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. | Hematorrhachis. | Acute Poliomyelitis. | |
|---|---|---|---|---|---|
| Onset. | Immediate. | Immediate. | Immediate. | Progressive. | Slow. |
| Anesthesia. | Immediate. | Immediate. | Immediate. | Incomplete. | Absent. |
| Paralysis. (Is of hemiplegic type when compression is unilateral, paraplegic when bilateral, and local when single nerve roots are involved.) | Hemiplegia or paraplegia. | Hemiplegia. In partial dislocation may be absent. | Paraplegia. | Hemiplegia or paraplegia. | Paraplegia. |
| Deformity. | Usually present. | Present. | Absent. | Absent. | Absent. |
| Temperature. | Rises after second or third day. | Same. | Same. | Same. | Precedes the paralysis of degeneration. |
| Bowels and Bladder. | Paralyzed. | Paralysis usual. | Same. | Affected late if at all. | No paralysis. |
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].)