the fact that the vertebræ are fractured, as that the cord may be injured. When the vertebræ are not displaced, the cord may at times altogether escape. More commonly, however, it is compressed, or, perhaps, completely divided, or again so bruised that it rapidly undergoes inflammatory softening. When the injury is situated below the second lumbar vertebræ, the cord necessarily escapes as it terminates at that spot, but the nerves of the cauda equina may be injured.

Signs and Symptoms.-The local signs are often but little marked. There may be pain at the seat of injury, or some inequality in the spinous processes; but as often as not these may be absent. The general signs depend upon the condition of the cord, and none will be present when it has escaped injury. But when it is compressed or crushed there will be paralysis of the parts below, more or less complete according to the extent of the lesion. Taking as an example a case of fracture in the lower cervical or upper dorsal region-the most common situationwith severe compression or crushing of the cord, there will be paralysis of both motion and sensation of the whole of the parts below the seat of injury (paraplegia), and perhaps a zone of hyperæsthesia immediately above the injured part. The intercostal muscles being paralyzed, respiration can only be carried on by the diaphragm, this muscle receiving its nerve supply through the phrenics which are given off above the seat of injury. Hence, while the chest is motionless, the abdomen rises and falls during respiration. The bladder and rectum and their respective sphincters share in the paralysis, so that there is at first retention of urine and fæces, followed by passive overflow of urine as the bladder becomes distended and will hold no more, and by involuntary passage of fæces. Priapism, or the involuntary erection of the penis, is frequently present, or is induced by the use of the catheter. The temperature varies; sometimes it may be lower than normal, but often it is considerably raised, even reaching as high as 107° shortly before death. Consciousness, unless any head injury has been received at the same time, is not affected. The reflexes are usually at first in abeyance, but return in the lower limbs if the patient does not succumb to the shock of the injury. Death occurs, as a rule, from twentyfour hours to a few days from bronchial trouble; but the patient, if the fracture is in the upper dorsal region, may linger on from two to three weeks. The secondary troubles which are then generally met with are bed-sores and chronic cystitis. 1. The bed-sores occur in situations subjected to pressure, and depend in great part on the congestion and lowered vitality of the tissues induced by the impairment of the nerve influence; but they are

also to some extent due to the soddening of the part with the urine and fæces from which it is very difficult to keep the patient free. 2. The chronic cystitis is probably also due in part to impaired nerve influence, and in part to slight injury in the passage of a catheter; or to the introduction by the catheter of a microscopic organism-the micrococcus ureæ. The urine, which is at first acid, becomes ammoniacal from the conversion of the urea into carbonate of ammonia, and thick from the deposit of phosphates and the presence of ropy mucus. The inflammation may then extend up the ureter to the kidney, where suppuration of the pelvis and substance of the kidney (pyelonephritis) may be set up.

Such may be taken as a typical example of fracture of the spine commonly met with in surgical practice. But the nature and gravity of the symptoms will depend upon the situation of the fracture, and the amount of injury to the cord. Thus, in some cases of fracture there may be no paralysis: in others the paralysis may be incomplete, i. e., confined to loss of motion only, or to paralysis of one limb or one group of muscles, or to impairment of sensation over some limited area. Such cases, however, are much less common than that above described.

Causes of Death.-1. When the fracture is above the fourth cervical vertebra, death is instantaneous in consequence of the severance of the phrenic nerves from the respiratory centre in the medulla. 2. In the lower cervical or upper dorsal region, death is due either to (a) hemorrhage in the cord gradually extending to the origin of the phrenic nerves, or (b), a low form of bronchitis induced partly by hypostatic congestion, partly by defective nerve influence, and partly by the inability. to clear the lungs effectually by coughing. 3. Later, death is commonly due to exhaustion produced by (a) the sloughing of bed-sores, or (b) the pyelo-nephritis, induced in part by the extension of cystitis up the ureters to the kidney, and in part by the defective nerve influence on the kidney structure.

The prognosis will depend in great part on the situation of the fracture. Thus, when it is in the cervical region, if death is not instantaneous, the patient may survive from twelve hours to two or three days; usually, however, death occurs in about twenty-four hours. In the upper dorsal region the patient may linger for two or three weeks. In the lower dorsal region, if he survive the period at which inflammation commonly occurs, he may recover, remaining, however, paraplegic. In the lumbar region he may recover, with perhaps only partial paralysis of one or other of the lower limbs or of a certain group of muscles, or even without any paralysis whatever. But even where the in

jury to the cord has been so high as to cause paralysis of the whole body below the neck, patients have been known in rare instances to live for several months or even years.

Treatment.--1. In cases where there is no paralysis, thus showing that the cord is not affected, the indication is to keep the fractured spine at perfect rest, for the purpose not only of obtaining union of the fracture, but also of preventing by any movement displacement of the fragments and injury of the cord. 2. In the more common cases, where there is paralysis, showing that the cord is injured, the indications are to remove any fragments that may be compressing the cord, and subsequently to keep the parts at rest till union has occurred. 3. Where, however, as is too frequently the case, the removal of the fragments is not practicable, or the cord itself has been crushed, all that can be done is to endeavor to guard against the formation of bedsores, and the occurrence of chronic cystitis and its attendant evils. Thus the patient should be placed upon a water bed, and his posture gently changed from time to time so that pressure may not be continuously made on one part, while he must be kept scrupulously clean and dry, and free from urine and fæces. The bowels should be cleared, if necessary, by enemata, or excessive diarrhoea controlled by morphia suppositories or starch and opium injections. Should bed-sores threaten, the skin should be hardened by sponging with rectified spirit, and dusted with oxide of zinc and starch powder. If formed, they should be dressed with mild antiseptics, iodoform, balsam of Peru, etc., and all pressure removed from the surrounding skin by the use of water cushions. To prevent cystitis from occurring a soft rubber catheter, thoroughly cleansed in carbolic acid and dipped in carbolic oil, should be passed twice daily. Should the urine become alkaline the bladder must be washed out by some antiseptic solution. 4. In cases where, from the marked inequality of the spinous processes, there is a probability of fragments pressing upon the cord, a cautious attempt to extend the spine and reduce the displaced vertebræ may be made, and a plaster-of-Paris case applied during the extension. In rare instances it may be justifiable to trephine the spine for the purpose of removing a fragment or extravasated blood; but space will not permit of the discussion of this interesting question.

