THE 
Surgery of tie Spine. 
BY 
J. WILLIAM WHITE, M.D., 
OF PHILADELPHIA. 
Keprint from Annals of Surgery, July, 1889. THE SURGERY OF THE SPINE. 
By J. WILLIAM WHITE, M.D., 
OF PHILADELPHIA, 
PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OF PENNSYLVANIA; SURGEON 
TO THE UNIVERSITY, PHILADELPHIA, AND GERMAN HOSPITALS. 
A CASE of spinal tumor operated upon by Mr. Victor 
Horsley on the 9th of December, 1887 (the diagnosis 
having been made by Dr. Gowers), and published in the Med- 
ico-Chirurgical Transactions, attracted the attention of surgeons 
all over the world. The address of Mr. William Macewen, 
delivered before the British Medical Association in August, 
1888, in which he reported six cases of removal of the poster- 
ior arches of the vertebrae with four complete recoveries, all the 
operations having preceded that of Mr. Horsley, intensified the 
very wide-spread interest which was already felt, and brought 
the subject of spinal surgery prominently before the profes- 
sion. I desire in this paper briefly to review the general out- 
lines of the surgery of the spine, which, I may premise, is not 
in the least a new subject. To systematise we can divide the 
cases which may require operative interference into three 
groups: 1st, Traumatisms; 2nd, Caries ; 3d, Neoplasms. 
1. Operation in cases of injury was suggested as far back as 
the days of Paulus Aegineta, who taught that in spinal frac- 
ture the surgeon must, if possible, attempt to extract the 
compressing bone by incisions, having first warned the patient 
of his danger (Adams’ Translation.) Ambrose Pare in the pres- 
ence of paralysis made a like recommendation. Heister advised 
removal of any fragment that pressed on the cord. In addi- 
tion Hildanus, Matz and Vigaroux all referred to the operation, 
though none of them performed it, while Heine, Roux, 2 
J. WILLIAM WHITE. 
Holscher and Dupuytren each removed portions of the verte- 
bras for disease. Malgaigne says Chopart and Desault are the 
first to speak of it as a very simple thing “to trepan between 
the spinous and transverse processes, to give issue to effused 
fluids or to elevate or remove pieces of bone which may wound 
the cord but it is not recorded that their suggestions bore 
any fruit, and a long interval elapsed without further mention 
of the subject. Dr. James in his “Medicinal Diet.,” Lond. 1745, 
said (in almost the same language employed by Heister): 
“ If the spinal marrow is wounded, death follows inevitably. Though 
as it may seem cruel not to attempt the relief of one under these un- 
happy circumstances, the surgeon should lay the injured part bare by 
the knife, and elevate the fragments, which press upon the medulla, in 
a proper manner; or when they are quite loose, extract them in a prop- 
er manner;. then let him cleanse the wound thoroughly and apply 
balsamic medicines, using the napkin and scapulary. He must con- 
tinue this until the wound heals or the patient dies.” 
The nearest approach to a formal resection of the spine 
at about this date was the operation of Louis in 1762, reported 
in the Arch. Generates de Med., vol. xi, 1836, p. 417, and per- 
formed upon M. deVilledon, captain in the Regiment of Vaube- 
court, who was paralyzed from a gunshot wound of back, 
received at the battle of Amenebourg. Louis and Duplessis 
consulted on the third or fourth day. They withdrew frag- 
ments of bone. 
They also spoke of “ the indication for the trephine, even without 
fracture to give exit to blood, or matter, or even to prevent suppuration 
in some cases of fracture.” M. Villedon recovered and was finally 
able to walk. Louis concludes, *• quoi qu’il en soit e’est une victime 
que Part a soustrait a une mort certaine.” 
The formal operation for the removal of a depressed verte- 
bral arch was, however, first performed by the younger Cline, 
in the spring of 1814, and though unsuccessful, showed the 
practicability of such an operation ; Cline considered (South’s 
Notes to Chelius’s Surgery) that the symptoms sometimes re- 
sulted from the pressure of the spinal cord by the spinous SURGERY OF THE SPINE. 
