, with separate sutures of the dura with the same material, the principle here being the same as in nerve suture, and the effort being to do as little harm as possible with the needle and the suture material. After a simple division there is but little tension, and the ends of the cord are easily approximated.

It has thus been proved that there is at least some possibility of regeneration of the cord after such destructive lesions; but the cases which permit of or justify this measure will be rare, although it is gratifying to learn that there has been so much encouragement afforded by experiences reported.

THE SPINAL COLUMN.

SPINA BIFIDA; SPINAL MENINGOCELE.

Spina bifida is the result of a congenital defect in the construction of the spine with incomplete closure of the spinal canal. The defect lies in the posterior arches of the vertebræ; the bodies are rarely involved. For this reason these lesions are centrally placed, _i. e._, in the middle line. The essential feature of a spina bifida is protrusion of the spinal membranes, and they are, to all intents and purposes, spinal meningoceles. These tumors sometimes have only the thinnest of skin coverings; at other times they will be covered by considerable masses of overlying fat or fibrous tissue.

These congenital tumors when more definitely described should be classified as--

1. _Meningocele_, where there is simply a protrusion (hernia) of the dura, which may be lined with some branches of the vertebral nerves;

2. _Meningomyelocele_, where some portion of the spinal cord proper is included within the sac;

3. _Syringomyelocele_, where the central canal of the cord is dilated into a cyst of some size, over which the structures of the cord proper are more or less thinly spread out, the whole being covered with the spinal dura.

The first form is by far the simplest and most amenable to treatment. The other forms are much more serious, and the third form is hopeless so far as operative surgery is concerned.

The greater proportion of these cases occur in the lumbar region, at least 70 per cent. being met with in the lower region of the spine, including the sacrum. It occurs occasionally in the neck and in the mid-dorsal region.

Fig. 411 illustrates the general appearance of such a tumor. The opening of communication may be very small or may involve the arches of several vertebræ. So with the tumor itself, it may be small and almost imperceptible, or it may attain almost the size of a child’s head. The overlying skin is rarely absent; it is usually covered with a growth of hair, and its presence in the region of the spinous processes, coupled with the presence of any perceptible tumor, should cause suspicions of the so-called _spina bifida occulta_.

[Illustration: FIG. 411

Spina bifida. (Bradford.)]

These tumors are situated in the middle line or very near to it, and are compressible in proportion to the thinness of their coverings. When small they can be collapsed by pressure, the same not infrequently causing pressure symptoms, as the fluid is forced into the cranial cavity, such as coughing, vomiting, vertigo, etc. If the fluid can be easily expressed from the sac the opening may be regarded as relatively large. If pressure makes no alteration in the size of the growth the case should then be regarded as one where the small original communication has been closed by natural processes. Some of these tumors have more or less of a pedicle and others are broadly sessile. The tendency is ever toward increase in size, being rapid or slow according to the thickness of the protecting membranes and the size of the opening. While spontaneous occlusion may occur there is practically no spontaneous repair of the bony defect. _The surgeon should beware of a tumor of congenital origin situated in or near the middle line, anywhere from the root of the nose, over the head, and down to the tip of the coccyx._ Such a tumor should be regarded with suspicion until shown to be harmless. Many cases of spina bifida are accompanied by other congenital defects, such as club-foot, or hydrocephalus. Symptoms may or may not be present. When present they will be of the paralytic type and affect those parts of the body below the level of the growth. They are due to the involvement of the cord or the nerves. The ever-present danger in such cases is of rupture with escape of the contents, with its proportionate reduction of intraspinal pressure, and the possibilities of infection, with rapid death from meningitis. Inasmuch as some of these cysts have such thin walls that transillumination is possible it will be seen how great may be this danger.

=Treatment.=--Treatment should be made to meet the indications. Only in cases which are deemed inoperable should some protection be relied upon and worn. This may be afforded by a common surgical dressing or by means of a plaster-of-Paris or waxed gauze. A molded shield may be prepared and so arranged upon a band or girdle as to protect the cyst from external harm. Efforts to reduce the size of the tumor by pressure are futile and useless. The skin may be protected by covering with collodion.

