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gouge. Through this opening a steel sound was passed and with but moderate force the depressed bone was loosened and raised into its proper place. Though it seemed firmly held in its normal situation, it was thought best to retain it by packing the antrum with a long strip of iodoform gauze. This was withdrawn on the fourth day after the operation and replaced, and finally withdrawn on the tenth day. One week later he was discharged, the little wound in the mouth healed, contour of face natural, function of mastication perfect, and only a slight irregularity along the orbit, to be felt but not seen. When inspected several months later the restoration remained equally satisfactory.
Case II: Charles K, aged 31 was struck by a flying hammer June 1, 1896, receiving a simple fracture of the left malar bone. Two weeks later he entered the New York Hospital. Besides the sunken appearance presented by the left side of his face, there was inability to open the mouth more than three-eighths of an inch. Above the left alveolar margin of the upper jaw, a piece of broken bone or tooth protruded, covered by mucous membrane. Under ether the attachment of the upper lip and cheek to the left superior maxilla was divided and the soft parts were reflected upward until the line of fracture appeared. The malar bone had been crushed down into the antrum of Highmore. No marked irregularity existed along the orbital margin. A urethral sound was passed through the incision under the lower edge of the fractured bone, and the displaced fragment was pried up into position. The antrum was tightly packed with iodoform gauze, which served to hold the malar bone in its correct position and acted as a drain. There was no reaction and four days later the patient was discharged, but the gauze was not finally withdrawn until ten days later. He was seen several months later and the shape of his face was fully restored. In this case, after the malar bone had been replaced, it was found to be so mobile, and to have carried with it a large flake of the anterior wall of the antrum, that difficulty was anticipated in being able to maintain the replaced fragment in good position, but a firm packing of gauze accomplished the purpose.
Discussing the case, Dr. Abbe said he had had his first experience with depressed fracture of the malar bone two months ago, and was not aware that Dr. Weir had had similar experience. His case was that of a young man whose head had come in collision with that of another man while they were playing football. Dr. Abbe saw him on the third day. His face was greatly disfigured. The malar bone was broken in, and when raised with a probe introduced under the lip it would not remain in place, but would dance back and forth in the
antrum. He then supported it with a drill passed through the solid part of the zygoma, and after ten days or two weeks it had healed solidly in place and the drill was removed. There was not a scar except a dent in the skin. The mouth wound was closed at once. He thought the advantage of this method over that of packing the antrum might in some cases be great. The procedure was very simple and preserved the antrum from possible infection. The only disadvantage was the small puncture scar made by the drill. Mastication was not interfered with. Dr. Abbe added that the lower wall of the orbit was also depressed by the injury and the appearance was very uncanny.
The president had once seen a case of depression of the malar bone and lower orbit caused by a railroad accident. Dr. Sands also saw the patient. Nothing was done, and there was horrible deformity the rest of life. Such an operation as had been described to-night would have been of inestimable value to that woman.-Medical Record.
Concussion of the Spinal Cord.
At the October meeting of the Philadelphia Neurological Society Drs. De Forest Willard and William G. Speller made the following valuable communication:
The following case of fracture is intersting from a pathological standpoint rather than from a clinical. The accident occurred during the service of Dr. De Forest Willard at the Presbyterian Hospital. We are indebted to Dr. W. E. Hughes, pathologist to the hospital, for the material.
In consequence of a severe blow from a trolley car the spinal column was fractured at the eleventh thoracic vertebra. The lower limbs were completely paralyzed, and no involuntary movements were noticed. Sensation was entirely lost below Poupart's ligament, except on the front and outer part of the thighs, in the distribution of the external cutaneous nerves. These nerves arise from the second and third lumbar roots (Gray), though in some cases they receive fibers from the first lumbar (Quain). The lesion in the spinal cord was located chiefly at the first, second and third lumbar segments. It has been shown that it is necessary to cut at least three spinal roots in order to destroy the sensation in an area of the body. This fact may explain the preservation of sensation in the distribution of the external cutaneous nerves notwithstanding the location of the spinal lesion.
