New Series, Vol. V. No. 5.

BY E. MAMMEN, M. D., BLOOMINGTON.

Injuries to the cerebro-spinal axis are of such serious character and present such an array of perplexing problems that a presentation of this subject and its discussion should not be without profit at this time.

Involving as most of these injuries do, the spinal cord, the sympathetic ganglia adjacent to the spinal column, and through these most of the internal organs as well as the muscular system, they present symptom complexes as well as conditions with which to deal requires the exercise of the most careful judgment.

It is not the purpose of this paper to present a scientific study of symptoms, nor to classify in statistical order a large number of cases. That has been ably done by a number of writers, and by Drs. Norbury and Black last year. The present purpose is to present a few principles in point, to provoke further discussion on this very important subject, and to urge an abandonment as far as possible of the policy of non-interference with these injuries as now practiced in many quarters.

Permit me to present a few cases and to point out the lessons which they teach.

S. T., a farmer, while in a stooping position, was stabbed in the back with a pocket knife, the blade of which was narrow and about three and a quarter inches long. It penetrated the laminae of the sixth and seventh dorsal vertebrae a little to the right of the spinous process, apparently in an upward forward and inward direction. I saw him about an hour afterward and found him unable to rise. There was apparently complete paralysis of both lower extremities. Examination revealed the clothing of his back well saturated with blood, which flowed freely from a wound about three-fourths of an inch in length situated as before stated and con

Read at 53d Annual Meeting, Chicago, May 30, 1903

SUBSCRIPTION $3.00 A YEAR.

Paralysis of

motion and sensation was complete in the left. lower extremity, while the right had no power of motion, but sensation remained complete.

The left inguinal region was hyper-aesthetic and had the sensation as if a sinapism had been thoroughly applied. There was nausea and some vomiting, paralysis of both bladder and rectum. Heart action and respiratory movements were both accelerated and irregular. Pupils were unequally dilated, the right smaller than the left and the patient complained of a peculiar vertigo.

The man was carefully put to bed, the wound covered with sterilized cotton but otherwise let alone in the hope that the flow of blood had rendered it aseptic. The character of the healing process proved this to be the case.

A few hours after the injury a plaster jacket was snugly applied, the spine being meanwhile placed in careful extension by partially suspending the patient from the head. Absolute rest in bed with attention to urine and bowels constituted virtually the entire plan of treatment. In five weeks motion was partially restored in the right lower extremity, in five weeks more, motion was partial also in the left, while sensation was still absent. Pupils were still unequal, but control over bowels and bladder had been restored. When the plaster jacket was removed the wound was healed by first intention. Some months later the patient was able to walk, but did not have perfect control of the left extremity. The hyperaesthetic area had vanished.

Measurement showed that the left extremity was on an average one inch greater in circumference than the right. Sensation had not returned. The foot was at one time severely burned when it was warmed in company with its fellow.

Prior to the injury the patient was a robust muscular man, but at this time he had become a confirmed hypochondriac and his

physical vigor had disappeared. This is evidently a case in which the columns of the cord both posterior and anterior had been partially divided and in which their fibers became to a great extent reunited, the motor fibers more perfectly than the sensory, aided by perfect immobilization, rest and the aseptic condition of the wound.

2. W. M., a brakeman, was thrown from a freight car when passing under a low bridge. He was precipitated to the ground, but his injuries did not at first appear to be of a very serious nature. He was confined to his room only about two weeks. However, during this time he complained of general soreness, and there was retention of urine, tingling numbness in both lower extremities. These symptoms abated in a short time and he was able to go about. However his neck However his neck remained stiff. Gradually contraction and spasm of the muscles of the left side of the neck appeared, with a marked degree of torticollis. His attending surgeon told him that this was due to rheumatic affection, and that it would soon subside. No thorough

examination was made.

The neck became no better. The patient came under my observation about three months after the accident. By that time he had been under the care of three surgeons, one of whom had given him a certificate stating that he was suffering from torticollis of rheumatic origin. This certificate was indorsed by the second who treated him. Examination revealed right posterior aspect of the neck swollen, red and tender, and elevated in temperature, while the head was rotated and bent markedly to the left side. Careful movements and palpation demonstrated a soft crepitus over the fourth and fifth cervical spines and processes. A colleague examined the case with me and confirmed the diagnosis of un-united fracture and displacement of some part of the vertebral arches or processes. Treatment by extension and immobilization was advised, and was carried out. The patient was put to bed with the head between sandbags for two weeks, then a jurymast was applied with a plaster jacket and worn for about eight weeks, when the swelling and pain had subsided.