3 
process or arch of the displaced vertebrae, either fractured or 
not, a condition which he thought analogous to that of the 
brain when a piece of the skull is driven in upon it and causes 
symptoms of compression, which are relieved by the re- 
moval of the cause of the compression. With this notion he 
held it feasible to remove the compressing vertebral arch, and 
so to relieve the palsy. In the clinical lecture which he deliv- 
ered, he explained the reasons that had induced him to perform 
this operation, and the grounds upon which he hoped for 
success. 
He considered that in fracture with displacement of the verte- 
brae, which compressed the spinal cord, this great nervous cord was 
under precisely the same circumstances as the brain when pressed by 
fractured skull, and that, therefore, as the elevation of the pressing 
bone was indicated in the latter case, and often effected with success, 
so was it equally called for in the former, and that no positive reason 
could exist why the operation should not be successful, provided the 
injury of the spinal cord itself were not great, a condition which, as re- 
garded the brain, could equally forbid operation, or render its success 
improbable or impossible. Before undertaking the operation of cut- 
ting out that part of the arch of the vertebra which compressed the 
cord, Cline proposed to himself the following four questions to which 
he gave the annexed replies: (i) Will the patient die of the opera- 
tion ? Probably he will, if the injury be severe.1 (2) If the cord be 
much hurt will it recover its functions? This is unknown but we do 
know that if a nerve be divided it will unite, and the greater part of 
the spinal cord may be divided in a brute and yet the animal recover; 
in proof of which he detailed an experiment which he performed on a 
bitch. (3) After the removal of the arch of the vertebra will the 
spine be sufficiently strong to support the body ? Probably it will for 
ordinary purposes, though the patient may not be able to lift heavy 
weights. (4) Will a patient recover from a compound fracture of the 
spine, which, by the performance of the operation, it becomes ? The 
nearer a fracture is to the source of the circulation, and the less com- 
pact, and consequently the more vascular, the bone is, the greater is 
‘South says: “ I do not exactly understand the answer given, for there is no 
danger in the operation, if it be performed with care ; but I suspect he thought the 
exposure of the spinal cord might hasten inflammation, and so death might more 
quickly result.” 4 
J. WILLIAM WHITE. 
the probability of recovery. Both these advantages are present in the 
spine, and therefore favor the successful issue of the case. He added 
that the only reasonable objection to the operation of trephining the 
spine is, that we cannot, previous to the operation, ascertain whether 
the spinal cord be simply compressed, or whether it be partially or en- 
tirely torn through, or whether the symptoms of compression result 
from the effusion of blood in different situations, neither of which in- 
deed can be ascertained after the vertebral canal has been opened, 
unless the sheath be rent. 
Cline’s operation, although his patient died, attracted 
great attention, and for a time its propriety was vigorously dis- 
cussed. An earnest argument, often degenerating into bitter 
and virulent personality, was kept up for many years ; Sir 
Astley Cooper, Benj. Bell, Tyrrell, South and others endorsing 
and upholding the operation, while Sir Charles Bell, John 
Bell, Sir Benj. Brodie, and others violently opposed it. The 
following quotations give an idea of the tone of a portion of 
the papers which were published about that period. Brodie 
wrote of the operation that “even under the most auspicious 
circumstances it must be doubtful whether it may not be pro- 
ductive of harm rather than of good to the patient;” while 
Sir Astley Cooper concludes his remarks on the subject as 
follows: “Though I may not live long enough to see the oper- 
ation frequently performed, I have no doubt that it will occa- 
sionally be performed with success. There is no reason why 
it should not; and he who says that it ought not to be at- 
tempted is a blockhead.” After a time, however, the contro- 
versy languished, though here and there a solitary operation, 
almost invariably entirely unsuccessful, was recorded. 
In the British and Foreign Medical Review for 1838 in a 
critique of Sir Charles Bell’s “Institutes of Surgery” the 
reviewer quotes a successful case, in which the operation was 
performed by a Welsh surgeon by the name of Edwards, re- 
section having been made in the lumbar region. The case, 
however, is very imperfectly reported. The cases of Tyrrell, 
Barton, Wickham, Smith, Rogers and others were all unfav- 
orable and Malgaigne, after having reviewed their results, joined 
the ranks of the opponents, deciding that the fatality of the SURGERY OF THE SPINE. 