CONCUSSION OF THE SPINAL CORD.-This term has been applied to various injuries of the cord received in railway and other accidents. It ought, however, to be restricted to those cases in which the cord is merely concussed or shaken; and the other injuries, such as hemorrhage into its substance or into the arachnoid, contusions, and lacerations, which have been included

under the term concussion, described as spinal hemorrhage, laceration of the spinal cord, etc. Concussion in this sense is one of the rarest of injuries, and need not detain us in a work of this character. For an account of the other lesions, and the very various, apparently anomalous, and, as yet, far from understood symptoms, which may attend them, and which are generally classed together under the term of the "railway spine," a larger work must be consulted.

INJURIES OF THE CHEST.

Injuries of the Chest Walls.

CONTUSIONS may be produced by any sort of violence applied to the chest, and may be attended by laceration or rupture of the muscles, or by extravasation of blood into the tissues, which, again, may be followed by suppuration and abscess. They owe their chief importance, however, to the fact that they may be complicated by serious injury to the contained viscera, such as contusion or laceration of the pleura, lung, heart, or pericardium, or rupture of a large vessel in the mediastinum.

FRACTURE OF THE RIBS is a very common accident. Cause. -External violence or muscular action. A. External violence may be-1. Direct, such as a kick of a horse, a fall upon the edge of a table, etc. The fracture then occurs at the seat of injury, the fragments being driven inward, often injuring the thoracic or abdominal viscera; or 2. Indirect, as a severe compression of the chest in a crowd. The fracture then generally occurs about the angle of the ribs, their weakest part, and several bones are usually broken. B. Muscular Action.—The ribs are sometimes broken in this way during violent coughing, or from straining during parturition.

Complication.-Fractures of the ribs may be complicated by an external wound; a wound of the pleura and lung, or pericardium and heart; laceration of a blood-vessel, as an intercostal artery; penetration of the diaphragm ; and more rarely by perforation of the peritoneum, and wound of the liver or spleen. Hence they may be followed by emphysema, pneumothorax, hæmothorax, hæmoptysis, hæmopericardium, and later by pleurisy, pneumonia, pericarditis, or peritonitis.

State of the Parts.-Fracture of the ribs is more common in the old than in the young, on account of the loss of elasticity as age advances. Like fractures of other bones, they may be simple, compound, or comminuted. The middle ribs are those usually affected; the first and second rib being protected by the clavicle, and the eleventh and twelfth being movable, are not often broken. Fracture of the upper ribs is more serious

than fracture of the lower, as the lung is more liable to be wounded.

Signs. Severe stabbing pain is felt over the seat of fracture, and is increased on taking a deep breath, or on coughing. On drawing the finger along the rib, some irregularity may be detected. Crepitus is usually felt on placing the hand flat over the fracture while the patient breathes deeply, or it may be heard on listening with the stethoscope. Emphysema, i. e., a crackling sensation, something like rubbing the hair between the fingers, may at times be felt on touching the part. It is nearly always due to a wound of the lung, the air being drawn into the pleura through the visceral layer during inspiration, and forced through the wound in the parietal layer into the subcutaneous tissue during expiration.

lief.

Treatment. In an ordinary case the injured side should be strapped with adhesive plaster, so as to control the respiration on that side, and thus place the fractured rib as much as possible at rest. A broad bandage applied round the chest often gives reUnion occurs by ensheathing callus in three or four weeks. FRACTURE OF THE STERNUM is rare. It may be accompanied by fracture of the ribs or costal cartilages, separation of the ribs from their cartilages, and sometimes by fracture of the spine. Causes. Direct violence; indirect violence in consequence of a forcible bend of the body, either backward or forward; very rarely, muscular action, as during parturition.

State of the Parts.-The line of fracture generally runs through the gladiolus, and may be transverse, oblique, or longitudinal, the lower fragment usually projecting in front of the upper; but at times the gladiolus is separated from the manubrium, a condition sometimes spoken of as dislocation of the sternum. The chief signs are pain, increased on deep inspiration and coughing, irregularity and crepitus at the seat of fracture, and emphysema if the lung is wounded. The fracture may be complicated with injury of any of the thoracic viscera, or hemorrhage, or suppuration in the anterior mediastinum. Treatment.-Rest on the back, and the application of a bandage, if it can be borne, around the chest.

WOUNDS OF THE CHEST WALLS may be divided into the penetrating and non-penetrating. The non-penetrating are of no serious consequence, and may be treated like wounds in other situations. The penetrating are those that pass through the parietes into the pleura, pericardium, or mediastinum, and may be complicated by a wound of the lung, heart, a large bloodvessel, an intercostal artery, or the internal mammary artery. When the wound is small, and there are no signs of injury to the