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bladder and bowels resumed their normal functions between two and three weeks after the operation, and he is at this date able to move about without crutches and perform light manual labor. It must not be inferred that complete recovery cannot take place after extensive injuries of the cord and column. They should receive the same careful surgical care that we give to all regional surgery. The source of irritation should always be sought for by removal of the vertebral arches if we are unable to do it otherwise. When the arches have been comminuted and no compression exists at the time, they should be removed, as this procedure protects the cord from subsequent inflammatory compression. All compression of the cord from deformities should be corrected by removal of the arches. When paralysis immediately follows injury we should remove the arches over the seat of the injury. To recapitulate: All traumatic injuries of the spinal cord or column should be subjected to immediate surgical research and repair; the cord should always be given a free canal and free drainage.
In all cases of the removal of the arches or fragments of the bodies of the vertebra, compression may take place by doubling of the cord unless extension be maintained by a proper brace until the bony structures are able to support themselves. This one that I exhibit is well adapted for the purpose. Deformities can be relieved by the surgeon and position maintained by a proper brace adjustment. There should be that exact nicety of the adjustment of the brace that the patient can be moved in various normal positions of the body without pain or displacement. I believe the surgery of the spinal cord and column has been too conservative, but in the near future it will receive the consideration and investigation at the hands of our surgeons that its importance demands. A brace to support the column in a natural position should be perfectly adjustable, as no two columns are balanced in the same exact lines. No operation for removal of the spinal arches or portions of the bodies of vertebra should be considered complete until the careful adjustment has been made of the spinal support. However desperate one may presume to consider an injury, the patient is entitled to an exhaustive examination and research at our hands that we may have a full
understanding of the case, removing the arches of the column if necessary to gain such information that we may give him the benefit of the advanced surgical treatment and care in such injuries.
All fixation of the spinal column should be posteriorily, excepting at the points of the shoulders, anteriorly, with no cast or bandage passing around the body. The spinal canal can and must be drained after operations in which it is opened.
DISCUSSION OF DR. BRIGGS' PAPER.
Dr. A. I. Bouffleur, Chicago: There are one or two points I would like to call attention to in regard to this paper, and upon which I must differ with Dr. Briggs. The first is in regard to drainage.. I think that free drainage of the spinal canal is entirely too dangerous unless there is some special indication for it, such as suppurative condition. The great danger attending these special operations is that of infection, which kills virtually ninetenths of our patients. A patient therefore, who is subjected to free drainage of the spinal canal, is in imminent danger. It is true, there are cases in which free drainage is resorted to, and yet there may be no infection, but it is the exception. The rule should be to drain the spinal canal only when there is suppuration.
With reference to postponing operation until the surgeon is able to fit an apparatus to the back; I should take strong exception to that, because I look upon it as being entirely immaterial under these conditions. If you are going to operate, do so, and the sooner it is done, the better. It seems to me also that these apparatuses are entirely unnecessary. A plain plaster of paris cast will accomplish more than any flexible apparatus. On the other hand, if operation is to be deferred two or three weeks, and we do a secondary operation, then we can take time in operating to properly adjust the apparatus. The application of a flexible dressing to the spinal column would not meet with my approval. I base this statement upon my own experience, which is not quite as extensive as that of some of the other gentlemen present, but I have had six or seven cases in which I have found no difficulty whatever in applying a plaster of paris cast, and I should not feel safe if I should apply
a flexible apparatus after having removed some arches of the vertebræ. The parts should be fixed and held in proper position, and to do that nothing is too strong or too stationary. Therefore, I should not care to use a splint.
Dr. W. S. Hoy, Wellston, O.: I am certainly greatly delighted to have heard the most excellent paper of Dr. Briggs, upon "Surgical Treatment of Injuries of the Spinal Cord and Column." I am confident the discussion will be replete with scientific knowledge and profit. We have already heard a diversity of opinions regarding this class of injuries and their treatment. I hope the gentlemen who have preceded me, and those who will follow in this important discussion, speak from actual observation, and not from some theoretical, pet idea. I know of no subject so broad in extent, so unlimited in the considerations which it embraces, and so important to the interests of humanity, as the surgical treatment of injuries of the spine and spinal cord. We must of necessity, gentlemen, give these injuries a distinct classification, and I see no means of lessening the number of distinct classes below eight.
