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In these notes brief reference will be made to cervical traumatisms only of the spinal cord and column. This list embraces no experimental cases, and little is at- tempted in lasix mg this synopsis except to very briefly give a few of the more dominant clinical and pathological features of those injuries in which the momentum of force is borne by lasix with potassium the neck chiefly, with resultant intrinsic or ex- trinsic lesions of the spine, as elsewhere '" the subject has been set forth more fully and systematically. Case I. Fracture of Posterior CeiTical iv lasix Arch of lasix buy Fourth Ceri'ical Vertehra. — Fig. i is a photograph of the posterior aspect of the apophyseal arch of the fourth cervical vertebra. The arch was fractured through the spinous lasix purchase process and through the transverse process on each side. Patient was a sailor, who fell from a mast, about twenty feet, striking on the back of his neck. Immediate paralysis. Laminectomy on the day after admission, when fragments were removed ; great hemor- ^ Abstract of an essay read at Omaha City, Xeb. , May 29, 1893. with new cases added since, all cervical. '^ Transactions of National Association of Railway Surgeons, 1893. Railway .-Xge Publishing Co., Chicago, 111. rhage during operation. No mitigation of paralysis fol- lowed, but pain became intensified. Excessive second- ary hemorrhage on third day, which was controlled with buy lasix online difficulty. Death on the fifth day, from exhaustion and consecutive meningitis. This case was one of unusual interest, lasix to buy inasmuch as it demonstrated that there may be immediate and extensive destruction of the cord without displacement of the frag- ments being discovered on operation, as there was none here ; and besides it was an instance which proved the 4 I ! utter futility of section, even when symptoms of medul- lary compression are unequivocal. The explanation of this lies in the modus operandi of injury. The cord is evidently crushed through by the dissundered fragments, which are driven in on the verte- bral bodies ; but, by their own resiliency and their ligamentous attachments they are immediately retracted and spring into place. Fig. 2 exhibits the interior as- pect of this broad fractured bone plaque. After the re- moval of this bone there was left a large, open hiatus, at the bottom of which the nude dura mater appeared, without any appearance of laceration. Now, in order to provide for the support supplied by this large loss of bone, the head was placed in a cuirass of gypsum. Herein lies one of the great difficulties in laminecto- mies in this situation after the bone is removed ; as it is ' never reproduced in the osseous chain, the power to support and balance the head is lost, and henceforth some sort of an apparatus must be always worn. Case II. Fracture through the Left Lamina of the Fifth Cervical (^Diagrammatic') (Fig. 3). — Patient, a man aged forty, while intoxicated fell into a bulkhead. Para- plegic on admission into Harlem Hospital ; movable spinous process of the fifth cervical. Had great lasix 40mg pain in the neck, which was rigidly locked by muscular ij spasm. Refused operative measures. Sudden rise of ^ I October 28, 1893] MEDICAL RECORD. 555 temperature on sixth day, with muscular twitching in the muscles of the face. Died lasik lasix of cerebro-spinal meningitis on the seventh day, being highly delirious before the end camf*. At autopsy, which was hurriedly made, it was dis- covered that there was fracture through the left lam- ina, with displacement to, the right, and free hemorrhage into the spinal canal, with a large extravasate into the ad- jacent muscular tissues pf the neck. As an autopsy was only permitted under protest, we did not venture to re- move, for inspection and lasix cheap the camera, the entire cervical lasix and potassium segment. Cavities not opened. Case III. Multiple Fracture of the lasix 40 mg Fourth ana Fifth Cervical Vertebrw. — Fig. 4 is an illustration of a speci- men which was removed by me with considerable diffi- culty on autopsy. The patient from whom it was taken was mortally injured by a fall from the Elevated Railroad structure, in this city, on June 14, 1S93. He fell about twenty-five feet headlong, striking on the back of his neck and shoulders. He was immediately paralyzed in parts innervated by the spinal nerves below the cervical plexus. Dr. Matthew D. Field, the chief surgeon for the Man- hattan Elevated Railway Company, saw the case once with me in my service. The question of operation, a lamin- ectomy, had been raised. He survived two days in a painless lasix order state, and died of a progressive asphyxia, the tem- perature mounting to 105° F. online lasix just before death. At post-mortem examination, on section through the pos- terior arches, no fracture could be found ; but there was an enormous hemorrhage into the spinal canal and all the overlying soft parts. It was only when the ver- tebral segment was detached at the occiput, lifted out and completely stripped of all its muscular and ligament- ous attachments anteriorly, that the extensive fracture had been discovered. The left vertebral artery was found torn in two at the junction of the fifth and sixth vertebree. This case also demonstrates the futility of operations in many of these cervical traumatisms ; besides, it impresses the importance of always resecting completely the dam- aged segment of the spine entire, in all fatal spinal lasix renal in- juries in which an autopsy is permitted. Case IV. Fracture through Posterior Arch (the Left Lamina') of the Fourth Ce)~vical Vertebra, with Rotation of Fragment Outward — Recovery, with Marked Deform- ity — No Paralysis. — Fig. 5 is from a patient, twenty-six years of age, who sustained a fracture through the lasix for pos- terior arch of the fourth cervical. This photograph was taken in the latter part of July, 1893, four weeks after injury, when the head and neck were in cuirass adjust- ment of gypsum. On June 26th he was injured by the rebound of a " sweep " on the windlass of a derrick. He was struck with such force on the back of the neck that he was knocked down on his face, and lay for some minutes in 556 MEDICAL RECORD. [October 28, i! an unconscious state. Was treated by rest in bed with the head well braced. A distinct fracture of the poste- rior arch, with marked mobility tablet lasix and lateral displacement, was detected on admission. There was no paralysis at any time, but for a while he quite lost control over the head, which could be moved only when lifted. After six weeks spontaneous readjustment with osseous reposition had so far advanced as to permit the removal of the plaster cast, which had been applied ten days after in- jury Now (September i, 1893), as is seen in Fig. 6, from a posterior view, the head inclines strongly to the right, and the cervical arching to the right side is unmistakable. It is quite impossible for him to raise the head without dra-\nng the entire thorax backward. The above cut (Fig. 7) indicates the present displaced position of the twisted posterior arcl). As there is now a distinct hollow felt under the finger potassium lasix in the median line, posteriorly, it is clear that the spinous process isldis- placed outward, and in further proof of this the spinous tubercle can be felt quite distinct in its new situation. This case is a typical one of fracture through the pos- terior plane of the spinal column, with distinct and per- manent deformity, yet not a trace of paralysis. It is es- sentially a " broken neck," and it tends to support a conviction which I have long held, viz., that a fracture of the spine is not by any means incompatible with the full functional integrity of the medulla spinalis. This, like nearly all apophyseal fractures, resulted from direct violence. The large mass of callus thrown out plainly indicates the active osteogenetic properties resident lasix furosemide in the osseous roots of the vertebral bodies, and that union here is as prompt and effective as in any other bone in the body. At the present time he suffers from torti- collis, dependent on the displaced bone. This condition must remain. It is hard to conceive here what good could have re- sulted from an operation. Nay, on the contrary, much harm would have fol- lowed through mutila tion of the parts, sacri- fice of bone, and expo- sure of the cord. Fig. 8 is a schematic ^ view of the nude bone indicating the seat and extent of fracture. It is seen that there is a frac- ture with complete de- tachment of the poste rior left lamina ; that the canal is exposed and the fragment is drawn far over to the right side m

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