than half an inch; and in these cases the spinous process of the projecting vertebra presses less or more the spinal marrow between itself and the back of the body of the lower vertebra. The least displacement of the vertebral body occurs in the neck; and indeed in the upper part of the neck scarcely happens.

Fracture of the spine may, however, exist without displacement, and without symptoms, even if the atlas be the fractured bone, as in the elder CLINE'S CASE.-“ A girl received a severe blow upon her neck; after which it was observed, that whenever she wanted to look at any object, either above or below her, she always supported her head with her hands, and then gradually and carefully elevated or depressed it, according as she wished, towards the object. After any sudden shock, she used to run to a table, and placing her hands under her chin, rested them against the table until the agitation occasioned by the concussion had subsided. Twelve months after the accident the child died, and on examination a transverse fracture of the atlas was found, but no displace ment. When the head was depressed or elevated, the dentiform process of the second vertebra became displaced, carrying with it a portion of the atlas, occasioning pressure on the spinal marrow, which was also produced by any violent agitation" (a).`

PHILIPS's case of fracture of the atlas, and of the pivot of the aris, has been already mentioned by CHELIUS; but he has omitted to state the very remarkable position and condition of the parts as found on examination. "The condyles of the occipat still rested upon the articulating surfaces of the atlas, but the atlas was found to be, not a separate and independent vertebra, but an appendix to the axis. So much of its anterior portion as includes the surfaces by which it is articulated with the occiput and with the axis, had been violently separated from the posterior portion of its ring, and had been carried in an oblique direction downwards and forwards until it arrived upon the same plane, but anterior to the axis, to the body and transverse processes of which it became attached by the perfect bony union, whilst the posterior fragment had suffered no displacement." (p. 82.)

The following instance of fracture, without displacement of the atlas and aris, occurred in St. Thomas's Hospital, and the preparation is in the museum there:CASE.-W. T., aged sixty-eight years, was admitted into George's Ward.

Nov. 10, 1838. Having fallen down stairs a few hours before his admission and been stunned. Has pain at the back of his neck, which is increased by pressure. All his limbs, except the left lower extremity, which still retains slight motion, are palsied. The sensibility of the whole right side of the body is morbidly acute; that of the left totally destroyed, excepting on the belly, where he feels slightly, and to which he refers a sensation of numbness when the left thigh is pinched. Next day he complained of pain in the right arm; the skin on the left side of the belly is less sensible. On the third day the morbid sensibility of the right side had diminished, and sensation had slightly returned on the left. Complains of pain in the right hypochondrion, and fancies his arms lie across his chest. On the following day the belly became tympanitic. On the fifth day there was slight motion of the left arm, and the capability of moving the right leg had increased; but he was rapidly sinking, although in good heart, and died, late at night. On examination it was found that the atlas was broken in two places, the line of fracture being diagonal, and traversing the left vertebral hole. The pivot of the axis was broken off at its root, and a small piece of the body also. The fifth vertebra was fractured through the body. With neither fracture was there sufi cient displacement to produce pressure. On cutting through the spinal cord. a central cell was found containing a small quantity of blood, and the substance of the cord broken down and disorganized, opposite the fifth vertebra.

On the other hand, dislocation of one vertebra from another, either partial or complete, may occur without fracture, but is so extremely rare, that, as regards dislocation of the body, DELPECH (b) entirely denies it; ABERNETHY (c) declares:-"There can be no dislocation (of the vertebra) surgically speaking-we do not take the word in its etymological sense; in surgical language, a dislocation is a displacement of bone, with a laceration of ligament unaccompanied with fracture, for if there be a fracture it is not a dislocation; but from their position, if one vertebra be knocked in, its articular surfaces must be broken." ASTLEY COOPER (d) says:-" If luxation of the spine ever does happen, it is an injury which is extremely rare, as in the numerous instances which I have seen of violence done to the spine, I have never witnessed a separation of one vertebra from another, through the intervertebral substance, without fracture of the articular processes; or if those processes remain unbroken, without a fracture through

(a) ASTLEY COOPER's Lectures, vol. ii. p. 8. (b) Précis Elémentaire des Maladies réputées Chirurgicales, vol. iii. p. 42.

