a hospital, where there are perhaps more skillful men than the average railroad surgeon. Again those of us who live in small towns have little experience in these cases and I hope, in the discussion that will follow, that those who have experience will give us the benefit of that knowledge, and by so doing bring out all that will be of service in their proper management.

While surgeon in the war of the rebellion I saw a number of these cases resulting from gunshot wounds, all of which were desperate cases. In a large percentage the injury to the cord was such that the men survived only a short time. Some of these lingered a long time before the end came, a few made a fair recovery; these latter had fractures with slight or no injury to the cord. In others. concussion was the prominent symptom; the patients were nauseated, blanched and helpless with more or less paralysis, especially of the limbs and sphincters, and a severe sense of pricking of the skin, chiefly along the extremities.

N. G. Williams, colonel of my regiment at the battle of Shiloh, Tenn., had his horse killed under him, a solid shot passing through the horse, cutting the skirt of his coat off, and breaking the saddle, leaving both man and horse in a mass together. In this affair there was only concussion, neither skin nor bones being broken, yet he suffered severely from paralysis, retention of urine, and still suffers at times from the effects of the injury. For six weeks he could not empty his bladder, and for a time a catheter was used a number of times each day. He was then sent to a hospital, where the surgeon advised me from time to time of his condition.

The case of President Garfield, many of us will remember, was one of great interest. This was a gunshot wound with injury to the body of the tenth vertebra, as well as the tenth and eleventh ribs. The assassin stood to the rear and left of his victim when he fired, the ball being a large one (44-caliber) striking the president two inches to the right of the spinal column, fracturing the eleventh and injuring the tenth rib, and taking into consideration the position of the murderer and his victim, had it continued in a straight line it must have passed into his liver. Dr. D. W. Bliss assumed control of the case and used the probe freely. He announced to the anxious public by telegraph that the ball had passed into the

liver, but owing to the president's extreme prostration, further probing would be dispensed with for a time, no mention having been made of the injured ribs. Had he bared his finger and introduced it into the wound he would have immediately found the fractured ribs, and, knowing that it would be impossible to tell the course of the ball, would simply have said "The ball has not been located." All this time the patient could not empty his bladder and complained of excruciating pain in the lower limbs and feet, which he himself described as being like the sticking of a million. needles into his legs; still they claimed the ball had passed into the liver.

I mention this case to call your attention to the important symptoms of pricking and numbness of feet and legs, together with the inability to evacuate the bladder. Some of you will remember his suffering from retention, and on using the catheter, which afforded so much relief, the president looked his gratitude, and said: "Doctor, you can draw on me at any time." If we find loss of motion, pricking sensation, combined with loss of power to evacuate the bladder, it should call a halt, and we should recollect that in cases of injury like those of which I am speaking, that they are almost positive indications of injury of the spinal cord. In some of our text books there are tables showing in groups the location of injuries. All above the fifth cervical are apt to be fatal. Starr gives quite extensive tables, which are in part as follows:

The fifth cervical segment includes the skin of the outer side of the arm and foream, from the wrist to the deltoid muscle.

The sixth cervical includes the upper or radical side of the hand, forearms and arm to the axilla.

The seventh cervical supplies the middle of the palm and the dorsum of the hand; also the middle and ring fingers.

The eighth includes the ulnar side of the hand, the little finger and the ulnar side. of the ring finger.

The first dorsal segment is a narrow one, supplying the inside of the arm and forearm, from the axilla to the wrist, but it does not extend to the hand.

It is useless for me to copy the entire table, but I beg leave to refer you to Starr's paper in the American Journal of Medical Sciences for July, 1892. Starr has also made a careful

study of local anesthesia and uses it as a guide to the diagnosis of injuries of the spinal cord. The centers of the cord, which control the sphincters of the the bladder and rectum, must be adjacent to each other, as they are always affected together; the control over these sphincters is lost when the three last sacral segments are injured.. The condition of the reflexes should be carefully noted, their presence or absence will aid us in our diagnosis. There are various ways of ascertaining or producing them, whether by sudden irritation of the skin, by drawing the fingernail across the surface, or tickling the skin by tapping or stroking certain parts, or by tapping or striking certain tendons. These are important guides in the matter of operation, as they are held to be an indication of the extent of the injury, whether the cord is wholly or in part destroyed.