The _radical treatment_ of spina bifida should only be attempted in favorable cases, but in such instances can be made exceedingly satisfactory and successful. A tumor with a small pedicle may be treated by ligation, the skin being divided by elliptical incisions, the pedicle proper being surrounded by a chromicized or silk suture and the sac then excised. When the pedicle is too large to be treated in this way and yet not very large, it may be closed by sutures after removal of the sac, and dropped downward into the spinal opening, and the adjoining tissues made to close over it by buried and superficial sutures. It is the larger and more sessile sacs which give rise to the greatest difficulties. The attempt may be made to excise a greater portion of the sac, to fold in its edges and to approximate these with sutures of fine chromic catgut. The fold thus formed may be laid downward and upon the spinal groove, the aponeurotic and other firm fibrous tissues in the neighborhood being loosened sufficiently so that they may be brought together by buried sutures, and the balance of the wound closed. I have a number of times been able to introduce either strips of metal foil or thin pieces of celluloid, or, better still, ivory trimmed to fit the bony defect, and so arranged as to be sprung into grooves made on either side of the osseous canal. If ivory be used for this purpose the thin small sheets which are used by miniature painters should be procured.

Such operations should be made at the earliest practical moment; in infants especially, but probably with all young patients, the head being maintained at a much lower level than the sacrum in order that only the smallest quantity possible of the cerebrospinal fluid may escape. I have also used a small amount of weak cocaine solution after exposing the cord in the spinal canal, in order that reflex impressions may be avoided so far as possible and shock thus prevented. With a young patient the amount of cocaine to be thus used should not exceed more than 2 or 3 Mg.

Osteoplastic methods have also been devised for the purpose and may be practised in cases permitting them.

Many of these cases do not come to operation until the skin is excoriated or ulcerated. It is exceedingly difficult under these circumstances to make an aseptic operation. The subsequent difficulties of maintaining asepsis should also be foreseen, especially when lesions are located low in the spine and in little patients, as soiling from diapers and discharges is so easy. After such operations oiled silk, or gutta-percha tissue should be fastened around the pelvis by rubber cement, in such a way as to make a water-tight covering for the deep surgical dressings, and this line of junction should be scrutinized frequently. These operations often give satisfactory results.

CYSTS AND COCCYGEAL TUMORS.

Many congenital tumors are met with about the region of the sacrum and coccyx, some of which have the essential characteristics of meningocele, while others are rather of the dermoid or embryonal variety. Tumors of great size develop from the region of the coccyx, and many are of interest to the pathologist.

True dermoids often begin to develop within the pelvis and then escape therefrom in this vicinity, some of them containing soft epithelial products, others being dense and hard. (See Figs. 72 and 73, p. 266.)

[Illustration: FIG. 412

Sacral cyst, showing defect in sacrum. (Warren Museum.)]

Every tumor of this general character and in this location should be removed as early as possible unless it can be determined that it is not only cystic but dangerously large. Of even these, however, it may be said that to leave them is to expose the patient to more danger of infection than is incurred during a legitimate surgical operation. There should be, then, about such a case serious complications and perplexities, which would tend to make a competent surgeon decline to operate (Fig. 412).

SPRAIN OF THE SPINAL COLUMN.

=Concussion of the Spine; Railroad Spine; Litigation Spine.=--In 1866 Erichsen published a series of lectures dealing with “Certain obscure injuries of the nervous system commonly met with as the result of shock received in collisions on railways.” In 1875 he expanded these lectures into his celebrated monograph on _Concussion of the Spine_, a work which served first to arouse the greatest interest in a hitherto neglected subject, and which has unfortunately served in later years as a basis for many a damage suit. The injuries described by him may occur as the result of railway accidents, hence the name often applied to the condition which they cause--_railway spine_. Cynical observers have noted the frequency with which these cases appear in court and have stigmatized the condition with the name _litigation spine_. Erichsen’s original work is now superseded by much better monographs, although his clinical descriptions were full and complete. Nevertheless he had no knowledge of minute changes in the nervous system and many of his explanations were based upon theories then prevalent but now abandoned.

These injuries involve the spine as a whole, and the spinal column is so firmly held together by powerful ligaments, and so abundantly protected by muscular and aponeurotic coverings, that its contents are exempt from injuries which would easily involve those of more exposed joints. An injury which would cause serious disintegration within the spinal cord must be so severe as to inflict other and well-marked damage upon the surrounding structures. Consequently a large part of the injury received consists in what may well be called strain and wrenching of all of these component structures. These may be accompanied by minute hemorrhages into the cord, with or without laceration, while exudates may result therefrom which may press upon the spinal nerve roots or cause adhesions within or without their sheaths, all of which may lead to signs and symptoms which may persist for a long time. But the theory to which too many have held in time past, that a mere concussion of these parts, without other injuries, can be followed by such extensive and durable lesions is not tenable.