(c) MS. Lectures.
(d) Above quoted.

the bodies of the vertebra." (p. 539.) And BOYER (a), without actually denying the possibility, seems to infer the impossibility of such an occurrence. Exceedingly rare, however, as these accidents are, there is no doubt that they do sometimes happen, although I do not believe that a tithe of the so-called dislocations are dislocations at all; as, for instance, a person thrown from his horse, and falling on his head, has it bent under him, and caunot of himself restore it to its proper place, or he may fall from a ladder, as in a case within my own knowledge, and the neck be twisted with the face over the shoulder, and unable to be replaced without assistance; but, as ABERNETHY says, "this is not dislocation; it is nothing more than we are sometimes ourselves doing, the muscles are overstretched, and cannot act, the head is put in its proper place, and all becomes right." I must confess that I at first thought of like character were the cases quoted by BOYER, the one mentioned by DESAULT in his Lectures, of the advocate who dislocated his neck, merely by turning his head suddenly round to see who was coming into the room behind him; and the other shown by CHOPART, of the young man in whom a similar accident happened from extreme rotation of the head, leaving it permanently inclined over the left shoulder; as also RUST's case (b), in which, after a severe fall on the head, the neck was completely bent to the right side, the upper extremities paralysed, and accompanied with repeated attacks of convulsions and hiccough, in which replacement was immediately effected by seating the patient on the ground, and forcibly drawing his head straight upwards. Since reading SCHUH's case (c), which will presently be given, I feel sure that these were cases of actual dislocation, and that the latter was, as well as SCHUH's case, reduced, although this could not be done in two other cases quoted by BOYER, as also mentioned by DESAULT in his Lectures, in one of which a boy, by turning heels over head, dislocated the right lower articular process of a cervical vertebra, and the head being turned towards the left shoulder, was so firmly fixed that it could not be replaced, although considerable force was used; whilst in another case, where one of the articular processes of a cervical ver tebra was dislocated forwards, the child was destroyed during the attempts at reduction. The dislocations, entire or partial, of the vertebra, which are referred to by LawRENCE (d) as dislocations, are, two of the four in St. Bartholomew's museum, displacement with fracture; the third appears to me neither dislocation nor fracture, but simply a stretching of the capsular ligaments of the articular processes, as his own description proves; "the inferior articular processes of the fifth cervical vertebra are partially separated from those of the fifth having been drawn upwards; but they have not been thrown forwards. The bodies of the same vertebra are partially separated behind, but they preserve their natural level and relative position in front." (p. 392.) A case of this kind occurred under my own care, in which the lower end of the second cervical vertebra was separated from the intervertebral substance so far that a shilling laid flat might be thrust between them, but there was no displacement. In this case there were no symptoms of injury of the spinal cord, although there was effusion of blood between it and its covering of dura mater. The boy had fallen on a post, died on the fourth day, having exhibited symptoms of severe injury in the belly, and on examination, his liver was found broken in two. LAWRENCE's fourth case is a complete dislocation of the fourth from the fifth cervical vertebra, and a most remarkable case it is. The patient, a young man of twenty-two years, whilst "carrying a heavy barrel on the back of his head and neck, slipped in descending some steps and fell on the buttocks, the burthen resting on the head and upper part of the neck. He was immediately deprived of sensibility in the trunk and limbs, and of all power over the voluntary muscles of those parts. When brought to the hospital he was completely insensible and incapable of voluntary motion below the neck.” On the following day, “there was pain in the lower part of the neck. He could move the arms very slightly, and had a little feeling in the front and upper part of the chest." On the third day, "he experienced a tingling sensation in the hands, and was sensible to impressions on the upper part of the arms and thighs." He continued to decline, and died very early on the morning of the fifth day. On examination, "after cutting away the muscles from the back of the spine, the cartilaginous surfaces of the superior articular processes of the fifth cervical vertebra came into view, in consequence of the inferior processes of the fourth vertebra having been completely dislocated forwards, and remaining fixed in their unnatural position. The yellow ligaments connecting the lamina of the two vertebrae were torn through, and the bifid apex of the fourth spinous process lay in close contact with the basis of the fifth. On the front of the (a) Traité des Maladies Chirurgicales, vol. iv. chap. iv. art. iv.