If the cord is severed or injured so as to destroy its functions, there will be complete paralysis of motion, as well as of sensation, also complete and permanent absence of the knee jerk and other deep reflexes in both legs. In partial injury of the cord transversely, the paralysis and loss of sensation will be incomplete, and the deep reflexes are many times only exaggerated; this also applies frequently to the sphincters of the bladder and rectum. In the absence of these reflexes we would not, as a rule, operate, yet there are cases of this kind on record in which, even after bed sores had been found, operation revealed the fact that it was only depressed bones that rendered them absent, and elevating the same saved the patient's life. It seems to me that an exploratory operation would be in order, especially if the patient lived some little time; but the general conclusion is that where these reflexes are absent for some time, no operation is admissible. Here is a point of great interest, which I will be compelled to pass over, but there seems to be a well fixed principle in the minds of those best informed on this subject that if we operate, the earlier the operation, the better. I think the rule is that if after two months the sphincters are still relaxed, little can be expected from nature, and an operation is justifiable; yet there are others who advocate an operation in all cases where there is displacement or crepitus indicating compression, and where extension immediately or as soon as possible, fails to reduce the displacement. This seems to be

correct, for if the compression is allowed to remain, inflammation of the cord and its membrances would be apt to follow. Now, from what I can judge from my experience in these cases, as I said before, they do not bear transportation, on account of further lacerations of the cord and the suffering the handling is almost sure to produce.

Patients should be placed on a stretcher or board and the body immobilized by pillows of sand, or cushions, placed in such a manner as to prevent motion; an anææsthetic may be given and gentle traction made to reduce displacement which, if accomplished, sometimes is followed by partial recovery, and no doubt the earlier this is accomplished the better. If the injury is in the dorsal or lumbar portion of the spine, after, the deformity has been corrected, a plaster of Paris jacket should be used to retain the fragments in place, as well as to give support to the body. This is applied in the same manner as in Pott's disease, and must be carefully watched, as it sometimes causes severe pain and paraplegia; if this occurs it must be removed.

Subsequent treatment will consist in the relief of pain, and the careful regulation of the diet; the latter is of the greatest importance. We must avoid bed sores if possible, which come early. We must be on our guard, and by the means of cushions relieve the pressure on prominent points and distribute it as evenly as possible over the surface coming next to the bed.

Later on, after all danger of inflammation has passed, electricity, massage, are indicated, and still later the active use of the legs, until the patient gains control over them, if so favorable result is ever attained.

There is one more point in all cases of injury, as well as of disease, that I wish to say a few words about, and that is diet.

This should be nutritious and within the ability of the patient to digest and assimilate; it is so common to find in a sick room, oat meal mush or some similar preparation or a piece of wet toast, that I would like to enter a protest against their use at such times. Let the food contain the greatest amount of nutrition in the least bulk, and that should be of a character not dependent upon mastication and insalivation for its digestion and assimilation.

Milk, eggs, oysters, all kinds of meats, animal broths, fish and fruit, and if the patient

is in the habit of using them, tea, coffee or broma.

Alcoholic stimulants if necessary.

DISCUSSION OF DR. COOL'S PAPER.

of

Dr. Hemenway: I do not know as I can remember any case, certainly of recent years, that I have had to treat where there has been a fracture or dislocation of the spine, positively diagnosticated, that death has not ensued. I have had, in fact, several cases where not only fracture of the spine, but other injuries were sufficient to cause death. One of the chief classes of cases that give us trouble with reference to the spine, are those in which the diagnosis is not sure, as for example: A freight brakeman, working at night, fell, some time ago, from the top of a very high box car. He fell upon his back across the rail. I am not sure that there was 'any fracture the spine. I think the first lumbar vertebra was struck. I found no displacement and no crepitation in the examination I made. I, however, did not regard it of enough importance to make a very thorough examination at that time to distinguish between possible fracture and a simple bruise of the soft parts. I say I didn't regard it as of sufficient importance, for this reason: If there was a very slight fracture of the arch, for example, the treatment would be primarily the same as if there was no fracture, provided, of course, there was no depression. The collapsed condition of the patient was marked; although he was within nine miles of his home, I did dare attempt to remove him, but put him in a hospital and kept him there a week. I am inclined to think there was no fracture of the spine at all, though an abscess developed in that region which necessitated an aspiration; but as I say, in this case it is not important to clearly distinguish between a fracture without dislocation of the body of the vertebræ, but also dislocation of the arch, which would compress the bone.