Obviously these cases are of a character frequently to appear in court. Unfortunately the signs and symptoms are so vague, so variable, and the latter so subjective that opportunity is afforded for deception, _opportunity of which both dishonest patients and dishonest lawyers too frequently avail themselves_; this to an extent which has almost brought the condition into disrepute among the better class of practitioners and caused it to be in some sense neglected. That serious lesions do follow injuries to the back is undeniable; that many of the resulting conditions can be simulated is unfortunately too true.

Nervous demoralization and more or less chronic invalidism frequently follow these injuries, producing symptoms which are mainly functional and maybe grouped among the _traumatic neuroses_. These symptoms are mostly ill-defined, often contradictory, and accompanied by very few objective features.

If _malingering_ can be excluded the best way to regard these clinical pictures is to consider them as indicating a _traumatic neurosis_--that is, a nervous disturbance, with perversion rather than abolition of function, comparable with similar conditions from other causes. As Angell has said, its symptomatology is largely built up of the emotional features, with such grotesque nervous disturbances as to be quite inconsistent with any true organic malady. In the latter there will always be definite indications with positive changes and normal reactions, while each segment of the spinal cord will have its own definite features. Quite the reverse is the case in a so-called railway spine, where paralyses are incomplete, where loss of sensibility fails to correspond with anatomical relations, where the reflexes are contradictory and the complaints out of all proportion to the injury received. Such a condition is, therefore, a psychosis or neurosis rather than a somatic disease. (Angell.) As a mental perversion it is often dependent upon the dominating influence of an imperative conception, which may or may not have an honest basis. Even if a patient be not tempted to malinger or simulate, his troubles may be exaggerated by expectant attention, which of itself has nothing to do with the injury, but rather with his mental attitude. This is a predominant feature of those cases which go to trial, and while it may persist after a settlement is reached, it should be admitted that the morbid condition usually subsides when litigation is terminated.

These imperative conceptions are intensified by emotion, fear, sympathy, or anxiety, while attention becomes more and more self-centred, the condition finally terminating in a more or less self-induced hypnotic state--a species of autosuggestion. Similar cases of non-traumatic origin are frequently observed, which are then called neurasthenia or hysteria. When in an individual already neurasthenic injury occurs it almost invariably produces exaggerated symptoms. To use Angell’s own expression: “Railway spine is a convenient and picturesque term which hypnotizes juries, even as shock has hypnotized patients. It is dramatic, but not accurate. The damage is not to the spine nor to the spinal cord, but to the mind. It is a psychical disorder, not a physical one, although it has a physical expression in its symptomatology.”

=Treatment.=--Viewed in this light it will be seen that there is the greatest value attaching to physiological rest, beginning immediately after the injury and continuing until the subsidence of the symptoms. This should be combined with measures which improve elimination and nutrition. Confinement to bed or the room will reduce elimination, which should never be allowed to decrease in any way. Bodily and mental rest, combined with the above features, followed later by massage, cold spinal douche, electricity (either for its actual or suggestive value), and mental encouragement, constitute the principal methods of treatment. A case of this kind tinctured by a hope of securement of ultimate damages will be not only resistant but difficult of successful treatment.

INJURIES TO THE SPINE.

The principal injuries to the spine proper to be considered here consist of:

1. Fractures;

2. Dislocations, or their occurrence together;

3. Injuries to the cord and spinal column;

4. Rupture or injury of the muscles, ligaments, and aponeuroses.

FRACTURES OF THE SPINE.

[Illustration: FIG. 413

Fracture of body of the vertebra. (Warren Museum.)]

[Illustration: FIG. 414

Crush of cord and its membranes. The result of a fracture of the spine. (Erichsen.)]

The spinal column is so strongly put together and its bones so protected that fracture of any one of its component parts is inconceivable except as a result of violence. This may occur by objects falling upon it or by the body falling a distance, or from violent twisting or wrenching. These injuries constitute but a small percentage--about 3 per cent.--of all fractures. They occur more easily and commonly in the upper portion than in the lower, where the vertebræ are larger. As a result of their occupations adult males suffer much more frequently than women or children.