Inability to urinate and defecate was observed. On examination the eleventh thoracic vertebra was found elevated and the twelfth depressed. By manipulation the prominence was reduced, but the depression remained. Death was chiefly due to exhaustion. At the
autopsy a large amount of blood was found in the muscular and connective tissues at the seat of injury, the laminæ of the eleventh thoracic vertebra presented an irregular line of fracture, and hemorrhage as noticed within the vertebral canal, but external to the dura. It is probable that most of this blood flowed into the canal in removing the posterior part of the vertebræ. There was no evidence of displacement of the vertebral bodies. The dura was intact, and after it had been opened no hemorrhage as observed within. The cord, even at the seat of fracture, was quite firm and of normal shape, and presented exteriorly no distinct signs of softening. It was placed at once in Müller's fluid and transverse cuts were not made at this time, as the material was desired for microscopic study. There were no indications of injury from pressure upon the spinal cord exteriorly.
As the vertebral bodies were not removed it could not be determined whether they were fractured or not; no evidences of this were noticed from examination in situ.
The accident occurred on a Monday, and the patient lived until the following Saturday.
From the picture given by Gowers' of the relations of the vetebral column to the cord, we would expect to find the lesion caused by dislocation of the eleventh upon the twelfth thoracic vertebra greatest in the first, second and third lumbar segments. This was exactly the area injured.
The microscopic findings consist of displaced fibers in one portion of the cord, numerous hemorrhages, altered blood pigment, masses of granular corpuscles, necrosed tissue, swollen axis cylinders, tumefied ganglion cells, and round-cell infiltration. The spinal roots contain a few swollen axis cylinders, and the medullary sheaths do not stain quite as deeply with hæmatoxylin as do those of normal fibers. The blood vessels everywhere are much dilated.
The case reported recently by A. Westphal' has many features in common with the case which forms the subject of this paper. His patient fell from the second story to the pavement in a delirium of fever. After the accident the movements of the upper extremities were free and the lumbar portion of the spine was very sensitive to pressure, although no deformity was present. Complete flaccid paraplegia of the lower limbs, with absence of the knee-jerks, was observed.
At the autopsy the bodies of the first and second lumbar vertebræ were found broken, and the vertebræ were dislocated, but nowhere, as in our case, was there pressure on the cord and its membranes. The muscular tissue at the seat of fracture was infiltrated
I Gowers. Disease of the Nervous System (English edition), Vol. I, p. 163.
2 Westphal, Archiv für Psychiatrie, xxviii, Heft 2, p. 554.
with blood. The dura was intact, and there was no hemorrhage within it. The form of the cord was well preserved. The greatest alteration was observed in the sacral region. When microscopical examination was made the ganglion cells were found alterd, swollen and rounded off; in some the nucleus was displaced, in others there was no nucleus or nucleolus. There was rarefaction of the gray and white matter, and small hemorrhages were found in the gray substance, especially about the central canal and in the white matter. In the sacral cord the normal outlines of gray and white matter were altered and could not be fully defined. In this case, as in our own, dislocation of the vertebræ occurred. This explains the displacement of fibers, but many of the other changes must be considered as the direct result of the concussion to the spinal cord, as Westphal himself says, in regard to his case. His patient lived seven days after the accident, ours survived the trauma five days.
Westphal states that most of the cases of traumatic myelitis known to him in the literature concern persons in whom death occurred immediately or else a long time after the accident, and are unfitted for the study of the early morbid changes. His case, therefore, and ours present such alterations as occur within a week. In a paper published by one of us' the changes which occur after thirty-six hours were mentioned. These consist mainly of swelling of the axis cylinders.
The two regions of the spinal column which seem to be especially liable to fracture are the lower cervical and the lumbar. In the paper already referred to (Spiller, loc. cit.) a case of fracture in the former of these two regions was reported, and the hemorrhage within the gray matter was described. In that case the anterior horns were most involved, in this one the left posterior horn in the eleventh and twelfth thoracic segments was destroyed.
Goldscheider and Flatau' have shown by injecting staining solutions into the thoracic region of the spinal cord of the living and dead animal that the fluid, if injected into the anterior horn, has a tendency to pass to the posterior horn and to ascend in this; if injected into the posterior horn it is not apt to enter the anterior. This may be explained by the difference in the formation of the two parts. From these experiments we must expect to find extensive hemorrhage in the posterior horns more frequent than in the anterior. Lamy has noticed after the injection of inert powder into the vascular system of the spinal
3 Spiller. International Medical Magazine. April, 1896. 4 Goldscheider and Flatau. Abstract in the Semaine médicale, 1896 Nos. 23 and 25.