(6) Medicinisch-chirurgiche Zeitung, vol. iii. p. 127. 1813.

(c) Einige Fälle von Luxationen und Brüchen

an der Halsgegend den Wirbelsaule; in voN RAIMANN'S Medicinische Jahrbücher des kais. kön. Oesterreichischen Staates, vol. xxi. New Series.

1840.

(d) Above cited.

column an unusual projection was observed, but the anterior longitudinal ligamentous expansion was entire. The body of the fourth was completely detached from that of the fifth vertebra, the connecting fibro-cartilage being torn through, and the body of the former projecting by its whole depth in front of the latter." (p. 394-97.) I have taken the opportunity of examining this preparation, and as it at present appears in its dry state, the right articular process of the fourth vertebra rests in the concavity between the transverse process and the body of the fifth; but the left process, although displaced, is not thrown completely off the corresponding articular process of the fifth vertebra.

Of the partial dislocation, in which only one articular process is thrown before the corresponding one of the vertebra below, and the body of its own vertebra on that side projected forward, is the instance in St. Thomas's Museum already alluded to of the right lower articular process of the axis, but of which unfortunately there is not any history. SCHUH's case (a) appears to me one of this kind, and the following is his account of this very interesting

ČASE.-F. H., twenty-four years of age, whilst engaged in his occupation of needlemaking, being suddenly called by a fellow-workman for the purpose of frightening him, turned sharply round, and at the very moment felt a crack in his neck and could no longer move his head. On the following day he came to the hospital, with his countenance turgid, his head twisted to the right side and brought nearer to the shoulder; upon the left side the neck was a little arched, and on the right rather hollowed. He had pain, increased by pressure, on the left side, from the third to the fifth vertebra; and every attempt to give the head and neck another direction was vain and painful. The direction of the upper spinous processes could not be closely followed with the fingers, but the neck muscles were not by any means morbidly stretched. The patient complained of weakness in the right upper extremity; could only lift it with exertion, and had much less power of closing these fingers than those of the left hand. Attempts were immediately made at replacement by lifting the head directly upwards by the chin and hind-head, the shoulders being fixed whilst the patient sat on the ground, but in vain. This was repeated in the evening without result, and both times without pain. Leeches and cold applications were used. Two days after the patient complained of the addition of weakness in the right arm, with the sensation of its being asleep. To gain more power, the mode of reduction was varied. The patient was laid on his back in bed, with the shoulders fixed by two folded cloths, and extension made by a towel which I carried under the jaw, whilst the pulling was kept up by an assistant who held the back of the head with both hands. After gradual strong pulling the patient felt, and afterwards the assistant also, a crack or snap, and after the extension had been continued the head and neck were restored to their proper position, and could be moved in every direction, although with pain on the left side of the neck. * In

a few days after the patient was quite well. (p. 547-49.) It is of course impossible to say that in this case there was no fracture of any part of the transverse or articular processes of the vertebra, as sometimes happens.

These are all the simple dislocations I know of, and I fully agree with the reason assigned by LAWRENCE for their occurrence specially in the neck. "The greater mobility of the individual bones," says he, "the comparative smallness of their bodies, and the obliquity of their articular processes, point out the cervical vertebræ as most likely to be luxated; at the same time the form of the neck, and its connexion with the head, are favourable to the application of such violence as may induce luxation.” (pp. 389–90.) I have introduced the consideration of dislocated vertebræ here, because it is so commonly accompanied with fracture, and because the effects upon the spinal marrow are so similar in both cases, that the two subjects cannot be conveniently treated of apart. But it would have been much better had CHELIUS placed the whole subject immediately after Injuries of the Head, with which it is closely connected.