=Diagnosis.=--The diagnosis of fracture of the vertebral column is rarely difficult. The disability produced is instantaneous if the cord itself be compressed. If the cord escape pressure there may be serious symptoms, but without paralysis. The most serious feature, then, of any fracture of the vertebræ is the amount of damage done to the cord proper. The so-called gunshot fractures of the spine have already been

## partially treated of above and in the chapter on Gunshot Wounds. They

constitute a somewhat different class of lesions, but have, in common with those above alluded to, the actual fracturing of the bone and the question of damage to the cord. In most respects they may be considered with the non-penetrating injuries. Fractures of the spine, therefore, may be divided into (_a_) fractures with injury of the cord, and (_b_) fractures without such injury. In many cases it is difficult to state whether the cord is crushed or simply more or less compressed by bone, fluid, or exudate, until the spinal canal has been opened and explored.

When the cord is totally destroyed there will be total loss of reflexes, with motor and sensory paralysis complete. (See Fig. 413.)

In some instances there is visible or palpable _deformity_. This is by no means necessarily the case. It is more likely to be noted in the upper portion of the column, where the vertebral spines are more easily palpated. If sufficient time have elapsed there will often be ecchymosis. The principal feature, however, of spinal fractures is the _paralysis_, which results in most instances as above. Its careful study is requisite both for minute diagnosis and localization of the injury. _Paralysis, then, whether of motion or of sensation, along with the condition of the reflexes_, deserves careful consideration in each instance. It is of the greatest importance, because by it, rather than by other causes, death is brought about in the majority of cases which outlive the first twenty-four hours after injury. Even injury low down, which causes paraplegia with loss of control of the bowels and bladder, may terminate fatally in time, through an ascending infection of the urinary passages, which may finally lead to pyelonephritis and death. This has often occurred as the result of inattention to precautions in the use of the catheter, and to carelessness on the part of the patient. Death, then, may be caused by roundabout methods of infection which have only accidental connection with the original injury. Other cases die of septic infection in consequence of lack of proper attention to bed-sores. Again, with cord involvement high up in the dorsal region there is very likely to occur a rapid ascending degeneration, by which, one after another, the roots of the phrenic nerves are involved in their order from below upward, until finally the patient dies of asphyxia from paralysis of all the respiratory apparatus (Fig. 414).

Aside from such evidences as actual displacement of the vertebral spines may afford the localizing diagnosis is made mainly by a study of the paralysis. In regard to this paralysis it should be remembered how it is produced from the very nature of the injury itself. That occurring within from a few minutes to a few hours after the injury is due to hemorrhage; that which occurs still more slowly is due to exudate or the presence of pus; while a late paralysis may result from poliomyelitis. The first form of paralysis may be produced by hemorrhage either within the central canal (hematomyelia) or hemorrhage within the membranes or structure of the cord itself (hematorrhachis).

There is another form of paralysis due to embolism which, however, has but little to do with the ordinary injuries. The following table, inserted by the courtesy of Dr. Dennis, will assist in localizing the lesion by a study of these paralyses and reflexes due to spinal injury:

_Paralyses and Reflexes due to Spinal Injury._

_Spinal_ _Motor_ _Nerve._ _Paralysis._ _Anesthesia._ _Reflexes._

{ 1. Death from { pressure of { odontoid. {2-3. Death from { paralysis of { diaphragm. { 4. Deltoid muscles Upper shoulder, Pupil. { of upper arm. outer arm. Cervical.{ 5. Supinators of Outside of arm Pupil, scapular, { hand. and forearm. supinator, triceps. { 6. Biceps, triceps, Outer half of Pupil, scapular, { extensors of hand. triceps, post. { wrist. wrist. { 7. Pronators of Inner side of arm Pupil, scapular, { wrist, latissimus and forearm. post. wrist, ant. { dorsi. wrist, palmar. { 8. Flexors of wrist, Inner side of Scapular, post, { hand, muscles. hand. wrist, ant. wrist, { palmar.

{ 1. Thumb. Ulnar supply to Scapular, palmar. { hand. {2-12. Muscles to back Skin over the Epigastric, 4-7; Dorsal. { and abdomen. back and abdomen abdominal, 7-11. { in areas corre- { sponding to { distribution of { spinal nerves.

{ 1. Psoas and Groin. Cremasteric. { sartorius. { 2. Quadriceps ex- Outside of thigh. Cremasteric, { tensor femoris. patellar. { 3. Abductors and Front and inside Cremasteric. { inner rotators of of thigh. Lumbar. { thigh. { 4. Adductors of Inside of leg, Gluteal. { thigh, tibialis ankle, and foot. { anticus. { 5. Outward rotators Back of thigh and Gluteal. { of thigh, flexors leg; outside of { of knee and foot. { ankle.

{1-2. Muscles of foot, Outside of leg. Plantar. Sacral. { peronei. {3-5. Perineal muscles. Perineum, anus, Ankle clonus. { sacrum, genitals.