We recognize from such authority as Thorburn, unilateral dislocation, bilateral dislocation without recoil of the displaced bone, bilateral dislocation with recoil of the displaced bone, fracture without recoil, fracture with recoil, injury of lamina or processes and compound fractures. Secondary lesions, hemorrhage and meningitis. We readily recognize
that fracture-dislocation and dislocation, are not always difficult of reduction, but do we have the chances of the cord's recovery greatly augmented thereby? I say without the least hesitancy, that my clinical experience in a number of these cases has led me to the conclusion that, a cord once crushed never makes a satisfactory recovery. Therefore, we are at once confronted with the question of laminectomy. When should we perform the operation, and what results of a beneficial character should we anticipate?
I wish to lay down this one rule: The sooner surgeons learn that a laminectomy, to be successful should always be performed immediately after a spinal injury in cases with positive evidences of pressure, the better for our patients and the more honorable for our
profession. I am thoroughly convinced, however, that in the vast majority of these spinal injuries, the operative interference will be of a useless nature, simply from the fact that when an injury is of sufficient force to fracture the spine, the cord is so disorganized in a short time, that restoration does not and cannot take place. We are therefore confronted with the fact that when the continuity of tissue in the cord is once interrupted, we need hope for no restoration to supervene.
I have no doubt a few surgeons have witnessed in laminectomy, a want upon the part of the operator of a thorough knowledge of the nature of the accident, calling for the operation. We must in this class of cases be governed by the same general laws that would guide us in any capital operation. We are fully cognizant that acute pressure whether by bone or blood clot must of necessity result in rapid anatomical destruction of the cord, and while our operative results may not be as brilliant in this field of surgery as we would desire, still, if we operate at all, we should, yes, let me say must, do so at a time that will prove the most beneficial to our patient, and that time, gentlemen, is as soon as possible after the inception of the injury. I have heard very little said regarding severe shock in this class of cases; it amounts to very little and soon passes away, and it is the early operator relieving the compression and irritiation of the cord that stands the best show of relieving a most persistent case of shock. Owing to its cheapness and convenience of application the plaster of Paris jacket has, no doubt, relieved many thousand sufferers who would otherwise have been left to their fate.
I am quite sure the jacket acts as an anterio-posterior support, but the moment it becomes loose, its entire leverage power is lost. We cannot adjust the plaster with the precision obtained by a steel apparatus. We find the strongest advocates of the plaster of paris jacket among surgeons who have had little or no experience with braces.
The subject of injuries to the spine is too serious and important a subject to pass by lightly. I do not know what the experience of the majority of the surgeons present has been in regard to injuries of the spine and operations for them, but it has been my mis
fortune, within the last eighteen months, to have had four cases in which I performed the operation of laminectomy, and I shall study my case a long time before I shall cut down on another spine, anticipating any marked beneficial results. Where you have traumatism, or a fracture of the bony structure, you will find a disorganized condition of the cord, and in such cases I can see no benefit to be derived from the application of a plaster of Paris dressing, excepting after an operation has been performed and the bony structure and pressure have been relieved. I have now three cases that are alive to testify regarding this operation. They have experienced very little relief, and you will find that this is usually the result in operations for the relief of injuries to the spine. I live in a neighborhood where there are forty-five hundred men who work underground. Every now and then some of the men are injured by the falling of slate and things of that kind, and among the injuries received are a good many spinal injuries. These men bend over in a stooping position and when the slate falls on them they go down on their haunches, and usually when there is a fracture we have a dislocation accompanying it. It seems to me there can hardly be a dislocation of the spine itself, without a fracture; in short, I do not believe an injury can be so great as to produce a dislocation without fracture.
I do not wish to consume any more of the time of the association, as there are others who doubtless have something to say upon this subject. However, I desire to say this, that out of the five cases, three of whom are living, they have received no benefit from the operation practically. There was, however, a return of sensibility following the operation, but not of motion.
