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SURGERY
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SURGERY OI' THE SPINE AND See also:SPINAL See also:CORD Fracture of the spine may occur from indirect violence, as when a See also:man falls from a height upon his See also:head, or in a sitting position; or it may result from See also:direct violence, as when he is hanged, or as when he is run over by a loaded See also:van, or in a fall from a height across a See also:beam. The vertebrae above the fracture being displaced from those below it, the spinal cord is generally torn across, and the parts of the See also:trunk, or the limbs, which are supplied by the spinal nerves passing out from the cord below the seat of injury are of See also:necessity cut off from their connexion with the See also:brain, and at once deprived of sensation and of the See also:power of voluntary See also:movement. In some cases of fracture of the spine there is at the See also:time marvellously little constitutional disturbance. The higher up the See also:column that the fracture occurs the more quickly does See also:death ensue. If the fracture is in the See also:middle of -the back the patient may linger for several See also:weeks, but even if he is lying upon a See also:water-See also:bed, and even if every care is taken of him, inflammation of the See also:bladder and intractable bed-sores are See also:apt to make their See also:appearance, and his existence becomes truly miserable. Operative surgery is unable to effect much in these cases on See also:account of the spinal cord being generally torn across or hopelessly crushed. Curvature of the spine may be due to deformity of the bodies of the vertebrae caused by irregular pressure, or' to the disintegration of their anterior parts by tuberculous ulceration, known as See also:Pott's disease or spinal See also:caries. Thus the causes of spinal curvature are very different, and it is necessary that the actual See also:condition be clearly recognized or treatment may prove harmful. Briefly, the curvature which is due to tuberculous disease requires See also:absolute and continuous See also:rest; the other calls for well-regulated exercises. Lateral or rotatory curvature of the spine is a deformity which comes on during the developing See also:period of See also:life, before the bodies of the vertebrae are solidly formed. In See also:young See also:people who are See also:MID-DORSAL LAMINA growing rapidly, and whose See also:muscular See also:system is weak, the See also:bad See also:habit of See also:standing, and throwing the See also:weight of the See also:body constantly on one See also:leg, gives rise to a serious tilting of the trunk; or, if, when See also:writing at a See also:desk, they sit habitually in a See also:twisted position, a lateral curvature of the spine is apt to take See also:place. By See also:constant See also:indulgence in these bad habits the spinal column gets permanently set in a faulty position. Sometimes the tilting of the See also:base of the trunk is due to a congenital or acquired difference in the length of the legs. In the concavity of the See also:curve there is increased pressure; and, necessarily, diminished growth; in the convexity of the curve there is diminished pressure with increased growth. The patient's See also:friends probably See also:notice that one See also:shoulder is higher than the other, or that " the See also:hip is growing out," and unless means are taken to alter the abnormal See also:distribution of pressure, the condition becomes worse, until See also:complete ossification checks the further progress of the deformity. 'The growth of the subject being completed, the deformity ceases to increase. And when the growth is completed and the bones are solid and misshapen the condition is quite incapable of improvement. The usual curvature is one in which there is a convexity of the spine in the See also:chest-region towards the right, with the right shoulder higher than the See also:left. Compensatory curves in the opposite direction See also:form in the loins and See also:neck. Along with the lateral bending of the spine a rotation of the bodies of the vertebrae towards the convexity of the Curve takes place, the spinous processes turning towards the See also:con-cavity of the curve. Since the See also:line of the spinous processes of the vertebrae can be easily traced through the skin, their deviation may mislead the superficial observer as to the actual amount of the curvature. To counteract this deformity in the earliest stages (and it is in the See also:early See also:stage that treatment effects most), the patient (generally a girl) should be encouraged to walk perfectly erect. Systematic exercises, to strengthen the muscles of the back, ought to be strictly and persistently carried out under the direction of a surgeon with the assistance of a skilled instructor of gymnastics. During the intervals of rest the See also:child should See also:lie upon her back on a See also:firm See also:board, and should avoid taking exercise which gives rise to weariness of the muscles; for when-ever the muscles become wearied she will See