5 Lamy. Comptes rendus des séances de la Société de biologie, July 25, 1896.
cord that the emboli are more apt to obstruct the branches of the anterior spinal system which nourishes the gray matter, and even when they invade the entire vascular system, the lesions are greater in the gray matter. After the vessels have been obstructed red softening of the gray matter almost invariably occurs. A central cavity may result from the softening, and in a dog he actually found such a cavity after the expiration of three weeks, which "resembled greatly syringomelia." Cicatricial tissue may replace the necrotic tissue and present the appearance of an old hemorrhagic focus.
It is not our purpose to discuss the possibility of a traumatic origin of syringomyelia; that has already been done (loc. cit.).
Emboli always follow the most direct current of blood, and these experiments of Lamy would strengthen the view already held, that in the vascular system of the cord the flow of blood is greater and more direct in the distribution to the gray matter.
Pfeiffer has published recently an interesting resume of the views held in regard to spinal hemorrhage.
Every neurologist has seen the cases of "railway spine" in which paraplegia or paraparesis, with increased reflexes, plays an important role, and usually such conditions are considered as functional. Frequently, however, the suspicion arises that after all we may be too quick in forming our diagnosis, and that possibly there is in some of these cases an organic change. The signs presented are often those which a lesion of the thoracic or cervical cord would give. Such a case is reported by Dercum.' The patient fell some thirty feet, and the resulting sensory and motor disturbances Dercum ascribes partly to actual physical injury, partly to traumatic neurasthenia. He speaks especially of the violence done to the muscles and the vertebræ after such serious accidents. Certainly the probability of the existence of these organic changes must be apparent to everyone. But have we not reason to think that the cord also suffers from such serious traumata? When the damage is so great that the vertebræ are fractured death frequently occurs, and we have an opportunity to study the spinal lesions. There are likewise cases of spinal hemorrhage from trauma in which the vertebral column is not fractured, but these are rare. Usually in the milder forms of traumatism the patient lives on, more or less of a cripple, and the opportunity for microscopic study is not given. Such a case as the one published by Westphal, or as the one by Higier,' in which the symptoms indicated a lesion of the conus, while injury of the
6 Pfeiffer. Centralblatt für allgemeine Pathologie, September, 1896.
7. Dercum. The Journal of Nervous and Mental Disease, 1892. 8. Higier. Deutsche Zeitschrift für Nervenheilkunde, vol. ix., 3-4.
eleventh and twelfth thoracic vertebræ was observed, therefore, above the portion of the cord affected; or, as the case we report, in which a large portion of the changes of the spinal marrow were probably not the result of fracture of the vertebra, but of the force which was great enough to cause the fracture-such cases must cause us to believe that even less severe trauma may produce cord lesions, though of less degree. If the paraplegia disappears after a period, it is quite possible that organic lesions, such as small hemorrhages and areas of necrosis, may have been present. The recuperative power of the spinal cord is astonishing. Probably the most remarkable case in evidence of this is the one given by Charcot with illustrations. The spinal cord in a case of Pott's disease at one part was only one-third the normal size, or about the size of a goose quill, and was much sclerosed. Ascending and descending degeneration was well marked, but the functions, both sensory and motor, in the lower limbs had been perfect. The nerve fibers in this compressed portion were much below the normal number, and the gray substance was represented only by a single horn containing a few cells.
The gray matter is more apt to be involved by a hemorrhage than the white. We refer to Lamy's experiments in this connection. Perhaps hemorrhage may give the explanation of paresis and increased reflexes in some cases, acting by pressure on and not by destruction of the pyramidal fibers.
Indeed, experience has shown that not only the center of the cord is more apt to suffer in trauma, but the center of the cauda equina is subject to the same laws. Bruns1 states that in tumor or trauma of the cauda, even at the upper part, the sacral plexus suffers more than the lumbar, and at first usually it alone is affected.
When in many of these mild cases of "railway spine" restoration of function occurs, it is probably frequently due to absorption of the hemorrhages, relief of pressure, possibly vicarious action of the nerve fibers still sound, and restoration of function to paralyzed fibers.
Undoubtedly in many of these cases there is an element of neurasthenia, but it seems to us that sometimes too much is classed under neurasthenia. Obersteiner" has abstracted a case of spinal concussion published by Struppler. The patient died five weeks after a fall on the back. The lesions found in the cord were softening, diffuse degeneration almost throughout the entire length of the cord, and descending degeneration of the lateral pyramidal tract. Obersteiner remarks that in consequence of the teaching of Charcot con
9. Charcot. Euvres complètes, vol. ii.. p. 103. 10. Bruns. Archiv für Psychiatrie, xxviii., Heft 1. 1896. 11. Obersteiner. Wiener klinische Wochenschrift, No. 30, 1896, p. 694, and Medizinische Jahrbücher, 1879.
cerning traumatic neurosis, the opinion held by himself and others regarding organic changes in some cases of spinal concussion has been forgotten. He, as far back as 1879, reported the microscopic examination of a case of spinal concussion.
