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;