5 
recorded cases should be sufficient to deter surgeons from so 
grave an operation. He believed that if the ordinary methods 
were not sufficient in case of fracture with displacement that 
we might try to act on the posterior fragment with forceps or 
tenacula to draw it backward, but that “ the extraction or 
trephining of the arch presents itself as so desperate a resource ” 
that he would not advise any one to adopt it. 
In 1861, Dr. Hutchison, of Brooklyn, published (.American 
Medical Times) the history of an operation for fracture, which 
resulted in death, and reviewed the histories of the recorded 
cases up to that time. He did not arrive at any general con- 
clusion as to the propriety of surgical interference. 
In 1865 considerable attention was again drawn to the opera- 
tion by Dr. Robert McDonnell, who reported the case of Dr. 
Samuel Gordon, in which trephining of the 12th dorsal verte- 
bra had been followed by the healing of a bed-sore, the disap- 
pearance of a virulent cystitis and the return of power over the 
bladder and of sensation in the rectum, the patient being still 
alive but unable to stand at the end of five months. 
Dr. McDonnell also reported a fatal case of his own and reviewed 26 
cases of trephining, in 7 of which life was preserved for some time. He 
called attention to cases of temporary paralysis from pressure by pus, in 
which the cord had entirely recovered, and to similar ones of paralysis 
from wounds of the spine, followed by recovery on the withdrawal of the 
foreign body which was causing the conpression. 
He concluded that instances of fractures of portions of the verte- 
brae, unaccompanied by fracture or displacement ot the body, are not 
very infrequent, being 10% of the recorded cases which he was able to 
discover, the majority of them occupying the cervical or upper dorsal 
region. 
He suggested that the loss of reflex movement in such patients might 
be due to a venous congestion of the cord below the seat of injury, not 
to structural change, and that such loss is therefore an additional indi- 
cation for operation. 
He thought that evidences of myelitis or meningitis, the girdle symp- 
tom, formication, cramps, spasms, fever, etc., contraindicated operation, 
but believed that the softening of the cord under pressure was quite 
different from ordinary inflammatory softening or “ white softening,” 
and that it indicated no structural change, from which the cord could 
not recover. 6 
/. WILLIAM WHiTE. 
In the discussion in the Royal Medical and Chirurgical So- 
ciety (Medical Times and Gazette, vol. ii., Dec. 9, 1865, pp. 
639, 640) which followed the reading of Dr. Gordon’s paper, 
Mr. Alexander Shaw called attention to the fact that in this 
successful case the operation was not performed till the second 
month after the accident, during which time the vertebral 
column must have undergone essential changes; so that, if the 
bones had not perfectly united, at least all the adjacent parts 
must have become consolidated by the processes of repair. 
“And” he added “observations show that when patients have passed 
through the first stages of the accident, and have lived long enough 
for the injured parts to acquire some solidity and firmness, their 
chances of surviving, although with paraplegia remaining, are greatly 
increased ; the probable reason being that, as they can be moved more 
freely in bed, and their positions more frequently changed, the bed- 
sores are more likely to be cured.” 
In 1866 Mr, Jonathan Hutchinson (Clinical Lectures and 
Reports of the London Hospital, vol. iii., p. 327) considered at 
length the conditions usually met with in spinal fractures and 
luxations, with the object of furnishing conclusive arguments in 
support of the usual practice at the London Hospital of ab- 
staining from operative interference in such cases. 
He asset ted that a good many cases recover, if put under favorable 
circumstances and let alone, and that of those which end in death, very 
rarely indeed, could it be said alter post-mortem examination, that an 
operation could by the barest possibility have done any good. In the 
great majority, then, since it could have done no good, its effect would 
have been to increase the patient’s sufferings, and aggravate his 
danger. 
With regard to the lesions usually met with in the post-mortem room, 
he made the following assertions, based on the examination of about 
twenty cases : First. Permanent compression of the cord, or of any 
part of it, is a very rare event. From my experience I should not 
think that permanent displacement to any material degree is met with 
once in ten cases. Second. As might be expected from the fact that 
almost all the more serious injuries to the spinal column are due to 
indirect violence (bends) the fractures of the laminae are of little conse- SURGERY OF THE SPINE. 
