the prevention of bedsores after injuries of the spinal cord in the war

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depending, it is thought, on the particular partof the alimentary canal that has been attacked.Researches conducted by Dr. Bahr on the com-

position of the stools pointed either to a completeabsence or to an inadequacy of the digestiveferments ; while examination of the blood and urinesuggested the view that certain of the more im-portant features of the disease are dependent uponan alimentary toxsemia. The pathological findings,too, appear to favour such a conclusion, and theyseem also to point to an infection with the thrushfungus (Monilia albicans) as the cause of the malady.Although the final results of this careful and com-prehensive inquiry by Dr. Bahr cannot be regardedas quite conclusive, nevertheless he has throwna considerable amount of light upon the subject,and his work will without doubt prove of value toother investigators, serving as a basis for futureresearches in localities where sprue is known to beindigenous.

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THE PREVENTION OF BEDSORES AFTER INJURIESOF THE SPINAL CORD IN THE WAR.

AT a meeting of the Académie de Medecine deParis on May 18th M. Pierre Marie and M. GustaveRoussy presented an important paper on the

prevention of bedsores after wounds of the spinalcord in the war. The conditions of trench warfarehave rendered wounds of the spine frequent amongthe French soldiers, for during their assaults theGermans naturally try to attack in the flank,while shells often burst behind the lines. As thecervical and upper dorsal regions are protected bythe knapsack, wounds are less frequent there thanin the dorso-lumbar and sacral regions. M. Marieand M. Roussy have found that the prognosis of theparaplegia produced, though grave, is much betterthan the prognosis of paraplegia observed in civillife. The military surgeon should therefore notadopt the pessimistic view that if the cordis injured the patient is lost. On the contrary,remarkable improvement is possible if means aretaken to avoid the serious complications-bedsoresand sphincter troubles. It is generally believedthat bedsores are trophic lesions, the direct resultof the spinal lesion, and therefore unavoidable. Thiswas taught by the old masters, Charcot, Vulpian,and Brown-Sequard, who knew nothing of antisepsis.M. Marie and M Roussy traverse it in their paper.They did not deny the trophic influence of the nervecentres, but they insisted that the failure of thisis not sufficient to produce bedsores. One of two factors is necessary and often both combined.These are prolonged compression and infection. Ina case of traumatic transverse lesion of the spinalcord with complete motor and sensory paraplegiathe patient cannot change his position, and theweight of half of the trunk and of the lower limbsrests on the sacrum and heels. The prolonged com-pression and impaired circulation produce slough-ing in parts, the nutrition of which is lowered bythe spinal lesion. Added to this is the lossof sensibility, which in normal persons causes achange of posture when the least sensible discom-fort from pressure is produced. The points of

pressure first become red, then an ecchymotic parch-ment-like patch appears and soon takes the appear-ance of several flattened bullse containing bloodyfluid. The dry eschar thus produced is relativelybenign, but is almost fatal if another factor-moisture-intervenes. This may be furnished bymoist dressings or by prolonged contact with urineor faeces. Decomposing urine becomes the vehicle

of innumerable microbes, aerobic and anaerobic,which penetrate into the tissues when the epi-dermis has been lost, and cause extensive slough-ing. This view of the pathogenesis of bedsores isproved by the fact that they have no relation tothe position of the spinal lesion. Whether this isupper dorsal, lower dorsal, or lumbo-sacral theyalways begin on the sacrum and then on theheels or other parts of the lower limbs. More-

over, they have no relation to the extent ofthe spinal lesion. Bedsores appear with the

sphincter troubles and if these cease they dis-appear. A man with a wound of the spinal cordwho has no incontinence ought not to have a bedsore. One who has incontinence of urine will havethis complication if the most rigorous measures arenot adopted. In case of retention of urine M. Marieand M. Roussy recommended, to secure that the

patient need not receive special attention during thehours or days of transport to the base, that a cathetershould be fixed with an obturator in the bladder.The bladder can thus be emptied from time to timeby an Mt/M’tey or by the patient himself. Thesame method can be used in the rarer cases of

primary incontinence. Rectal troubles are moredifficult to deal with. If there are soft liquid stoolsopium should be given at the moment of evacua-tion to induce constipation. In all cases the skinshould be protected with talc or coated with grease orvaseline. The patient should be placed on an aircushion or a leather cushion with a central hollowwhich will prevent contact of the skin with thedejecta during transport. After arrival at the basehospital the majority of the patients have bedsores.Their position should be changed at least hourlyduring the day and every two hours during thenight. In this way, said the authors, even if deepsores have formed during transport they will yieldto this attention with antiseptics and dry dressings.

LATENT FRACTURE AND FRACTURE-DISLOCATIONOF CERVICAL VERTEBRÆ.

IN the Medical Journal of Australia Mr. AlanNewton has published a valuable paper on a subjectwhich has not received much attention-latentfracture and fracture-dislocation of cervicalvertebrae. Before the introduction of the X raysthe term " latent " was applied to cervical fracturesunaccompanied by injury of the cord. From timeto time cases were reported of death from displace-ment of the fragments of an unsuspected fracture.Such injuries are probably not uncommon, and arenot recognised because in the majority of cases

they do not give rise to subsequent inconvenience.In 1855 Mr. Simons reported the case of a girl,aged 18 years, who fell down an embankment12 feet high. She remained quite well until 15days later, when she was admitted into St. Thomas’sHospital, where she died three days later. At thenecropsy horizontal fracture of the body of theseventh cervical vertebra and a large abscessbetween the dura and the vertebrae were found.Sir Astley Cooper mentions the case of a girlwho, after a severe blow on the neck, was compelledwhen she wished to look upwards or downwards tosupport her head with her hands and carefully toelevate or depress it. She died of an intercurrentdisease 12 months later, and a fracture of the atlaswas found. Fracture of the atlas without injuryof the cord is comparatively uncommon. On theother hand, dislocation is not infrequent and maybe complicated by fracture of the axis. Mr. FredBird has reported the case of a man who fell from