With regard to the resources of spinal surgery it is essential that it should be understood that there is no process of regenera- tion in the spinal cord; any destructive damage is permanent and incapable of remedy, so that if for example a part or the whole thickness of the cord is cut across conduction is finally in- terrupted at the divided place, and no suturing or grafting opera- tion can restore it. Wherein, then, it may be asked, is the field of usefulness of the surgeon ? The answer lies in the fact that con- duction is frequently interrupted by pressure on the spinal cord without destruction of its substance, and in so far as an inter- ruption is due to pressure only and. has not been in existence long enough to produce secondary destructive effects it can usually be relieved and unction restored by operation.
Spinal Injuries. When an injury is severe enough to break the wall of the spinal canal (falls, severe blows on the back, bullet or shell wounds), the total body of spinal cord symptoms is made up of three factors. First, shock to the cord which may abolish its functions, though there may be no corresponding gross and visible injury; this shock effect tends to pass off within a period extending to three or four weeks. Secondly, destructive injury of the cord by crushing or laceration, which in so far as it is destructive is per- manent. Thirdly, interference with the cord by 'compression ; the ebrd may thus be pressed on by a foreign body (bullet or shell frag- ment), by displaced bone of the spine, by swelling of the soft tissues (including the cord itself), from bruising, and at a later period by the results of scar formation in the injured tissues.
The surgeon has to take these three factors into account before undertaking an operation for spinal injury, and he must always remember that it is the third alone that he has any power favourably to influence. He will, therefore, necessarily wait until the shock element has passed off, and will determine this by the reappear- ance of reflex activity in the cord. He will then have to decide whether the probabilities are in favour of any considerable propor- tion of the symptoms being due to compression rather than to destruction of the cord. The difficulty is that there is nothing in the actual symptoms themselves to decide this, but experience shows that when very gross interruption of conductivity remains complete after the shock effect has passed off the proportion of Symptoms due to the factor of compression is likely to be very small. The most hopeful field in the surgery of spinal injuries lies therefore where interruption of conductivity is manifestly incomplete.
Spinal Tumours and Inflammatory Swellings. These conditions interrupt conduction in the spinal cord by slowly developing com- pression, so that there is nothing in the actual state of the cord inconsistent with recovery provided the compression has not lasted too long. Complete recovery may follow the removal of a com- pression that has caused total interruption of conduction for several months. When the compression has lasted very long incomplete recovery is the rule. The actual lesions that may occur are as fol- lows: (l) Malignant tumours of the bones of the spine, primary or secondary, and much the more commonly the latter. Radical removal of the tumour is impossible, and operation for the relief of the pressure it is exercising on the cord is justifiable only in very exceptional cases. (2) Benign tumours of the spinal bones (ostcoma, chondroma), of the spinal membranes (endothelioma, ammoma, fibroma), of the spinal vessels (angeioma), of the nerves (neuro- fibroma), and of the substance of the cord itself. Radical removal of the tumour can be carried out in most cases of this class. In early cases when the operation is successful complete recovery is the rule, and the results are brilliantly satisfactory. Spinal angeioma and tumours of the cord substance are not usually removable. (3) In- flammatory swellings. Chronic localized meningitis (meningitis circumscripta serosa) produces a loculated collection of fluid in the arachnoid membrane and causes pressure on the cord in much the same manner as a benign tumour. The results of operative treatment are usually satisfactory. Tuberculosis of the spine by extension of the granuloma or of an abscess into the spinal canal frequently causes compression of the cord. If the condition persists in spite of adequate treatment of the primary disease operation may be necessary to relieve- the pressure on the cord.
The application of surgery to the relief of compression of the spinal cord by disease is on the whole, then, very satisfactory. When secondary malignant disease of the spine has been shown not to be present, the surgeon is able to enter upon an operation for compression paraplegia with the practical certainty of being able to give relief and the fair probability of attaining a cure.