Injuries low in the lumbar segments cause incontinence of urine and feces because of the location of the centres for the rectum and bladder at this level. Injuries higher up cause retention by paralyzing the expulsive muscles of the abdomen. The reflexes which most interest the surgeon and which are of importance to him in diagnosticating these and other traumatic conditions are the following, with their method of detection (Bradford):

Pupillary: Dilatation produced by pinching side of neck. Scapular: Scratching skin over scapula causes muscles to contract. Supinator: Tapping tendon at wrist causes flexion of arm. Triceps: Tapping tendon at elbow causes extension of arm. Posterior wrist: Tapping tendons causes extension of hand. Anterior wrist: Tapping tendons causes flexion of wrist. Palmar: Scratching palm causes flexion of fingers. Epigastric: Stroking mammæ causes retraction of epigastrium. Abdominal: Stroking abdomen causes retraction. Cremasteric: Stroking inner side of thigh causes retraction of scrotum. Patellar: Striking patellar tendon causes extension of leg. Gluteal: Stroking buttock causes dimpling in gluteal fold. Plantar: Stroking sole of foot causes flexion and retraction of leg. Ankle clonus: Forcible extension causes rhythmical flexion.

Much will depend upon the minute character of the injury, its location, and the amount of displacement of fragments. Fracture of a spinous process causes irregularity of the tips of the spines, with frequently the displacement of a fragment which may be moved beneath the skin, with or without crepitus. Fracture of one or both laminæ will permit mobility of the spinous process, with perhaps displacement. It is difficult to elicit crepitus. The neural arch may thus be broken without serious involvement of the body of a vertebra. On the other hand, the body itself may be fragmented, compressed out of shape, or so loosened as to permit of easy displacement.

DISLOCATION OF THE SPINE.

A limited proportion of serious and paralyzing injuries to the spine consists of dislocation of some of its component parts without fractures. These may be considered as pure types of dislocation, but they constitute less than one-fourth of such cases. In a large proportion of these spinal injuries the actual lesion consists of the combination of fracture with the displacement which it permits. Such conditions are referred to as _fracture dislocations_. Unilateral dislocation in the cervical region produces a distortion of the neck simulating wryneck, the face being turned to the opposite side. Except in very fat individuals irregularity will be perceived in the line of the cervical spines. When high up dyspnea is a constant feature. Traumatic dislocations are sharply differentiated, so far as the treatment is concerned, from those of slow production as the result of cervical spondylitis. In the acute cases the muscles are spasmodically contracted on the dislocated side. Irregularity of contour may be detected with the finger in the pharynx.

[Illustration: FIG. 415

Fracture dislocation with great displacement--patient almost completely recovered. (Buffalo Museum.)]

In the lower portions of the spine, which are both larger and more protracted, are more frequent combinations of both injuries and fewer instances of the single type of either. Except in the cervical region it is exceedingly difficult to distinguish between these lesions, for the question of operation or no operation is decided by other and more conspicuous features (Figs. 416 and 417).

[Illustration: FIG. 416

Dislocation between the fifth and sixth cervical vertebræ. (Erichsen.)]

[Illustration: FIG. 417

Dislocation of the spine forward (Bryant.)]

=Treatment.=--The injury having been localized, so far as deformity and careful study of its paralytic features will permit, the questions of prognosis and treatment become insistent. In the pure type of dislocation the prognosis will depend, first, upon whether reduction can be accomplished, and, secondly, upon the amount of damage suffered by the cord previous to such reduction. Every injury of the cervical spine is of most serious import because of the possible damage to the phrenic nerves. Rapidly ascending changes may terminate life in two or three days even though reduction be accomplished. The injuries to the lower part of the spinal column which produce paraplegia threaten life much less directly, but too frequently terminate fatally after the lapse of weeks or months, as the result of infections from spreading bed-sores, or infections through the urinary tract permitted by the constant necessity for and carelessness in the use of the catheter. The prognosis, then, in almost every case of these severe spinal injuries is unfavorable, at least if it be let alone (Fig. 415).

It becomes, then, a question of what can be done to improve the local conditions. Certain cases of cervical spinal dislocation have been reduced by forcible traction upon the head, assisted by rotation and manipulation with the hands in the direction indicated by the displacement of the patient’s head, as well as by such indications as may be secured in the pharynx. A considerable degree of traction may be necessary in this effort, and there is the possibility not only of failure but even of serious harm, and perhaps immediate death, since a fragment loosened may be made to produce promptly fatal pressure upon the cord. Such a measure, then, should be undertaken with the greatest care, and not without a complete understanding with those interested regarding its dangers (Fig. 418).