Schmaus" has examined the cord from some of these cases of traumatic back at different periods after the occurrence of the accident, and has found very positive changes-such as areas of softening, accumulations of granular corpuscles, gliosis, cavity formation, primary degeneration of the pyramidal tracts, and, in one case, round cell infiltration. In one case he speaks of infraction of the vertebral column, but the alterations he describes were also found when the vertebral column was uninjured, and these alterations are similar to the changes noted by us.
Schmaus produced concussion of the spine in animals. He found in these cases swollen axis cylinders and some destruction of the myelin. In one case he observed a focus of softening, in two cases gliosis in the gray matter, but rarely did he find hemorrhage of any amount. The spinal vessels in all his experiments were congested. From these investigations it was positively determined that organic lesions may follow spinal concussion, and it was seen that the alterations produced experimentally represented earlier stages of those changes which he had found in man.
According to Schmaus, the important change is direct traumatic necrosis of the axis cylinders. He believes that if the trauma is not very severe the fibers are only functionally altered and may recover, and even if the trauma has been very violent the degeneration found at the examination does not represent all the fibers which have been deprived of function, for certain of these are in the earlier stages of the degenerative process. Bikeles" also has found destruction of the myelin sheaths after concussion of the brain in animals.
While we are not treating of commotio cerebri, we may, nevertheless, mention that Koch and Filehne, Witkowski and Polis have shown that cerebral concussion may exist without visible organic changes. On the other hand Duret, Bright, Rokitansky, Nélaton, Beck, etc. (quoted by Michél"), have found numerous capillary hemorrhages in the brain, and have attributed the symptoms observed to these. It is quite possible that some of the cases in which organic lesions were absent were not studied by the finer methods of microscopic technique, as Michél suggests. This author also calls attention to the fact that Bollinger first showed that the signs of commotio
12. Schmaus. Münchener medicinische Wochenschrift, 1890. p. 485, and Virchow's Archiv, 122, 1879.
13. Bikeles. Arbeiten aus dem Institut für Anatomie und Physiologie. Obersteiner, Heft 111.
14. Michél. Wiener klinische Wochenshrift, No. 35, 1896.
cerebri may not develop for some time after the trauma. The trauma causes necrosis and alteration of the vessels, and in consequence of these changes late hemorrhages occur.
Interesting in this connection is the case reported by Hirschl." Dementia and hemiatrophy of the tongue developed in consequence of trauma. Both conditions were supposed to be due to minute hemorrhages. The statement that the hemiatrophy of the tongue was the result of organic changes will hardly be disputed. New York Medical Journal.
Judgment in Surgery.
The following is from the columns of the American Therapist:
It is an acknowledged fact that greater advances have been made in recent times in surgery than in general medicine. A quarter of a century ago nobody dreamt it possible to achieve the brilliant results which are now of every day occurrence in abdominal surgery. Ovariotomies, hysterectomies, appendectomies are now looked upon as ordinary operations with a trifling mortality. Can general medicine with the exception of the serum treatment for diphtheria-show any such positive advance in diseases like tuberculosis, pneumonia, typhoid fever, gastro-enteric disturbances, or the contagious diseases of childhood?
It must always, however, be remembered that surgery never "cures" in the sense of a "cure" expected in general medicine. In surgery "cure" means mutilation, destruction and the presence of a scar of cicatricial tissue to attest forever the injury done by the surgeon's knife. It is well, therefore, to hesitate before recommending surgical intervention. Certain conditions-injuries, abscesses, new growths, etc.-not only justify but demand the use of the knife. Other conditions-pleuritic effusions, dropies, intussusception-often get well without operative interference.