I may have misunderstood Dr. Cool, but I would slightly differ with him in his proposed treatment if I did correctly understand him. It seems to me where there is a depression of the arch and paralysis we should always operate, and operate as soon as possible. If in a case where the diagnosis is not sure as to a fracture or dislocation, I would, whether there

was the presence or absence of paralysis, postpone the operation awaiting results. If, after due time, the paralysis continued, and especially if the paralysis was inclined to increase, I would then operate. I most heartily agree in the suggestion that the best probe is the aseptic finger. I feel that the probe is much more frequently used than is best. For example, a boy was brought to me some time ago in whose axilla a probe had been used, and the result was an opening clear up to the bone, yet the most careful examination I could make of the case led me to think that the trouble was in the axillary glands and followed skin trouble. There was perhaps a little excuse in this case for the surgeon, inasmuch as there had been a previous abscess year or two before.

Dr. Bouffleur: This subject is one of a great deal of interest because it is of such importance, and also the fact that it is something we are yet in considerable doubt about. There is no doubt but what we need a great deal of information, more particularly in regard to the import of the so-called loss of reflexes below the point of the supposed injury. Some authorities tell us that with the cessation of the conducting power of the cord by the injury, we should have the same symptoms that we would if the cord was cut off with a knife, which, as you all remember, is an excitation of the reflexes, and not a loss of them. however, has not been the case; it is shown in nearly all cases in which the cord has been destroyed by accident, that the reflexes have been lost. This is just an illustration of the fact that our symptomatology of compression and destruction of the cord is not complete and definite as yet.

That,

As to the advisability of operating, I can best, perhaps, recite a few experiences. You have all seen cases of fracture of the spine, I presume, with the resultant paralysis below the point with some other disagreeable features and the permament invalidism of the patient, and while we find those who advise waiting in regard to treating these cases of injury to the spine, still, on the other hand, if there are any of you who have seen a single case of recovery after an operation, and seen that individual within a month out and walking around upon the street, you cannot help but contrast the condition of the two, and as far as

you are individually concerned, at least, you will operate in every case that comes under your care. I have had personal experience of this sort, and I know if I was to sustain an injury of the spine resulting in paralysis, that I should insist on an operation, and that immediately. To see a man with a paralyzed limb, both in sensation and motion, to find a marked deformity and to operate, and then within a few days see the sensation return, and later, motion, and see him within six months earning his own living as a carriage driver, is certainly a great incentive to the operative treatment under those conditions. On the other hand, perhaps some of you will say you have seen cases with some of these symptoms, perhaps all of them, and that after months, possibly years, they have regained the use of the members. Again, you probably have seen some that have submitted to an operation die very soon afterward. But give us one recovery to twenty-five deaths, if you please, because death is much preferable to continuous paralysis, and if we can get one recovery out of twenty-five, let us do so and give that one man something to live for, even if in doing so we endanger the lives of twenty-five. I think that is a justifiable position at the present time.

I would like to say, in regard to the time of operation, that there are two sides; one set of authorities, will advise immediate operation, others will advise a late operation. They are both correct. In all those cases which come under our care where we can immediately get an antiseptic operation, by all means do it, regardless of the condition of the patient. If we had a strangulated hernia patient we wouldn't consider the matter of the shock, but the pathological condition causing the shock and desire to remove that. So with the spine; if the conditions are not good for an immediate operation, if we cannot do an aseptic operation, we must not do it at all, and if we cannot operate within two or three days we should wait and see what nature will do, and get the part in as good condition as possible for an aseptic operation subsequently. The operations which have given the best results are those which have been performed within the first two or three days, and those which have been performd after a lapse of three or four weeks. That can be readily understood, I think, because after three or four weeks the

damage to the surrounding tissues has been. recovered from and the danger from infection is much less.