[Illustration: FIG. 418

Method of reducing dislocations of the cervical vertebræ by manipulation. (Lejars.)]

In most cases it is impossible from the exterior to estimate either the damage to the cord or the amount of fluid outpour until the spinal canal be opened. If there be complete loss of reflexes, with absolute insensibility and motor paralysis, then complete transverse destruction of the cord may be inferred. In these instances it may be decided not to operate. On the other hand it may be felt that unless the damage appear irremediable an open operation for inspection and relief should be performed at the earliest possible moment, since pressure on the cord allowed to persist even for a few hours causes damage for which there is no compensation. These cases may then be viewed in this light--if left to themselves they are almost hopeless. It therefore is a question simply of what can be accomplished by operation. On one hand the patient’s condition _may_ be materially improved; on the other it is scarcely possible to make him worse. The dangers of such operations inhere especially in the anesthetic and in the possible introduction of sepsis; not that the operation itself cannot be properly conducted, but that it is often difficult to keep these cases free from contamination during the subsequent course of events. To operate through bruised or infected skin would probably be fatal. These operations, then, are begun as explorations intended to reveal deep conditions. When one has freed the spinal cord from pressure and has removed the products of hemorrhage he has done nearly all that can be accomplished in such a case.

Until recently it has been supposed that complete transverse division or crushing of the cord was necessarily hopeless and fatal. As previously mentioned, Estes, Harte, and Fowler have reported instances of complete division of the cord, with subsequent approximation by suture and with at least partial restoration of function, that have lent an element of hope to cases previously regarded as hopeless.

For my own part, although I regard these cases as discouraging, I do not feel like withholding from patients the only possibility of improvement which can be offered them, but I am more and more impressed with the necessity for prompt intervention if this benefit is to be obtained. To wait a few days, then, until it has been made evident that nothing can be done, save by operation, or until a tardy consent is obtained, is to rob the patient of the hope which it may afford. The operative treatment should be begun immediately after the diagnosis is made, providing that this be promptly done. Delay is more than inexpedient--it is absolutely dangerous. As Burrell has pointed out it is scarcely fair to decide upon a course of treatment from a study of statistics alone, as lesions vary within widest limits, as do also results of individual operators. Let each case, then, be decided upon its merits, _but let whatever is done be done promptly_. If there be excuse for delay it is in those cases where paralysis is incomplete and where the cord apparently has not been seriously compromised. But these would afford the most promising results after operation.

The operation itself will be described at the conclusion of this section, and in connection with other operations practised for exposure of the cord when involved in other lesions.

HEMATORRHACHIS AND HEMATOMYELIA (INTRASPINAL HEMORRHAGES).

These occur, as do hemorrhages within the cranial cavity, with or without serious other lesions of the investing structures. They are expressions, of course, of transmitted violence, depending so far as known essentially upon injury, whether the hemorrhage occurs within the central canal of the cord, within its structure, or within the subdural or even extradural spaces. Everywhere within these regions bloodvessels abound, from which may occur sufficient outpour of blood to make pressure upon the cord to a degree producing complete paralysis. The duration of time between reception of injury and the occurrence of diagnostic paralysis will be to some degree a measure of the rapidity of such outpour, while a study of the paralyses themselves will permit of localizing the injury. The symptoms consist mainly of pain in the spine radiating to some distance, often referred to the distribution of the nerves most involved. This pain is often associated with muscular spasm, while paralysis may be a very early or somewhat tardy symptom.

=Treatment.=--Once the fact of pressure upon the cord is established these cases come under practically the same rule as above. While there is a possibility that a moderate amount of bloody outpour might be absorbed there is nearly as much danger of its organization and of permanent involvement of the cord. In fact there is more reason for operating in cases of spinal hemorrhage than in cases of fracture, since it may be possible to thereby accomplish more.

The _non-operative treatment of fractures or dislocations_ consists mainly in external support, preferably by a plaster-of-Paris corset properly applied, and by maintaining elimination and nutrition, while affording physiological rest for a sufficient length of time. These cases will need massage and electricity, _i. e._, stimulation of the compromised muscles, and _extreme care should be given to the prevention of bed-sores_, to which they are peculiarly liable. _Every precaution should be taken also against any possible retention of urine or feces. The incontinence of an overdistended bladder should not be mistaken for that of paralysis of its sphincter apparatus._ The specimen of dislocation from which Fig. 415 was taken was removed from a patient who almost completely recovered from the effects of the injury, but who became careless about the condition of his bladder and who suffered an ascending urinary infection that terminated his life.

