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.