The plaster jacket was then abandoned. He was advised to wear the jurymast for some time longer, and was in fact entirely cured of his trouble.

An interesting sequel to this case is, that after recovering one thousand dollars from a railroad brotherhood for permanent disability as a brakeman, he brought suit against the company which had employed him, for $20,000 damages. Apparently to cultivate sympathy he wore the jurymast for more than a year and a half, exhibiting himself meanwhile at county fairs and shows as "the man with the broken neck." His suit was tried three times and finally the Supreme Court of the State of Illinois sustained a verdict of seven thousand dollars and interest. Had he been properly examined and cared for in the beginning, all the expense and damage to the road might have been avoided.

3. H. J., restaurant keeper, was watching workmen take a rod out of a well. While

stooping over to examine a part of the material from the well, a heavy piece of iron fell from the derrick striking him over the lower dorsal region. Complete paraplegia immediately ensued. It was evident that a fracture of some portion of the dorsal arches had occured. A casuel examination was made by a physician, but nothing was done. A surgeon was then summoned from a neighboring town, but he also did not advise active measures. Hence the patient was allowed to lie in bed without other attention than that required to relieve the bladder and rectum. The functions of these gradually improved. When I saw him several weeks later he was in a fairly comfortable condition. Paraplegia remained complete but there was good control over the urine. The case appealed so strongly to my belief that the cord was compressed only, and that relief by means of laminectomy might still be possible that I advised this course. The patient and his friends readily consented and they decided to bring him to the hospital in a few days. Meanwhile my visit had been made known in the town where he lived and a local osteopath persuaded the friends to take the patient to Kirksville, Mo., where he was to be

cured without an operation.

He died in Kirksville within a few weeks after his removal. Had operation been resorted to this might have been also too late, but if immediately performed this would have been apparently a favorable case for recovery. According to Johnson, Jour. Am. Med. Assn., April, 1900, recovery is still possible three months after injury. He reports a case of a removal of a mass of cicatricial tissue from the dura three months after injury, when rapid recovery ensued.

4. J. W., a carpenter, fell head downward through a window into the basement of a house he was constructing, and fractured the arches of the fourth and fifth cervical vertebrae with resultant paralysis of all parts supplied by the cord below. Three weeks after the accident his physician asked me as to the proper course to pursue. So far no radical treatment had been attempted.

The doctor desired to have me see the patient but waited three weeks longer before I was called. I found the patient in bad shape. There was the odor of ammonical urine which dribbled away. Bedsores existed all along the spine. He was greatly emaciated but in good spirits. He very much desired an operation although there was little to encourage the attempt. There was distinct depression over the back of the neck and it was certainly a source of regret that an operation had not been attempted at the time of the injury.

Operation disclosed that the fracture of the arches had produced simple pressure upon the cord, which was easily removed. The patient rallied nicely.

In a few days some degree of motion began to appear in his lower extremities, proving the possibilities of this case had an operation been performed sooner. There was primary union of the wound, but the patient succumbed to a progressing pyelo-nephritis about ten days afterward.

These with other instances, similar accidents observed in the practice of others and which are of frequent occurrence, which cound be cited, have led to the conclusion that many men in our profession are exceedingly slow or disinclined to institute active

measures in cases of injury to the spinal cord or column. It would seem that some discussion is needful to spur men to active skillful and effective measures when life is imperiled by these serious injuries and can evidently be prolonged in some instances at least, and the individual restored to a degree of health. In fact time is an essential element in the attainment of success. With increasingly exact knowledge of the interpretation of symptoms, with better technique, always with the exercise of good judgment the profession should strongly advise, in some cases urge consent to those measures, whose value the laity can only learn by their effective demonstration. There is no more reason why we should procrastinate in the performance of laminectomy in the presence of pressure upon the cord, than that we should hesitate to trephine for fracture of the skull. If such hesitation is the result of timidity, then counsel should at once be sought. The general practitioner should be willing to concede that this is the field of his specialist friend, the surgeon. It will increase confidence in his ability and good judgment, when in such a case he says; call counsel, call a

surgeon.