The time which persons live after fracture and displacement of the vertebræ varies considerably according to the situation of the injury, but even when nearly the same part is injured, one patient will live much longer than another, doubtless on account of the less or greater injury of the spinal cord. In general the higher be the injury, the more quickly is the patient cut off. ASTLEY COOPER says, that "in fracture with displacement above the fourth cervical vertebra the person generally dies on the instant, because the diaphragm is paralysed." This, however, is not correct, for the spinal cord is not always sufficiently compressed to cut off the nervous influence from that muscle. I have seen several cases live two or three days, or more; and PHILLIPS's case lived above forty-seven weeks. So far as I have had opportunity, I should say, that in fracture of the cervical vertebræ, the patient dies earlier or later within a week; in that of the

(a) Slightly mentioned in the preceding page.

dorsal, from one to three weeks; and in that of the loins, in two, four, or six mouths, or he may live for two or three years, as mentioned by COOPER and BRODIE.

Sometimes if a patient live long after fracture of the spine, a false joint is formed, of which there is a remarkable example in the Museum of the Royal College of Surgeons of England; the arch of the third lumbar vertebra has been broken, and the separated portion having dropped, has formed a false joint with the margin of the arch of the fourth lumbar. Unfortunately there is not any history to the preparation. It not unfrequently happens that if the patient with fractured spine live many months, the injury is partially repaired by ossification, producing a broad band or splint from the edge of one to that of the other vertebra across the front of the intervertebral substance, similar to that not unfrequently observed in old people. An instance of this kind is in St. Thomas's Museum, in which, the patient having lived five months and nine days, ossification had thus taken place between the last dorsal and the first lumbar vertebra, the former of which, with its arch fractured, having been displaced forwards with fracture of the front of the latter. In the Museum of the College of Surgeons there is also a preparation in which the twelfth dorsal had been completely smashed, but the pieces had united and there is a splint in front with great angular curvature forwards. Its history is unknown.

Sometimes without any fracture or displacement, after a severe blow, and without any immediate symptoms of concussion or compression of the cord, to distinguish which from each other, we have no means, except in the quick subsidence of those in the former, and the absence of distortion of the spine, the patient is seized with severe pain in his back, and becomes paralytic. Such a case is described by ASTLEY COOPER (a), and on "opening the spinal sheath milky fluid was found within it just above the cauda equina; and higher than this, for the space of three inches, the spinal marrow was ulcerated to a considerable depth, and was in the softened state which the brain assumes when it is rendered semifluid by putrefaction." (p 561.)

BRODIE doubts (b) that the process of softening and dissolution of the spinal cord after concussion is the result of inflammation, as held by some writers, and observes, that "there is a manifest resemblance between the softening of the spinal cord, which follows mechanical injury, and that softening of the brain and spinal cord which takes place from internal causes, and which was first particularly described by M. ROSTAN under the name of Rammollissement du Cerveau." (p. 126.) The whole of this paper of BRODIE'S is well worth a careful perusal.-J. F. S.]

614. The diagnosis in fracture of the body of a vertebra is always doubtful, because on account of its deep situation, it cannot be thoroughly examined, and because the just mentioned symptoms of palsy and so on may be produced merely by severe violence without fracture.

615. If one or more spinous processes be broken and displaced, they may be replaced by the fingers; a compress is to be applied on each side, which should be fastened with a broad bandage (a).

In fracture of the bodies of the vertebræ, the treatment can only effect the removal of the dangerous symptoms, as every attempt to set the fracture, even in well determined diagnosis, is to be considered most highly dangerous (b). Repeated general and local blood-lettings, proportionate to the age and constitution of the patient, dispersing bathings, and so on, are to be employed to diminish the inflammation. The urine collected in the bladder should be frequently drawn off with the catheter, because it soon decomposes and acts injuriously on the walls of the bladder. Volatile infrictions are to be made on the distended belly as well as on the palsied limbs, to which infrictions of tincture of cantharides may be added. If with the fracture there be injury of the soft parts, as shot wounds and so on, we must endeavour to remove the loose splinters of bone by incision. If the patient improve, he must be supported with strengthening remedies, and with the use of strengthening baths for the improvement of his health. If after previous injury of the spine symptoms of chronic inflammation continue, continued issues in the neighbourhood of the spine are the most proper remedies.