7 
quence and never cause compression of the cord. In almost all our 
cases the laminae, spinous processes, etc., are more or less fractured, 
but I have never yet seen a case in which any of the fragments were in 
contact with the cord. Third. Having thus denied that the cord is 
permanently compressed, either by the bodies or the laminae, I now 
extend my statement to extravasations of blood. I have never myself 
seen any effusion to the extent of possible compression, and in the 
majority of cases there is little or none. The injury is a crush, and is 
not one at all likely to cause much bleeding. There are no large 
arteries to be injured. Fourth. Instances of great displacement of one 
vertebra do sometimes occur. They are exceptional, however, and 
very rarely of a kind which we could rectify by force or by operation. 
Fifth. The cases in which, during life, there is evidence of considerable 
displacement are not by any means always the most serious ones. 
The irregularity, perceived externally, concerns rather the spinous and 
transverse processes than the bodies, and it is very possible that they 
may have been fractured without any crush of the cord ; and, on the 
other hand, that the bodies may have been displaced for a moment, al- 
lowing complete crushing of the cord, and yet no permanent irregularity 
may have resulted. In justification of the strong opinion which I have 
already expressed against operations with the intention to elevate de- 
pressed portions of bone, I must say a few words more. My chief 
reason is that by doing so you convert a simple into a co7tipoundfrac- 
ture, and add the risks of pycetnia, together with those of spinal menin- 
gitis. Then, I urge that depressions of bone very rarely exist, perhaps 
not one in twenty cases, and that it is utterly impossible to select the 
case. 
Injuries of the Spine. 
In 1867 Dr. John Ashhurst reviewed the subject up to that 
date, publishing a table of 26 cases, many of which were in- 
cluded in Dr. Hutchison’s and Dr. McDonnell’s collections, 
reviewed their clinical history, said that there was not in fact 
one well authenticated instance .of recovery from spinal resec- 
tion and concluded that in no case did resection or trephining 
offer a reasonable prospect of improving the patient’s condi- 
tion ; but that on the contrary there was reason to fear that 
they increased the chances of fatal termination. 
In 1809 Mr. Thomas Nunnely, in an Address on Surgery be- 
fore the British Medical Association, again brought the sub- 8 
/. WILLIAM WHITE. 
ject to the attention of the profession. He said that while the 
great majority of surgeons had had an unfavorable opinion of 
the operation of resection of the spine after fracture or dislo- 
cation with symptoms of compression, and while for many 
years it seemed to have been almost forgotten, yet he could 
not but think that this position had resulted more from sub- 
mission to habit or to traditions 1 authority than from a due 
consideration of the subject. He reported four cases of his 
own with one recovery, reviewed the tables of McDonnell, and 
concluded that out of 33 cases of fractures in various parts of 
the spine, life had been permanently saved in three, and con- 
siderably prolonged in three others, and that in still others 
general improvement had resulted. He called attention to the 
fact that all the successful cases were most unfavorable at the 
time of the operation and should, therefore, not be compared 
with large collections of injuries to the spine, of all grades of 
severity. His general conclusion, therefore, .was distinctly fa- 
vorable to the operation, and he quoted with approval the dic- 
tum of Sir Astley Cooper who, more than once, declared that 
if one patient out of one hundred could be saved it would be 
better than could be hoped for from nature alone. During the 
same year, however (1869), Mr. LeGros Clark, in a lecture on 
Diseases of the Spinal Cord (The British Medical Journal, vol. 
ii, July 17, 1869, pp. 49-52), took equally strong ground against 
the operation. His argument may be summarized as follows : 
The end proposed in an operation of this kind is to remove dis- 
placed bone which is supposed to press upon or irritate the cord. But 
such a proceeding is most likely to prove abortive from the inaccessi- 
bility of the displaced bone, fractures of the arches alone being very 
rare except from direct violence. But the direct violence which would 
suffice to fracture the arch and drive the spinous process into the cord, 
the body of the vertebra remaining unbroken, must almost inevitably 
prove hopelessly destructive to the nerve tissue. Again : If the sur- 
geon operate early he does so before it is known whether the injury is 
permanent, a fact which can only be developed by time ; if he wait he 
diminishes his chances of success. If he does operate, he converts a 
simple fracture into a compound fracture, and a communication is es- 
tablished with a canal having the most delicate and susceptible rela- SURGERY OF THE SPINE. 