By active, immediate and judicious measures a life may now and then be saved. No surgeon should hesitate to perform laminectomy when it is indicated. Such indication may exist much more frequently than has been supposed. If laminectomy is to be performed, then it should be done as soon as the symptoms and displacements of the case can be clearly defined, and as soon as shock has subsided. If accessible the X ray may be used to demonstrate position of the fragments of the arch or bodies. Only those cases in which complete separation of the cord exists should be relegated to the hopeless class, but others thought to be hopeless will be found in the class where prompt interference will bring surprising results. The columns and fibres of the cord when once destroyed are probably not regenerated, but operation may be necessary to determine this point.

The operation of laminectomy should be performed over the exact site of the injury,

the incision extending upward rather than downward from this point, and should extend between the spinous and transverse processes so as to reach over not less than three or four vertebrae, and is made to pass well down to the bone. The spinous processes of these vertebrae may now be divided close to their roots so as to furnish ample opportunity for spreading the margins of the wound by means of a pair of strong retractors, the divided ends of the spinous processes remaining attached to the muscular structure to be replaced as nearly as possible in their normal relations when the operation is finished. The rounded beak of a strong pair of laminectomy shears is now inserted beneath the lowest lamina included in the operation and division made from below upward of not less than three of them. These may be then carefully drawn over so as to expose the dura spinalis fully and clearly to view. This will be easy in the dorsal region, but more difficult in the cervical. Any fragment or spiculae of bone which may have penetrated the cord should now be sought for and carefully removed. The dura should be carefully slit up with small scissors and all clots removed from the subdural space. The extent of injury to the cord itself can now be accurately determined. If displaced it may be gently restored as nearly as possible to its normal position, if lacerated, efforts to restore will be of little avail. The wound should now be closed and all the parts placed in as nearly normal relations as possible, a small drain of gauze being left to project from the lower angle. If there has been extensive injury an immobilizing apparatus or plaster jacket should be applied. The drain may be removed through a fenestrum left in the jacket. The patient himself should be as nearly as possible immobilized in his bed.

This description briefly outlines the salient points in the performance of this operation. Andrew J. McCosh in the Journal of the Am. Med. Assn. reports six operations of whom two recovered, four died. He discusses the subject from a standpoint favoring laminectomy. J. C. Munroe in the same journal reports eighteen cases of operation with quite a proportion of successes. He advocates operation even though the case is

nearly hopeless because it offers the only hope for the patient. These cases well illustrate the varying characteristics of this class of injuries, in fact each presents its own peculiar aspects. Still it is possible to formulate certain principles which may help to a conclusion in any given case.

1. In those injuries where no fracture or dislocation has occurred but where a degree of paralysis exists, rest, absolute and physiological is of prime importance.

2. In fractures or dislocations, as in fractures elsewhere, attempt should be made to restore the parts to their normal position by manipulation, extension, or if need be by operation.

After injury or operation the spinal column should be held firmly in position by a proper immobilizing apparatus, jurymast, jacket, splint or brace, or a combination of these.

4. Where pressure exists from depression of the arch or haematomyelia laminectomy should be resorted to at the earliest possible moment.

Promulgate throughout the profession the dictum of Sir Ashley Cooper, "If you could save one life in ten, aye, if you could save one life in a hundred by such an operation, it is your duty to attempt it."

Discussion.

Edward H. Ochsner, Chicago: Mr. Chairman.-The essayist has called attention to one point which is of great importance. I understood him to say that when there is a rupture of the spinal cord operation is futile. As a rule, the diagnosis can be made. If the patient is intelligent, and if the friends, at the time of the examination of the patient, are seen, one can usually tell whether rupture of the cord has occurred or not, and if we are positive it has, operation would not only be futile, but would give additional pain and suffering to the patient. If the patient is intelligent, and was not stunned by the injury, did not lose consciousness, with a loss of motion below the seat of injury immediately following the injury, it is proof positive that the cord is ruptured, and so far as I know, there is absolutely no authentic case on record which has been relieved by operation when there was such a history. There is one reported, but there is some doubt about it.

There is one other point I would like to call attention to, and it is, that Goldthwaite, of Boston, has given us a little device which is extremely useful in all forms of spinal injury

and spinal disease, either acute or chronic.

Goldthwaite has devised a frame for the purpose of treating tuberculosis of the spine, and