(a) On Dislocations.

(b) Above cited.

[(a) If the unnatural mobility of one or more spinous processes lead to the fair presumption of their fracture from the vertebral arch or arches, but unaccompanied with symptoms of injury to the spinal cord, it is better to leave them alone and merely apply a few leeches. But if symptoms be present, then it may be suspected that there is further mischief, and it will become a question as to the propriety of proceeding to an operation for their relief.

(b) The attempt to set a fracture through the body of a vertebra, accompanied, as it almost invariably is, with displacement, and most commonly with fracture of the ver tebral arch, or articular processes, is, as CHELIUS says, most highly dangerous, and ought never to be attempted. BRODIE, however, thinks differently, and says, “there can be no doubt, that when the injury is in the lower part of the spine, the attempt to effect reduction may not only be made with impunity, but that it may be successful." (p. 159.) And he quotes the case of a man upon whom a mass of chalk fell. "Mr. HARDWICKE, of Epsom, being sent for, found the first lumbar projecting over the last dorsal. With some difficulty he reduced the displaced vertebra to its natural position; the reduction (as I was informed) taking place with a jerk or snap:" he was afterwards admitted into St. George's Hospital, and then had "some power of using his lower limbs whilst in bed, but he could neither walk nor stand, and he was unable to empty his bladder without the aid of a catheter." (p. 157.) In another case where the fracture was between the third and fourth lumbar, BRODIE " endeavoured, by fixing the therar, and cautiously extending the pelvis to restore the vertebra to their proper place. The attempt was, in some degree, successful, and no ill effects, of any kind, resulted from it." (p. 159.)

I must confess that HARDWICK'S case does not appear to me satisfactory, as the patient was in precisely the same circumstances as a person with this accident for whom no thing has been done. He lived two or three years without improvement, which is the ordinary history of these cases; though, after the first few weeks, they, for a time, seem to be recovering sensation and motion, but beyond a certain point they do not mend. I fully agree with CHELIUS, that it is better not to attempt any reduction; the only mode in which it can be possible, as seems to me, is by bending the body forward, so that the displaced arch may be put into the same position as at the time of the accident, and then rise over the arch beneath it; the old method. therefore, of stretching over a barrel, is certainly the most proper mode of attempting the reduction, if it be attempted at all.

The only remedies, practicable, are the palliative treatment here proposed, by which it is hoped to accommodate the spinal cord to its unnatural position and to the pressure to a greater or less extent made, by keeping down the inflammatory disposition, but which does not materially relieve the palsy and restore the functions of the parts below the injury—or by an operation to remove the compressing vertebral arch; a subject which will be presently considered. If the case be a compound fracture, which can scarcely happen in any other way than by a ball or bullet, then the loose pieces should, as CHELIUS recommends, be removed.-J. F. S.]

616. In fracture of the vertebra with inpression, as in similar injuries of the skull-bones, it has been recommended to lay bare the injured part with an incision along the spinous processes, and separating the muscles on their sides, to remove the arch of the injured vertebra with a small trepancrown, or with HEY's saw (HEINE'S osteotome would be best.) This operation has been performed by the younger CLINE (1), WICKHAM, ATTENBURROW, TYRRELL (a), HOLSCHER, SMITH, and ROGERS; but the result in every case was unfortunate. Experience has not, therefore, yet contradicted the opinion given by CHARLES BELL (b), which is directly opposed to ASTLEY COOPER'S (c), in reference to trepanning the spine; and it is only to be considered as a means of alleviating the patient's condition. JÆGER, however, thinks that, as after this operation, there is not any aggra vation, but rather in most cases immediately improvement, with restoration of motion, although in no case has there been an entire cure, the case calls for the performance of the operation in decided inpression and palsy,

(a) TYRRELL's second and also fatal case in the Lancet, vol. xi. p. 685. 18.7.

(b) Above cited, p. 23.

(c) COOPER, A., On Dislocations, p. 559.-Ler tures, p. 11.