9 
tions, and which must be liable to the intrusion of the products of in- 
flammation during such period as the patient may survive the effort to 
repair the lesion. If the cord has been crushed, and the operation 
has been consequently useless, probably life may be, thereby, only 
curtailed ; but if (as must be presupposed for the operation to have a 
chance of success) the cord be not crushed, it appears that the best 
chance for the patient’s recovery is thereby extinguished. The opera- 
tion has been advocated on the erroneous hypothesis that the spinal 
cord can be compressed, without serious disintegration of its texture. I 
believe this is scarcely ever the case, unless such pressure result from ex- 
travasation of blood, a condition which, if it could be ascertained, 
would not be regarded as indicating operation. 
The only supposable form of spinal surgery which, in my opinion, 
might be benefited by operation, is a fracture of the vertebral arch 
alone, with limited depression, or the recent intrusion of a spiculum of 
bone within the theca, whereby the cord is pricked and irritated. But 
where are these cases to be met with, and how are they to be recog- 
nized ? I fear w,e must abandon this operation. It can scarcely be 
alleged by its advocates that, if unproductive of good, it is harmless. 
To weaken still further the remaining connections of a broken spine, 
to convert a simple into a compound fracture, to expose the sheath of 
the cord and possibly the cord itself, and to entail the risks attending 
the period of repair, cannot be regarded as circumstances of indiffer- 
ence. 
At present, with every disposition to regard this subject impartially, 
and to give their due weight to the arguments and facts which have 
been advanced in its favor, I cannot regard trephining the spine as 
brought within the pale of the justifiable operations in surgery. 
In 1870, M. Brown-Sequard, from the point of view of a neu- 
rologist, as well as an experimental physiologist, upheld very 
strongly the theory that death after fracture of the spine is usu- 
ally due to the effect of continued irritation of the cord by pieces 
of broken bone and not to the results of a partial or complete 
section of this nervous centre. (Physiology and Pathology of 
the Nervous Centres.) He quoted the clinical history of many' 
cases to prove that section, or even crushing of the spinal cord, 
had not proved fatal, and emphasized the fact that in animals 
death is rarely caused byr complete section of the cord in the 
dorsal region, while they die as quickly and as often as men 10 
/. WILLIAM WHITE. 
after fracture of the spine if the broken pieces are not removed. 
He further called attention to the removal of the body of the 
third cervical vertebra by an Italian surgeon in a case of 
sypnilitic caries, to another analogous case also operated upon 
by an Italian surgeon, and to two cases of cyst in the spinal 
canal with erosion and expulsion of portions of the vertebrae, 
all of which recovered. 
He believed that as the result of his investigations the following 
conclusions were justifiable : (i) That the laying bare of the spinal 
cord is not a dangerous operation ; (2) that death after a fracture of 
the spine is usually due to the effects of pressure, or of excitation of 
the spinal cord, and is not the result of a partial or a complete section 
of this organ ; (3) that reunion may take place after a wound of the 
spinal cord, so that its lost functions may return ; (4.) that the removal 
of some parts of the vertebrae may be followed by a production of new 
bone ; (5) that the cases of fracture of the spine in which the trephine 
has been applied show the usefulness of this operation.* 
In spite of this pronunciamento, another long interval en- 
sued with very few reported cases which I have been able to 
discover, of resection of the spine in case of injury. Two 
cases in 1870, operated on by Cheever, of Boston, both re- 
sulted fatally, as did one operated on by E. R. Willard in 1871, 
and one by Lucke in 1880. Stemen, of Indiana, in 1883, reported 
three cases, one relieved, one not benefited, one fatal in eight 
days. 
In 1884 Dr. John A. Lidell, in the article on Injuries of the 
Back, in vol. iv of the International Encyclopaedia of Surgery, 
quoted Ashhurst’s statistics, recorded the statement of Prof. 
Eve, of Nashville, to the effect that resection of the dorsal ver- 
tebra is “one of the most difficult in surgery, if not impracti- 
cable,” and concluded that the operation of resection or tre- 
phining the vertebrae is unjustifiable, because it does not offer 
a reasonable prospect of improving the patient’s condition in 
any case, while, on the other hand, there is always reason to 
fear that it may increase the chances of a fatal termination. 