Of these cases it may also be said, then, that a much better prospect of exact diagnosis and atonement for harm done is afforded by exploration, since as between compression of the cord by clot or by bone there is little essential difference.

The subjoined table may afford assistance in the diagnosis of the injuries above considered:

_Differential Diagnosis of Diseases and Injuries of the Spine and Spinal Cord._

_Fracture._ _Dislocation._ _Hematomyelia._

_Onset._ Immediate. Immediate. Immediate. _Anesthesia._ Immediate. Immediate. Immediate. _Paralysis._ Hemiplegia or Hemiplegia. In Paraplegia. (Is of hemiplegic type paraplegia. partial dis- when compression is location may unilateral, paraplegic be absent. when bilateral, and local when single nerve roots are involved.) _Deformity._ Usually Present. Absent. present. _Temperature._ Rises after Same. Same. second or third day. _Bowels and Bladder._ Paralyzed. Paralysis Same. usual.

_Hematorrhachis._ _Acute Poliomyelitis._

_Onset._ Progressive. Slow. _Anesthesia._ Incomplete. Absent. _Paralysis._ Hemiplegia or Paraplegia. (Is of hemiplegic type paraplegia. when compression is unilateral, paraplegic when bilateral, and local when single nerve roots are involved.) _Deformity._ Absent. Absent. _Temperature._ Same. Precedes the paralysis of degeneration. _Bowels and Bladder._ Affected late if No paralysis. at all.

COCCYGEAL OR PILONIDAL SINUS.

In the neighborhood of the coccyx, usually below its tip, between it and the anus, sometimes above the tip, a small depression or sinus mouth is occasionally seen. This is usually known as the _pilonidal sinus_. It is the persistent remnant of the original fetal termination of the spinal canal. It varies in size from a mere dimple to a cul-de-sac, in which sebaceous matter, with any other epithelial products, hair, etc., as well as foreign material and dirt from the skin, may collect and excite suppuration. In this way an abscess of considerable size may form. Sometimes its contents will be found to be principally hair; hence the name pilonidal. Frequently this sinus can be traced down to the periosteum and into the remains of the original neurenteric canal. When it is distended so as to give trouble it needs only to be freely incised and thoroughly cleaned.

CONGENITAL COCCYGEAL TUMORS.

In the region of the coccyx and lower part of the sacrum there appear tumors of congenital origin which are often present at birth or may not develop until later. These assume various sizes and aspects, varying from mere protuberances to large pendulous tumors. While covered with integument their internal structure varies within wide limits, and they are usually made of such a mixture of embryonal elements as to entitle them to be considered true teratoma. Even organized tissues or rudimentary organs may be found therein. They are rare and constitute practically surgical curiosities. Such a tumor, if troublesome, calls for removal, which should be accomplished with the strictest precautions, as the spinal canal may perhaps be opened during the procedure and most inflammable tissue thus exposed to infection from the perineum.

The sacrum, like the coccyx, is also the site of numerous congenital cysts and tumors which may appear posteriorly or anteriorly. Occasionally they form within the bone itself. Cysts that connect with the spinal canal will be found filled with cerebrospinal fluid, and some of them are essentially _spina bifida occulta_. The sacral region is also the site of predilection for those teratomas which consist in whole or in part of vestiges of an attached fetus. The advisability of operation must be determined for itself in each of these cases. (See Fig. 412, p. 627.)

COCCODYNIA; COCCYGODYNIA.

Under this name are included severe and chronic neuralgias of the coccygeal region, including its joint, which occur most often in women, and usually as the result of contusion or direct injury. Occasionally it results from an injury inflicted during parturition. It gives rise to a degree of pain and tenderness which sometimes is almost disabling. Because of the insertion of the levator ani into the tip of the coccyx defecation may become distressing, to an extent which leads to fecal impaction in the rectum from postponement of evacuation as long as possible. The symptoms are subjective, but the tenderness is frequently exquisite.

In regard to treatment subcutaneous division of the tissues around the bone may afford relief, but in most instances, particularly those of traumatic origin, an excision of the coccyx will afford the only cure. (See below.)

OPERATIONS ON THE SPINE.

These are included under the general heading _laminectomy_, which is used in a comprehensive sense, as is also the term trephining.