also:attempt to take up a position which throws the See also:strain on to her ligamentous and bony structures. One of the best exercises is to See also:lay the patient on her See also:face, See also:fix her feet, and encourage her to See also:rais&herself by using the muscles of the back. Whilst she hangs from a See also:trapeze the weight of the See also:lower limbs and See also:pelvis will help to straighten the spine as a whole, necessarily diminishing" the increased pressure upon the cartilaginous bodies of the vertebrae towards the concavity, and increasing the pressure between the sides' of the bodies towards the convexity. It is often a See also:good thing to remove a girl with commencing lateral curvature from the sedentary life of school or See also:town and to let her run See also:wild in the See also:country, exercising her muscles to the full. If the deformity is due to inequality in the length of the legs, a high See also:boot on the See also:short leg may correct it. In smiie' cases of lateral curvature a tilted seat is useful. See also:Mechanical "spinal supports " are as expensive as they are' inefficient. As a See also:rule, indeed, they are positively harmful, in that they add to the weight of the trunk' and hinder needful muscular development. By kyphasis is meant an exaggerated degree of 'roundness of the shoulders. It can be effaced only by constant drillings and exercises whilst the spinal column is still plastic. When once the bones are solid no See also:great improvement is possible. The deformity is sometimes due to short sight. It is well, therefore, to have the child's See also:vision duly tested. Lordosis is an exaggeration of the normal concavity of the See also:loin-region of the spine. It is most often met with in those cases in which from congenital displacement of the head of the thigh See also:bone, or from old disease of the hip-See also:joint, the "subject has acquired the habit of throwing the shoulders back in See also:order to preserve the See also:balance.
Tuberculous disease of the spine (See also:Poll's disease), is the result of a See also:deposit of tubercle-germs in the body of the vertebra.in the parts below.
The treatment of tuberculous disease of the spine demands absolute and uninterrupted rest. The best thing is to put the patient See also:flat on his back for as many months as may be found necessary, but not in a See also:close bedroom. If he is compelled to lie in a bedroom the windows should be open See also:night and See also:day. If the patient is a child, he should be laid flat in a See also:box-splint, or upon a thin horsehair See also:mattress, and should be carried out of doors every day—but always lying flat. When the pressure-symptoms, such as the pains in the legs, thighs or arms, the " belly-ache," or the pains in the chest or neak have passed away, a firm See also:leather splint may be moulded on to keep the parts quiet until consolidation has taken place, or a See also:cuirass of poroplastic See also:felt or of See also:plaster of See also:Paris may be applied. The danger in these cases is of leaving off treatment too soon: they must not be hurried, or the trouble will be likely to come back again with, perhaps, increased deformity.. If the disease is in the upper See also:part of the dorsal spine, or in the neck-region, a cervical See also:collar of leather, or a See also:double See also: Sometimes in the See also:case of tuberculous disease, where the propriety of resorting to the operation is being discussed, the symptoms of the See also:compression begin to clear off and the child makes a complete recovery without being operated on; the moral is that we should wait patiently and give Nature a full See also:chance of doing her See also:work in her own way. The operative treatment of these,cases is not highly satisfactory. Still, there are a certain small number of cases in which it may be given a trial. The treatment of spinal See also:abscess has been greatly influenced by the Listerian method. The collection of broken-down tuberculous material or fluid is not an abscess in the usual sense, for it does not contain " pus " or " See also:matter," being, as a rule, destitute of septic micro-organisms. A spinal abscess is therefore no longer drained: it is incised, scraped, washed out, and swabbed dry, the opening being carefully and permanently sewn up. In this way septic germs are effectually excluded from. the cavity, and the patient is spared the depressing and tedious discharging of the cavity which so often followed the old methods of treatment. It must be clearly under-stood, however, that every spinal abscess does not undergo cure after being 'subjected to the evacuation and See also:closure treatment mentioned Inflammation having thus been set up, ulceration (caries) of the vertebra, or of several vertebrae, occurs, and if the case runs on unchecked extensive abscesses may form in the thigh, loin or See also:groin. The trouble is often begun by a See also:blow or by a sprain of the spine, which, by lowering the power of resistance of the delicate bone, prepares it for the bacillary invasion. The earliest symptoms are likely to be a dull aching in the back