In September, 1884, Dr. Halsted, of New York, operated at 
the Roosevelt Hospital on a patient, who three days previously SURGERY OF THE SPINE. 
11 
had suffered a fracture of the spine of the twelfth dorsal ver- 
tebra with rotation and forward luxation of the body of the 
same vertebra and fracture of the right transverse process of 
the first lumbar. The displacement was reduced with the help 
of Langenbeck’s hook, but the patient died seventeen hours 
later. [Medical News, January 3, 1885). 
In November, 1884, Dr. Pinkerton, acting as house-surgeon 
for Dr. E. L. Keyes, removed the spinous process and lamina 
of the twelfth dorsal vertebra, which had been fractured four 
days previously. The patient died five days later. [Ibid). 
In February, 1885, Mr. William Macewen [British 
Medical Journal, August, n, 1888) operated in the case 
of a man who, six or eight weeks previously, had had a severe 
injury to the spine at the level of the lower dorsal vertebrae. 
He had absolute motor paralysis, incontinence, liyperaesthesia 
followed by anaesthesia, rapid muscular atrophy, cystitis, bed 
sores, pyrexia, etc. Resection was performed; the arch of 
the 12th dorsal was found fractured and depressed ; a connec- 
tive tissue tumor between it and the theca was removed, as 
well as the laminae involved. The patient made a good re- 
covery and a year later could walk about with ease and with- 
out support. 
In 1886, Dr. Robert T. Morris reported (Annals of 
Surgery, June, 1886) the case of a patient who, as 
the result of a fall upon the head, had complete para- 
plegia with loss of sensation and of motion at nearly all points 
below the neck. Two years and three months after the acci- 
dent the laminae and spinous process of the 7th cervical verte- 
bra and the spinous process of the 6th cervical vertebra were 
removed. The patient lived ten months but was not mater- 
ially improved. At the autopsy very extensive disease of the 
cord itself in the neighborhood ot the injury was found. The 
membranes were thick and firmly adherent to each other and 
to the vertebrae. 
In 1886 Dr. Carl Lauenstein, of Hamburg, reported [Cen- 
tralblatt f Chirurgie, No. 51, 1886; London Med. Record, March 
15, 1887) the case of a patient who, five weeks before coming 
under observation, had had a fall of forty feet. This was fol- 12 
/. WILLIAM WHITE. 
lowed by paraplegia, incontinence of urine and faeces, trophic 
changes, etc. There was a projection in the dorso-lumbar re- 
gion, most prominent over the spine of the last dorsal. The 
use of a plaster jacket had failed to give relief. The arches of 
the last dorsal and first lumbar vertebrae were removed by 
means of a chisel. 
Six months later the patient was able to walk, the inconti- 
nence had disappeared, and he was reported as quite recov- 
ered. 
With the view of deciding the question whether such improvement 
as had resulted in this case could possibly be attained without the per- 
formance of a surgical operation, Dr. Lauenstein has looked over pub- 
lished reports of similar cases, and studied especially the statements 
referring to paralysis of the bladder. The relief of this condition, he 
states, is a point of much importance, for, with the exception of bed- 
sore, which usually occurs in such cases, cystitis is, undoubtedly, the 
most formidable of all the secondary symptoms. Of fifty-three cases 
of so-called cure of fracture of the spine, collected by Gurlt in his 
work on fractures, there are fifteen instances of spontaneous restora- 
tion of the functions of the bladder and rectum. The shortest interval 
between the date of the accident and that of complete restoration of 
the functions of these organs was a few hours, and the longest interval 
eight weeks. 
In not one of six cases of fracture of the spine with paralysis of the 
bladder, treated by Lauenstein during the last six years, was any spon- 
taneous improvement observed in this latter condition after long inter- 
vals. It is concluded from these returns that when, in cases of com- 
pression of the cord from fracture of the spine, the functions of the 
bladder and rectum are restored, this restoration usually takes place 
after a brief interval, and that if no improvement has taken place in 
the course of ten weeks, any subsequent spontaneous change for the 
better in the condition of the bladder can hardly be anticipated. In 
the case reported by Dr. Lauenstein the bladder symptoms just before 
the operation were increasing in severity. Since the introduction of 
the antiseptic method into practical surgery two other instances in ad- 
dition to Macewen’s and Morris’ cases had been reported up to this 
date (1887) of operative interference for the relief of paralysis from 
injury to the spine. 