Hence it is that the element of judgment ought to go hand in hand with mechanical skill. The skillful plumber discovers the leak in the pipe before proceeding to repair it. The skillful surgeon makes a careful diagnosis of his patient's general as well as local condition before beginning to operate. The best surgeons-that is, those exercising the best judgment-have usually been graduated from the ranks of the general practitioners of medicine. The best surgeons are not necessarily those most skillful in the technical details of their work, but those of careful habit and mature judgment. Such men are not apt to have the largest list of cases or most brilliant series of results, for they do not operate every case, and are apt to first try methods used by the general practitioner of medicine. Such men do not
operate every hernia, remove every hardened testicle, or every ovary which seems somewhat enlarged. Such men are willing to work with pessaries before fixing the uterus to vagina or abdominal wall, and will not do hysterectomy because the uterus has a tendency toward chronic catarrh or prolapsus. Such men rather leave these cases to the general practitioner to treat on well-tried and satisfactory lines.
In operative work the surgeon with judgment will act on "conservative" principles. On opening the abdomen he will only remove hopelessly diseases tissues and will leave inoperable cases severely alone. This all requires profound diagnostic knowledge as well as "technique." If the vaginal route is safer for the patient he will select it in preference to opening the abdomen from above. If a finger or limb can be saved in part he will sacrifice his love for a beautiful stump and save a useful structure. If the ovary is only atrophied or slightly cystic he will leave it alone. If the patient has a slight pain over the appendix-a catarrhal appendicits his love for a large series of "appendix operations" will yield to his judgment and he will turn the case over to the physician. Thus will surgery best subserve its functions in the diseases of mankind.
Fracture and Dislocation of the Second Cervical Vertebra as a Result of Muscular Effort.
Lobingier (Colorado Medical Journal,, February, 1897, p. 41) has reported the case of a machinist, twenty-one years old, and an experienced athlete, who in the performance of some feat on the horizontal bar fell limp and lifeless. In "snapping under," instead of easily emerging on the opposite side of the bar and finishing in a graceful vault, the man's head fell upon his chest and his body forward, semiprone. No sound was heard by the observers, as of the snapping of bones or ligaments, and it was insisted that his head struck nothing in passing beneath the bar. Examination of the cervical spine failed to disclose any deformity. The reflexes were abolished and only feeble cardiac activity persisted. The vertebral column was adjusted so as to prevent injury from a possible fracture, and artificial respiration was instituted and maintained for an hour. Respiratory and cardiac stimulants besides were given hypodermically and repeated at frequent intervals. Electricity was employed and inhalation of oxygen practiced. Despite every effort the patient could not resuscitated and death took place. Upon post-morten examination no cerebral lesion was discovered, but the second cervical vertebra was found to be thrown forward and to the right on its articular bearings for fully an eighth of an inch. The anterior common spinal ligament was ruptured
through its three layers. The lip of both the second and third vertebræ was broken off irregularly along the line of junction. On the right side this fracture extended into the inferior articular facet of the second vertebra. On removing the spinous process of the second vertebra the cord was found soft and degenerated for a distance of an inch. The greatest change in the cord existed at the point opposite the articulation of the second with the third segment of the spine, showing that the pressure of the odontoid process on the cord would not fully account for the softening. The neck of the patient measured sixteen inches in circumference and was intensely muscular, with an unusually large amount of ligamentous and aponeurotic tissue. It is believed that the lesions found resulted from violent contraction of the left posterior group of cervical muscles, with simultaneous and co-ordinate relaxation of the right anterior group, allowing the head to drop violently backward and to the left.Medical Record.
Massage in the Treatment of Fractures.
At a recent meeting of the New York Academy of Medicine Dr. George Woolsey read a paper upon the above subject, of which the following is a brief abstract from the Medical Record:
Until very recently less advance had been made in the treatment of fractures than in any other field of surgical practice. Comparatively recently the ambulatory treatment had received much attention. He had tried it in a number of cases, especially in fractures of the leg, and with considerable satisfaction. Under it the general condition of the body was maintained, and it was especially useful in the aged and alcoholic, in that it shortened their stay abed. It prevented stiffness of joints, allowed the patient to go to business, and cleared the hospital wards. It did not shorten the period of healing. Keeping the patient abed, as was done under the rest-and-fixation treatment, had an ill effect upon the health and weakened the muscles. These objections were overcome by massage treatment. Dr. Woolsey, in presenting the claims for this method, quoted freely from Championnière, its champion. Among the effects of massage were the relief of pain, diminution of swelling; secondary cedema, which under other treatment often came on after five or six weeks, was conspicuous by its. absence; the muscles were kept from atrophy, the skin remained soft; the callus was stronger, the general health was maintained. When there was great mobility, immobilization could be applied until consolidation began; then massage should be commenced. In other cases massage could begin at once, and if a splint was applied it could be removed during massage once daily. Massage should be prac