with stiffness of the spine. The child complains of being tired, and is anxious to lie down and be left quiet whilst his little c0}npanions are See also:running about. If the disease is in the middle part pf.the spine, pains are complained of in the front of the chest or at the See also:pit of the See also:stomach. Unfortunately such pains are often •ascribed to indigestion. If the disease is in the upper part of the spine the pains may be in the head, the shoulders or the arms. If in the Igin-region of the spine they are in the lower part of the trunk, the thighs or the legs. (These obscure peripheral pains are often misunderstood and are apt to be attributed to See also:rheumatism). The back is stiff so that the child cannot stoop. In trying to pick up anything from the See also:floor he keeps his back straight and bends his knees. If the disease is in the neck-region he cannot easily look upwards, and, instead df turning his head to look sideways, he wheels See also:round his whole body. In some cases, though the disease is far advanced, there have been no complaints of See also:pain in the back. As the bodies of the vertebrae crumble away, the spine bends for-wards under the See also:influence of the weight of the head and of the upper part of the trunk, and a See also:projection may,. appear in the middle line of the back. In the neck, and in the loin-region, the projection is rarely well marked, but in the chest-region a conspicuous See also:boss may make its appearance-the "hump-back." .The projection is often spoken of as an angular curvature—a See also:contradiction in terms, for a thing which is angular is not curved. When the deformity is great there may be pressure upon the spinal cord with more or less See also:paralysis above, but that the surgeon is sometimes compelled to use See also:irrigation C structure or its. See also:function. It is merely a part of that great See also:nervous structure which throughout the length of the body forms the central See also:meeting-place of the See also:nerve-paths arriving from and issuing to all regions with which nerve See also:fibres are in See also:touch. To See also:separate from the rest of this system the part which lies within the spine is an artificial and in many ways misleading See also:provision. This artificial treatment is the outcome of crude,ideas See also:drawn from the study of merely the See also:gross form of the bodily parts. But crude, as the distinction is, its historic priority has influenced the study of the vertebrate nervous system, not only in regard to morphological description but also in regard to exposition of the functional reactions of the nervous system and even up to the See also:present day. Hence it is still. customary arbitrarily, to detach certain of the reactions. of the nervous system into a separate See also:group and describe that group by itself, simply because they occur in nervous arcs whose central courses in the great central nervous See also:organ lie within that part. of it extending along the spine. An additional inconvenieace attaching to the mode of description of the nervous system customary in See also:works on human See also:anatomy, is that in such works the parts of the nervous arcs outside the central organ are described apart from it under the See also:term peripheral nerves. This severs artificially structures. which are functionally indissolubly See also:united. The study and description of the working of the nervous system is hampered by this unphilosophic sub-See also:division of its structural parts. To gain a broader and truer point of view as starting-point for understanding the working of the spinal cord one must prepare the exposition by a short reference to the See also:general function of the nervous system in the bodily See also:economy. Relation to General Nervous System.—An See also:animal of microscopic See also:size may continue throughout its life to he constituted entirely by one single See also:cell. Animals of . larger bulk, although each begins its existence as a single cell, attain their development by the multiplication, of the See also:original single cell, so that, from it there comes to be formed a coherent See also:mass of cells very many millions,in number. In these multicellular animals each of the constituent cells is a See also:minute self-centred organism, individually See also:born, leading its own life and destined for individual death. The corporate power of the complex animal is the sum of the See also:powers of those manifold individual existences, its cells. In the complex animal the several See also:organs, even the most homogeneous, such as muscles or glands, are each composed of many thousands of cells similarly specialized but living each per se. The solidarity of See also:action which a complex animal thus built up exhibits is the result. of the binding together of the See also:units which compose the complex"organism. Of the agencies which integrate the complex animal, one of the most potent is nervous action. , A certain number of the unit cells composing the animal are specially differentiated from the rest to bind the whole together by nervous action. These specially