The first of these, reported by Maydl, from the hospital practice of SURGERY OF THE SPINE. 
13 
Albert, had been diagnosed as a case of fracture of the spine in the 
dorsal region, but was found to be one of luxation and crushing of the 
cord. The patient recovered from the operation. In the second 
case, reported by Lucke, the operation was performed two days after 
an injury to the spine, which was found to consist in fracture with 
crushing of the corresponding part of the cord. This patient also re- 
covered from the operation, but died nine months later from maras- 
mus, and without any but very slight improvement having been ob- 
served in the condition of the paralyzed limbs. In six only of thirty- 
one cases collected by Werner of operations performed on fractured 
spine in the pre-antiseptic era did the patients recover from the effects 
of the operation. These results, however, Dr. Lauenstein held, can 
not be brought forward to discredit the operation of trephining the 
spine, since sufficient care was not taken in their selection ; and the 
treatment was applied in instances both of recent and of old injury, 
and even of complete crushing of the cord. 
Dr. Lauenstein would not operate in a case of recent injury to the 
spine, as it is well known that occasionally in such instances the symp- 
toms of paralysis disappear spontaneously in the course of a few 
weeks. 
In the Edinburgh Medical Journal for March, 1889, Mr. 
John Duncan reports three cases of fracture of the spine with 
paralysis which were operated upon by removal of the laminae 
of the broken vertebrae. One case died on the following day ; 
the others recovered from the operation but were unimproved. 
Horsley, in a foot-note to his paper on the case of spinal tu- 
mor, says he has operated on a case of fracture and that the 
wound healed rapidly, but gives no other details. In the pa- 
per itself he also mentions a most interesting case of opera- 
tion for the paralysis following fracture, in which the wound 
healed rapidly, as did a large bed sore. There was but little 
general improvement. 
It was found in this case that the spinous process of the 
nth dorsal vertebra was jammed forward between the 10th 
and 12th, and also that there was backward compression of the 
cord against the lamina of the 10th vertebra. These were 
removed. Mr. Horsley makes the following remarks apropos 
of these cases, and with reference to the dictum that 
when there is evidence that the cord has been severely jammed 
or compressed at the time of accident, an operation is contra- 
indicated. 14 
J. WILLIAM WHITE. 
“In this case no doubt the spinal cord was momentarily jammed at the 
time of the accident so severely as to practically, i. e., functionally, di- 
vide it. Though laminae were found compressing it at the time of the 
operation, nevertheless they did not do it so severely as to thereby 
alone cause the excessive degree of the symptoms, therefore it would 
seem that the cord, as suggested, must have been compressed at the 
time of the accident. Now, this is just a case in which, if any atten- 
tion had been paid to the ruling before quoted, the patient’s life would 
have been lost, and indeed it must be obvious that, considering the 
necessarily small amount of information on this subject, it should be 
our duty to operate in every case, since we may possibly do some 
good, and certainly, if proper antiseptic precautions be taken, we can, 
to use Mr. Erichsen’s words, do no harm. 
This question of the damage to the spinal cord not appearing to 
discount the possible benefit of surgical interference so much as has 
been hitherto expected, gains additional illustration from the case 
which forms the subject of this paper, since nothing could well have 
appeared more hopeless than the indentation of the spinal cord pro- 
duced by the tumor. This indentation appeared to divide the lateral 
column completely, and yet, owing doubtless to the gradual character 
of the compression, the restoration of motor and sensory function has 
been complete. I would repeat, therefore, that, so far from its being 
unjustifiable to operate on the spine owing to the possibility of the 
cord being hopelessly damaged, it seems to me to be criminal not to 
operate.” 
Mr. Ernest Hart reports (The British Medical Journal, 
March, 23, 1889,) a case of Pean’s in which paraplegia, reten- 
tion of urine, etc., followed a severe contused wound of tne 
mid-dorsal region caused by the bite of a horse. The spinous 
processes of the 7th and 8th dorsal vertebras were not to be 
felt. Pean removed by operation the fragments of these pro- 
cesses, and of the corresponding laminae which had pierced 
the membrane and entered the substance of the cord itself- 
He resected the irregular ragged fragments of the transverse 
processes. Mr. Hart reports that the operation was completed 
without complication, and that “the patient is now restored to 
almost his ordinary condition.” 