Dr. W. B. Outten, of St. Louis: This subject has always been an intensely interesting one to me, simply for the reason that I know of no cases in all surgery where a feeling man realizes so completely that we are utterly unable to accomplish good results as in injuries of the spine, particularly fractures. My conception of these cases is that they have to be interpreted upon a purely scientific basis. There is no doubt but that we may have varying degrees of spinal injury, and right here is a point where we often find it absolutely nec
essary to call to our aid neurological science, and even with all of the assistance we get from the neurologist we find conditions that we cannot interpret. Let us take a case, for instance, of fracture of the twelfth dorsal vertebra. In such a case a series of nervous phenomena would invariably be manifested, in which we have a dividing line between increased traumatism from the varying degrees of absolute concussive force to absolute transverse spinal injury. When you get beyond that point of the twelfth dorsal vertebra, you come in contact with a condition which, marvelous as it may seem, is just as efficient as though you had a fracture of the spinal column, or as though a segment of the column was broken into a thousand pieces. Take, for instance, the first two or three dorsal vertebræ up to the cervical region, you have a positive condition which has been clearly demonstrated by Thorburn-a condition of recoil, in which the vertebræ are forced upon the medullary mass and crush it transversly as though it were crushed by a hammer, when it will spring into position again, leaving no effect except a pathological condition of the spinal cord. You may try to determine exactly as to whether you have a dislocation or sublaxation, if I may use that term. In cases of this kind we have got to seek the greatest diagnostic skill which neurology can afford.
As regards performing the operation of laminectomy, it is a serious operative procedure, and before performing it in certain cases I have repeatedly pondered over the question as to whether the patient would be materially benefited by it. I have opened the theca, have come in contact with an unusual exudation of cerebro-spinal fluid in some cases, while in others I have found none. In doing this operation we have to proceed step by step; we have to know the series and sets of nerves that are involved. Under certain conditions, the spinal cord may be partially lacerated or so involved that the operation of laminectomy is forced upon us. Picture to your
selves a man with a transverse lesion of the spinal cord. He lies on a bed and day by day you find the paralysis extending; there is disorganization of the tissues; you find every element of misery. Now, I maintain, that so far as this operation is concerned, in cases of absolute fracture, it is the surgeon's duty to
perform it at once, and not wait an hour. If the surgeon is certain that this condition of the spine exists, he should not wait to apply a mechanical appliance, but should cut down and find out the actual condition.
The history of laminectomy is, that it is a procedure which has been followed in a great many cases by absolute failure, so far as the permanent results are concerned. It is true that relief in some cases is temporarily afforded, but not in all.
With reference to drainage of the spinal canal, I would hesitate before resorting to it, because I am convinced that there are conditions in which, by the application of any aseptic dressing, we are utterly unable to prevent the occurrence of septic trouble. In injuries of the spinal column where we have a partial dislocation-a sub-dislocation, if I may be permitted to style it-we rarely have any difficulty, and in all of the cases I have treated a well adapted plaster of Paris bandage, as advised by Sayre, has met the indication. I can show you case after case where there is some rigidity of the spinal column where the injury occurred, yet the patients are able to perform all of the functions of activity, minus those which require excessive bending of the spinal column.
Dr. Hoy said that he did not believe a dislocation would occur without fracture. I am convinced that it can occur without fracture. If I have interpreted the conditions rightly, I have had at least two such cases.
Finally, of all the grave surgical cases I have come in contact with in my practice, which require acute sense, good judgment, and an active, rapid and proper interpretation of the existing conditions, I have met with none that have perplexed me so much as those unfortunate accidents which occur in connection with the spinal column.
Dr. J. A. Barr: Just a word in reference. to the instrument or brace shown. I agree with the reader of the paper in devising and advising an instrument by which we can relieve the pressure on the spinal cord. I have a man under my care at the present time who was injured last December by jumping off a moving train. There is an area of about three inches in the lumbar region which is sensitive and of which he complains. There is no swelling, no dislocation, in fact nothing to
show that there was any injury except that there is soreness in the region referred to. This case showed evidences of paralysis of the lower extremities and of pain running over the top of the head and into the eyes, etc. It went on in the usual way until there was an improvement in the weather, when the spinal cord also showed slight improvement and signs of the patient's recovery. When the man got out of the house into the open air, and breathed God's oxygen, he seemed to improve a little. When he undertook to use crutches for the first time, he could not do so. When the crutches were placed under his arm and he attempted to straighten his back, it caused such intense pain that he could not use them. He meandered around outside of the house as far as he dared to go, for a short time. I then procured a shoulder-brace from an instrument maker and applied it with the idea that some slight appliance to the spine would overcome the pain incidental to the stretching of the body. This afforded some relief, and I think a light instrument such as we have seen to-day will meet the indications in these cases of spinal trouble. A plaster of Paris cast, as we all know, is one of the finest things that we have, but it is weighty, as a rule, and if we could get something that is light and apply it so as to give us the necessary motion without allowing the body too much freedom and hurting the parts, we will have arrived at something that will be of value to us in the treatment of these cases.