In a general way the measure is about as follows: Through a long median incision over the spines of the region where the lesion is localized their tips are exposed, while the muscle groups on either side and posterior to the laminæ are separated by the knife and by retractors. Dense fibrous bands may be nicked. In this way the posterior aspect of the neural arches is exposed to the desired length. The exposed spines should be removed by cutting them off at their bases with bone forceps, although they may be left and later removed with the posterior bony arches. To clear them away, however, affords a better view of the field of operation. The ligamenta subflava are then divided transversely at their upper and lower margins, after which, either with cutting forceps, saw, or chisel, the laminæ are divided on either side, and the section which is loosened pried out from the bed in which it rests. More or less fatty tissue will be found outside of the dura and in this tissue veins, sometimes of considerable size, freely ramify. These may be seized and divided, those of considerable size being tied. Great care should be given during the procedure to avoid perforation of the spinal membranes by the points of the instruments used. The cutting forceps are preferable to the saw or chisel, except for work in the lower lumbar region, where the parts are stout and strong. Especially in case of fracture, and at the upper end of the spine particularly, care should be given, with the force used, that no loose fragment be so handled as to increase the damage already done to the cord.

The dura being thus exposed and the blood cleared away, inspection may or may not reveal the nature of the lesion. A probe, gently handled, passed upward and downward into the canal, will reveal whether the cause of the pressure has been cleared away or not. According to the nature of the lesion it can then be decided whether to open the dura. To open it is to pave the way for fatal infection, unless the strictest aseptic technique has prevailed. On the other hand, to leave it unopened is to fail to appreciate the actual condition of the cord and to leave an important matter still undetermined. The dura if opened should be closed by suture.

Reference has already been made, in three cases now on record, to suture of the cord as a whole. Such sutures may be applied, if necessary, in a manner to do the least possible damage to the structures of the cord. If cerebrospinal fluid escape too freely the patient may be operated in a position with the head lower than the trunk, avoiding leakage.

_Osteoplastic methods_ of temporary resection of the posterior arches of the vertebræ have been devised and practised, but they offer no

## particular advantages, and are attended by disadvantages which have

caused them to be almost abandoned, save in rare instances and by individuals of large experience. (See Plate XLVII.)

In regard to wiring fragments of a fracture or displaced spine, Hadra, of Texas, was perhaps the first to carry out the measure. It comprises simply the fixation of fragments by wire sutures or ligatures which bind them together after they have been replaced through a more or less open wound, such as is included in the term laminectomy. But resort to wire is to be left to the judgment of the operator and the needs of the case. There is no reason, however, why it may not be used here, as in other fractures which are thus made compound, if there would seem to be prospect of benefit attaching to its use.

[Illustration: PLATE XLVII

Osteoplastic Resection of Posterior Vertebral Arches. (Urban.)]

_Laminectomy_ is practised also in _Pott’s disease_, with the hope of relieving pressure upon the cord, due to the deformity or to the presence of tuberculous foci. It is possible that in some of these cases an incomplete operation will serve the purpose. Sufficient should be done, however, to relieve pressure if such a measure be indicated.

When laminectomy is practised for the purpose of attacking a _tumor of the spinal cord_ the exposure of the cord should be followed by the removal of the tumor. Some of these are so placed as to make the procedure simple, while at other times it will be exceedingly difficult, if not impracticable. If the growth has so extended as to involve the bones themselves, then the measure will be futile and should be abandoned; but an isolated tumor, either within or without the dural space, in or on the substance of the cord, can usually be removed by a process of blunt dissection. Sometimes the small wounds thus made will ooze considerably and hemorrhage may prove troublesome; it should be checked before the parts above it are closed. Pressure forceps and ligatures and the occasional use of adrenalin solution will afford the necessary means for combating bleeding.

For nearly all of these operations upon the spine the chisel and the cutting forceps will suffice. Some operators, however, prefer a small saw, like that suggested by Doyen, which has a guard that can be so set as to determine the depth to which the instrument may pass. No matter what instrument be used, great care should be taken lest it pass through and beyond the bone in such a way as to lacerate the dura or the plexus of veins outside of it.

The _sacrum_ is rarely attacked except in connection with some of those tumors already described.

The _coccyx_ is easily removed through a median incision, the parts around it being entirely separated and the bone thus freed removed at the joint with stout scissors or cutting forceps. The instruments used should be kept in contact with the bone and not allowed to injure the veins between it and the rectum. Such a wound should not be closed completely, as a cavity always remains, which it is better to pack and permit to heal by granulation. (See Coccodynia.)

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