by some surgeons at the present time, as for example Dr. A. C. Wiener of Chicago. It should be borne in mind that a limited degree of motion at the seat of fracture, rather hastens than retards the union, and lessens the liability to non-union. The old law which was so forcibly impressed upon our minds, as students, that the joint above and below the fracture. should be constantly immobilized during the process of repair, must be effaced from our code, and a new one inserted, viz., that all joints in the neighborhood of a fracture must be passively exercised after the fifth or sixth day.

Another subject that I hope will receive attention at this meeting is, the importance of repose, prolonged, unconditional repose, to the patient sustaining cerebral and spinal concussions. The conspicuous place which spinal concussions have occupied for the last five years in medico-legal practice is in some degree, at least, due to the surgical management of the case immediately after the injury. True, it may not be the fault of the surgeon, for many of these patients do not consult a surgeon, and if they do, they are reluctant, and very often, even refuse to obey his order, to remain in bed for from four to six weeks. The pathology of the process of repair of physical derangements of the tissues of the brain and spinal cord teaches us that repair and regeneration in these are slower than in that of almost any other tissue in the body, and not only are they slower, but unless the process be complete, they are liable to produce recurrence of symptoms and initiate new changes. It is, therefore, our duty to insist that they be given ample opportunity for repair, and, as we are conscious that medicine contributes comparatively nothing to these changes, the resources of nature must be depended on exclusively, and the conditions must be rendered as favorable as possible.

The teachings of modern pathology and the glorious achievements in the new fields of surgery have carried us away from the daily from the daily routine of our labors. We are prone to overlook the little things that contribute to the relief of the sufferer, and the comfort of our patient. The same spirit prevails with the clinical; when he has made his diagnosis he considers that there his labor ends, forgetting that the primary and most essential aim of the diagnosis is to suggest means for the relief of

the patient. For this reason, gentlemen, at this meeting, I trust we will descend from our revellings with the gasserian ganglion, from our ideas of direct inspection of the floor of the fourth ventricle, to the more matter-of-fact every-day topics, remembering that there are a hundred, yes, even a thousand of the commonplace cases that are indifferently, if not imperfectly treated, to the one requiring these wonderful acrobatic surgical feats.

Gentlemen, the time for this meeting is very limited, the programme very long, the number of papers which appear on it embrace a wide range of subjects. In order that we may have time for the consideration of every topic, I trust you will all be punctual in your attendance, present at every session and take a truly scientific interest in the discussions, always bearing in mind that this is not a mutual admiration society, and that our sole object is to arrive at the truth.

I thank you for your attention.

SURGERY OF THE SPINAL CORD AND COLUMN.

By T. H. BRIGGS, M. D., BATTLE CREEK, MICHIGAN.

The surgery of the spinal cord and column is brought prominently to the attention of the surgical world by a number of distinguished operators and authors of to-day, and the fact that this is an association of surgeons who are often brought in contact with injuries of the cord and column, either traumatic or otherwise, is my excuse for trespassing on your time to-day. Practically a more definite field is being opened in the primary and secondary treatment of spinal injuries. The surgical procedures in this fieid that were, in the near past, considered perilous in the extreme are to-day adopted as worthy of careful consideration and analysis. It has long been a tradition that following injury of the spinal cord atrophy was one of its necessary sequela, even though the cord was without maintained compression, and that pathological change supervened that could not be remedied by our art. Some of our eminent pathologists now question this position and claim that the paralyses following injuries of the cord are due to an inflammatory exudate producing and maintain

ing compression of the cord in its bony canal, and that on the removal of this product the cord will resume its normal functions.

In 1887 Drs. Horsley and Gowers reported the removal of a number of spinal tumors, and as some may not have even the report, I will give a brief synopsis of the same. The first is the case of a man 42 years of age who had been suffering from a growth in the spinal canal for three years, and for the four months preceding its removal had been completely paralyzed in the lower extremities, and at the time. of its removal paralysis extended to the base of the sixth dorsal nerve with spasms in the legs and feet, cystitis and retention of urine. The tumor was removed from the dorsal region. On removal of the arches and tumor the cord was found to have been compressed by the growth and an exudate. The wound healed. by first intention, and there was complete recovery, the patient being enabled to walk and dance with ease. This was followed by the remarkable paper of McEwen reporting six cases of the removal of the arches of the vertebræ for various pathological reasons, consisting of tumors, injuries and caries of the column, causing compression of the cord and producing paralysis. All of the patients were relieved by operation, except the sixth, which was a case of traumatism treated by opening the spinal canal and elevating the arches, and if my understanding of it is right, not draining the canal, as should have been done. A majority of these patients recovered and returned to their various occupations.

Since 1887 some thirty cases have been reported of surgical treatment of the spinal cord. and column, the large majority of them having been relieved by operation. Mr. Horsley has analyzed the reports of fifty-seven fatal cases of tumor of the cord, and has shown that eighty per cent. of them would have recovered had the proper surgical treatment been rendered. This is a sad reproach to the surgery of this age. The spinal cord is a segmental organ with a fixed series of nerve centers protected by a bony canal. Therefore, whatever produces compression, be it from injury or growth, the results are the same, and are to be remedied only by operative procedure. A partially separated cord should be aseptically sutured through its enveloping membranes and the sutures passed beyond the point of separation

through its covering and the raw surfaces placed in perfect contact.

In looking over the surgical history of the late war I find that all cases of this class of injuries were fatal and the treatment in the great majority was nil, presumably largely from the fact that the proper agencies were not at the command of the surgeons for their treatment at that time. Since that day a systematized care and procedure in this class of cases has been established. I wish to call your attention to one case of a number that have come under my care.

W. J. M., Canadian by birth, aged 27 years, a man of strong muscular development, on July 21, 1894, was injured near Hunt's Mills., Minn., by having a team, drawing a binder, run away with him, the binder passing over him, injurng the spinal cord and column. He was taken to St. Luke's Hospital at Grand Forks, Dakota, on the following day and there remained until the 27th day of November, 1894. I have been unable to get any report as to his condition when he entered the hospital at Grand Forks, but from his statement and condition when he entered the Memorial Hospital at Battle Creek, Mich., on the 28th day of December, 1894, I found that the spinous processes had been removed at the time of the accident from the third and fourth lumbar vertebræ. The wound had healed, but he was still suffering from incontinence of urine and fæces, was unable to move his legs or the lower part of his body, and this inability had gradually grown upon him since the time of his injury. In the region of the fourth, fifth and sixth dorsal vertebræ there existed an inflammatory and fixed condition of the column, with swelling and tenderness. I removed the arches of the three vertebræ mentioned and found the vertebral canal filled with inflammatory product about one inch each side of a small round stone about the size of a large grain of wheat which was resting against the cord, compressing the same, having been driven therein at the time of his injury. I removed the arches and the exudate, drained the canal, dressed with gauze and maintained drainage for two months, when the wound healed by granulation, not one drop of pus having been developed. On closure of the wound the patient was allowed to move on crutches with a proper spinal support. The

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 diffculty 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. 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

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