Dr. Jabez N. Jackson, of Kansas City: I desire to call attention to one point with reference to the use of a brace or a plaster of Paris cast, in the treatment of spinal troubles. I do not think any brace has ever been devised thus far which will meet the indications like a plaster of Paris cast, in the primary fixation of the spine. A brace, such as the one that has been exhibited, may serve very well to prevent flexion or antero-posterior motion of the spinal column, but I do not see how it can prevent rotary motion of the spine. There is but one thing that will bring about complete fixation of the trunk, and that is the use of a plaster cast. If the doctor's device has any place in surgery, it will be in the later stages, after the reparative process has taken place, having for its object the partial strengthening of the spine while the patient is able to get
around. In the later stages of treatment of spinal troubles this brace may be of some benefit, but I do not think it can be used with benefit in the primary treatment.
Dr. J. B. Murphy, of Chicago: I think we can explain the disparity between the comments of Dr. Hoy and Dr. Outten as regards the beneficial effect of operation, if we will consider for a few moments the pathology and the degree of the injury referred to by Dr. Outten. We know from experiments that where we have a complete division of the cord above the point mentioned by Dr. Outten, there is no particular barrier to the production of motion. We do know, however, in further analyzing these cases, that where we have a fracture which produces a complete division of the cord we have nothing to hope for from the operation of laminectomy; but unfortunately we are not able primarily to tell whether the paralysis that is being produced after the injury is due to a complete division, to a concussion, to a hemorrhage, or to continued pressure of the deformed spine without a division of the cord. If we could tell the difference, then we could say in one class of cases we will operate, where the cord is not divided, and on the other hand, we will not operate. Furthermore, the paralysis in the case of the man from Dakota, mentioned by Dr. Briggs in his paper, is typical of the class of cases reported by Victor Horsley at the last meeting of the British Medical Association, that recover after a secondary operation. It must be borne in mind. that these cases gradually get worse. The paralysis is not complete at the time of the injury. The paralysis is due to an inflammatory exudate within or without the cord, producing compression on the cord at the seat of injury. This is exactly the same as the paralysis which we have as a result of triangular deformity in tuberculosis. It is not due to compression by bone at the site of the deformity, but to an abscess formed within the canal and compression by that abscess. This abscess can be opened and drained on the side of the cord without interfering with the meninges of the cord and it will relieve the compression.
Dr. Briggs (closing): There seems to be a misunderstanding in regard to the statements I made in my paper. I said no opera
tion should be considered as complete upon the spinal column until the cord had been properly supported. I did not say that you must wait until the fragments are raised. These things we all consider imperative. I believe any appliance that will support the spinal column posteriorly is far more acceptable and useful than one which passes around the body.
Our special correspondent in Rome writes: At a meeting of the Perugia Medico-Chirurgical Society held on February 5, Professor Salvioni, teacher of physics at the university, made a most important communication on the new results obtained by him in Roentgen's rays. In studying the question his aim was to invent an apparatus which would enable one to see direct and without the intervention of photography certain bodies inclosed in wood, flesh, cardboard, etc. He therefore studied the possibility of rendering the retina. sensitive to Roentgen's rays. In this he has succeeded by inventing an apparatus which he has called a cryptoscope, which he exhibited at the meeting, and by means of which one can clearly see the contours of the bones of one's own hand, objects inclosed in cardboard boxes, leather purses, etc. This apparatus is very simple, and consists of a black cardboard tube inclosed at one end with a disc of black cardboard coated internally with a fluorescent substance (barium platino-cyanide, sulphate of calcium, etc.); in the other end is placed a lens which permits one to clearly see the fluorescent surface. The object to be observed is placed before the luminous source given by a Crookes tube, and then one looks at it through the cryptoscope placed at a suitable distance. As in the fluorescent cardboard the parts of the object impermeable to Roentgen's rays are drawn in shadow, thus one clearly sees the contours of the bones of the hand, etc. A model of the instrument was made under the direction of Professor Blasema at the physical cabinet of the Roman University on February 11, and with it one could clearly see the bones of one's own hand, coins in a purse or the clenched hand, etc. It is evident from these results that the apparatus, when perfected, will be of great use in medicine and surgery. -British Medical Journal.
The tendency to ultraism which influences public opinion in great social questions * * * has been also prevalent in the affairs of practical medicine.-Dr. J. Bigelow.