differentiated cells are called " neurones." They constitute living threads along which waves of physico-chemical disturbance are transmitted to.. See also:act as releasing forces for the See also:energy in distant cells, where they finally impinge. It is characteristic of this nervous system, the system of neurones, that, although ramifying far and wide through the body, it is a continuum from end to end. The peripheral nerves are formed of bundles of neurones lying See also:side by side, but these, although packed close together, are strictly isolated one from another as conductors and remain isolated throughout the, whole length of the nerve. The points of functional nexus of the neurones one with another are confined to one region only of the whole system. All their conductive connexions one with another take place solely in the central nervous mass which constitutes the so-called central nervous system, a nervous organ extending axially along the length of the body midway between the body's lateral halves. Thither the neurones converge in vast See also:numbers, those of each body segment converging to that fraction of the central organ which belongs to their body segment. The central nervous organ thus receiving these neurones is, where it lies in the head, called and drainage. In 1897 Dr Calot of Berk-sur-Mer reintroduced the method of straightening out the hump of the back, so often left after 'disease of the spine, by stretching the child on a flat table and dealing with the hump, under See also:chloroform, with what is commonly known as " See also:brute force." A considerable number of hump-backed See also:children on the See also:Continent as well as in See also:England and See also:America were thus dealt with, but it is doubtful whether the records of those cases, could they all' be collected and published, would be found to justify the See also:enthusiasm and publicity with which the method was inaugurated and its details were spread abroad. It is scarcely necessary to say that the forcible straightening of a spine which has See also:developed a hump because tuberculous disease has wrecked the front of the vertebral segments is in no sense a curative operation. Diminishing the size of the projection does not cure the tuberculous ulceration of the bones; indeed, it may increase the ulcerative See also:process or determine a scattering of the germs of tubercle throughout the body. The operation has not been accepted by See also:British and Atnerican surgeons. In the practice of the See also:foreign surgeon death ensued in three cases out of thirteen that were operated on, and an See also:English surgeon reported fourteen cases " in all of which the deformity had recurred although the spines had been fixed in plaster of Paris afte' the straightening.'
Being deeply placed in the mass of the muscles of the back, and, moreover, being jealously locked within the bony canal of the vertex brat column, the spinal marrow or spinal cord was, until the last few years, generally considered to be beyond the reach even of the most enterprising surgeon. Still, like other tissues, it was liable to diseases and injuries. The exact situation of a See also:tumour pressing upon the spinal cord can now be located with great precision by noting the areas of pain and numbness, and the height in the limbs or trunk to which loss of power of voluntary movement ascends, and by noting also whether these effects are symmetrical upon the two sides or appear more upon one side than on the other. By cutting away the posterior parts of certain segments of the vertebral column, tumours of various sorts have been successfully removed from the interior of the canal. Displaced fragments of bone in tuberculous See also:affection of the spine, abscess-contents and inflammatory See also:tissue have alsp been similarly dealt with. See also:Sir See also: One might as well speak of concussion of the See also:skull as of concussion of the spine, for the spine is but the bony envelope of the spinal cord, as the skull is of the brain. The violent Shaking of the spinal cord and the spinal nerves in a serious See also:accident may, however, be followed by some functional disturbance, which may be associated with pains in the back, by numbness and tingling in the limbs, or with muscular weakness. In some cases the disturbance is due to slight haemorrhages into the nerve sheaths; 'which' may clear up with rest and quiet. But when the presence of these obscure symptoms, after a railway accident for instance, becomes the subject of an action-at-See also:law, there is a great chance that they will not pass off until the case is settled in one way or the other. Not, perhaps, that the individual concerned is dishonest in his estimation of them, but because the anxiety of the overhanging lawsuit has so grievously disturbed his mind and altered his See also:perspective that his sense of proportion is for a time in See also:abeyance. After the action-at-law the symptoms may clear up with a rapidity which to some people appears surprising. (E. Additional information and CommentsThere are no comments yet for this article.
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