Are all cases equally operable? Upon this you will find also differences of opinion, but I think that in general, operations about the cervical region are practically always fatal, although I believe there have been a couple of cases recorded where an operation in the cervical region has been recovered from. In the dorsal, and especially in the lumbar region, operations have been recovered from in many cases and the patients have been restored to useful lifes. I have not had the misfortune to have any cases of this sort in the last two or three years, but in the course of the two years previous to that I believe I had something like eight or nine cases in which there was a fracture of some part of the vertebral column, and in those cases where an operation was performed the individuals were not in any instance made worse by the operation; in one instance complete recovery took place; in another instance it was a late operation and the nutritive functions of the parts were very much restored, so that the patient regained a good nutrition of the lower limbs, and the improvement was permanent. In another case I think the operation hastened death a little; that was one which occurred to an employe of the Milwaukee road, in which there was an undoubted fracture, a communited fracture of two of the vertebræ, in which the operation demonstrated definitely the character of the injury to the cord. The patient was not improved by the operation, because the cord was destroyed for a distance of a couple of inches, and septic symptoms developed in the course of a week or ten days. I think I did him a good service in giving him the chance of the operation, perhaps in hastening his death, because he was a fearful sufferer; his injuries were exceedingly painful. I am sorry Dr. Johnson is not here, as he could perhaps recall the subsequent history of the case, as he had the man in charge. It would be interesting for all of us to keep a close watch of all of those cases and report them, so that they can be placed on record. We need a great deal of light as to the significance of the very symptoms Dr. Cool has brought out. It is only by careful observation and an accurate record of these symptoms and observations that we will ever be able to decide

more definitely and more intelligently than we are at the present time.

Dr. Marks: I would like to record a case. It was that of a man about fifty years of age, who came into the city and got very drunk. He started for home, and when within a half a mile of home got hold of the lines and drew his old horse on the railroad track and went to sleep. A very heavy freight train came along and the old horse went to the left, the wagon went to the right and the man went straight ahead and struck his head against the boiler. He wasn't killed, but his head was driven down between his shoulders and he ever after carried it in this position. It shortened his neck. What became of the spine? What was his condition, speaking pathologically? He couldn't move his head much. There was no paralysis, but he complained that his fingers felt "funny."

Dr. T. C. Clark: I think I can explain this case. We had a case in our town of a man who always carried his head around in this position. Finally he died and we examined him and found a dislocation of the atlas upon the axis. I think that took place in Dr. Marks'

case.

Dr. Sugg: I had a case I would like to relate that may be of interest. Some years ago a circus came to our town. One of the men was coupling the cages together. He had one containing a bear, and the team he hitched to it wasn't accustomed to hauling that kind of game and became fractious. He started through a door, and there was a platform there that raised the wheels so that when the cage went through the door there was only about eight inches between the seat and the top of the door. As he started in he ducked his head and the door caught him just back of the shoulders; the team was unmanageable and kept on pulling. It finally resulted in breaking the seat upon which he was sitting and shooting him down in a narrow space and then out behind the cage. I was called a few minutes after the accident. The blood was running from his mouth and he was complaining of terrible pain in his feet. I supposed that he would soon be out of pain. We took him to his hotel and an examination revealed a protrusion, evidently a dislocation of one of the dorsal vertebræ, in the lower portion of the dorsal region. I had two or three men pres

ent and we made an extension. This reduced the dislocation at once. Much of the deformity disappeared in a short time and he said the pain was less in his feet. Within six weeks I suspended him and put a plaster of Paris jacket on. I saw nothing more of him for two or three years, when he again turned up in town with another show, apparently as good as he ever was, but still with a deformity in his back.

Dr. Hemenway: I would like to speak of one other case that came to my knowledge. I had to deal with a man who was thrown off a fast train on the Michigan Central some years ago, while the train was going forty-five miles an hour. There was a concussion in that case with immediate paralysis, but the next day the patient was not paralyzed to the same extent and recovery took place.

Dr. Sarles: Brain concussion, wasn't it? Dr. Hemenway: Both brain and spine. Dr. Marks: Was there any contusion at the same time?

Dr. Hemenway: Nothing that amounted to anything.

Dr. Plumbe: Let me ask Dr. Cool about one statement he makes in his paper. Did you ever know of an injury to the spine during the war, a serious injury, from which the patient recovered? Is it not a fact that in both cases you spoke of where the men walked off the field, that both eventually died from those injuries?

Dr. Cool: I had two cases in the regiment where there was a gunshot wound, breaking the spine of the vertebra and both recovered, no injury to the cord, just a shot cross ways of the body, going through the flesh. I can't tell now the exact point of the breaking of the spine of the vertebra. I never saw a case of recovery from a serious injury in the army.

Dr. Plumbe: I call up the case now, because I don't remember the exact time. It was some time during the early summer of 1862. I was dresser at a hospital on the Mississippi River. At that time we received two men, both of them with paralysis, total paralysis of the lower extremities, with incontinence of the urine and paralysis of the bladder; both of them walked off the field after the injury. One of them was a cavalryman and the other an artilleryman. The cavalryman's horse had