Surgery of the Peripheral Nerves. This department of surgery is almost wholly concerned with the repair of nerves which have been injured, and the relief of certain diseased conditions of which the principal symptom is pain. Outside of these two fields of activity the occasions on which surgery has to deal with the peripheral nerves are not many. There is only one common tu- mour of nerves and that is the neuro-fibroma. When this occurs on the auditory nerve within the skull or on a spinal nerve within
the spinal canal its situation gives it an importance it does not in itself possess, which has already been referred to. Occurring elsewhere it is important only if it causes pain or tenderness, when it should be removed by operation.
Treatment of Nerve Injuries. It is only in the peripheral nerves that the nervous system possesses the power of regenerating after destructive injuries. The common form of such injury is the division ol a nerve by an accidental wound or a wound of war. After such a division the essential part of the nerve beyond the seat of the injury disappears, leaving only the framework of protective and supporting tissue by which it had been surrounded. After such a divided nerve has been stitched together a new growth of nerve fibres pushes out from the original cut surface downwards into the surviving old framework, and ultimately reestablishes the functions that have been lost. This process of regeneration is by no means always fully accomplished even in favourable circumstances, and is very easily interfered with if the conditions are at all unfavourable. Favourable circumstances are that the divided ends should be sutured together early and with the proper operative technique, that the wound remain free from infection, and that the affected limb be kept in a state favourable for the resumption of its temporarily lost func- tions. Any deviation from these conditions greatly increases the normal uncertainties of the regenerative process. No limit, however, can be set to the time within which suture must be carried out in order to give some hope of effective regeneration. When so much of the length of a nerve has been destroyed that the ends cannot be brought together by any device short of a grafting operation, the chances of a satisfactory return of function are much reduced. In certain cases when recovery after nerve suture has failed to occur, or is extremely improbable, a limb satisfactorily useful from the motor point of view can be obtained by redistributing such motor power as remains by an operation of tendon transplantation. The maintenance of a healthy condition in the affected limb during the abeyance of function is an essential part of the treatment. The neglect of this aspect of the case may deprive a technically satis- factory operation of nerve suture of ultimate success.
The Treatment of Neuralgia. The term neuralgia is used here to indicate the rather indefinite group of conditions in which pain is the sole or the wholly predominant symptom. To bring a given case within this group it must be shown that the cause of the pain does not lie outside the affected nerve. Only when this requirement has been satisfied can the appropriate surgical measures directed to the nerve be justifiably undertaken. This precision of diagnosis is indispensable, because the treatment to be used consists in the destruction by one means or another of the affected nerve, and it is plain that such a procedure would leave unaffected any condi- tion of disease outside the nerve.
Injuries of nerves are a fruitful source of persistent pain of the neuralgic type under consideration. Any injury of a nerve is a potential starting point for neuralgia, but the division of nerves in an amputation is perhaps the commonest, especially in cases where the wound has become infected. Of neuralgias not associated with injury the dreaded trigeminal or trifacial neuralgia (tic douloureux) is the most frequent and most formidable. In both conditions three types of surgical procedure are in use the removal of the terminal and affected part of the nerve, the injection of alcohol into the nerve above the affected part, or the division of the nerve close to its origin from the spinal cord or brain. The last-mentioned type of operation is not usually effective in the treatment of pain due to nerve injury, but it is curative in trigeminal neuralgia, and in spite of its gravity has in suitable circumstances to be undertaken.
(W. T.)
NETHERLANDS INDIA (see 17.466; 15.284; 26.70; 4.256; 5.596). Netherlands India is divided into territories under direct (Dutch) rule and under native self-government subject to Dutch regulation. As regards the self-governed territories, the elaborate individual agreements originally made between the Dutch and native princes have in recent years been replaced in large measure by a form of political contract known as the "short declaration," which has helped to simplify relations between the parties. In the Outer Possessions or Outposts (i.e. the islands other than Java and Madura) there were in igipabout 280 territories self-governed under the short declaration and only 19 under more detailed contracts; in Java (Surakarta and Jokyakarta) four native principalities remain, with little power. To the Dutch colonial system of government there has been recently added a people's council (Volksraad) of at least 39 members, including a chairman appointed by the Crown, five native and 14 European and foreign oriental members appointed by the governor-general, and 10 native and five other members elected by local councils. This body opened its first session on May 18 1918. The governor must consult it on the budget and certain other financial questions, on any question of general military serv-