Mr. Herbert Allingham reports (British Medical Journal, 
April 13, 1889, p. 838) two cases of fracture of the spine treat- SURGERY OF THE SPINE. 
15 
ed by trephining. In one there was fracture with depression 
of the lamina of the sixth dorsal vertebra ; the spines and 
laminae of the fifth, sixth and seventh were removed. The 
wound healed in ten days. The symptoms of ascending 
changes were checked. Improvement to some extent occurred. 
In the second case the spines and laminae of the third, 
fourth, fifth and sixth dorsal vertebrae were removed; the 
wound healed in a fortnight. No mention of the subsequent 
course of the case is made except the fact that the woman 
died seven weeks later, and that the cord was found almost 
divided. 
I believe I have now given a fairly complete view of the 
history of this operation in cases of fracture and luxation and 
with sufficient detail to permit of a reasonable estimate of its 
present position before the profession. 
The arguments employed against operation in these cases of 
pressure upon the cord from fracture or displacement may be 
summarized as follows: It was said that there was great cif- 
ficulty of diagnosis between the cases in which the operation 
would probably prove useful, and those in which it would 
probably afford relief on account of the limited extent of the 
injury. This is undoubtedly true, but a precisely similar argu- 
ment will apply to many other serious and frequently em- 
ployed operations, and all the most recent additions to our 
knowledge of the subject, whether derived from clinical ex- 
periments or from experimental and pathological investigation* 
lead us to assign to the cord a much greater power of repairing 
damage than was formerly thought to be conceivable. 
It was said that the position of a fractured bone often ren- 
dered it impossible to reach it; and that the pressure was com- 
monly from the bodies of the vertebra which could not be re- 
moved. A careful review of reported autopsies shows that 
the proportion of cases in which the pressure is from the 
laminae is much greater than has been supposed, and that this 
assertion is as true now as when originally made by Mr. Nun- 
nely 20 years ago. 
It is very easy to demonstrate that the sweeping statements 
which have been quoted, as to the rarity of direct compres- 
sion by the arches and spinous processes, are not justified by 16 
/. WILLIAM WHITE. 
the facts. I append a number of references to cases of this 
character selected almost at random from medical literature, 
while seeking information as to other points. They might be 
multiplied indefinitely.1 They demonstrate that, in addition to 
the relief which we may fairly expect to give by removal of 
the lamina even in cases of compression by posterior displace- 
ment of the bodies, we may also expect in a very considera- 
ble proportion to remove completely and permanently the act- 
ual compressing and irritating factor, thus giving the cord an 
opportunity for reparative action if it has not been hopelessly 
crushed or disorganized—an opportunity which could not con- 
ceivably occur if the patient were left to the unaided processes 
of nature. 
Perhaps the following case recorded by a distinguished neurologist will serve as 
well as any, as an example of a group of cases which a very little research shows to 
be by no means infrequent. 
Dr. Charles K. Mills has reported(The Polyclinic, vol. I, No. 9, 1884) the case of a 
man who had been crushed by the roof of a building falling upon him; he had motor 
and sensory paralysis, never recovered, and died of exhaustion five years later. 
A post-mortem examination was made thirty hours after death by Dr. Flick. The 
vertebra1 column had been fractured at the position of the 12th dorsal and 1st lum- 
bar vertebrae. The posterior portion of the upper of these bones had been broken 
and driven inward, and its fragments were overridden by a portion of the lower in- 
jured vertebra. The dura mater was adherent to the bone at the seat of the frac- 
ture. In the external layer of the dura, just at the lower end of the spinal cord, 
was a bony mass, one-half inch long by one fourth inch wide. The membrane, for 
a short distance above this point, and down the cauda equina, was much thickened 
and covered with a dirty exudation. The cord at this point was red and very soft. 
The spinal canal contained a large effusion. 
Cases more or less similar, but agreeing as to the occurrence of fracture of acces- 
sible portions of tie vertebrae,have been reported by Astley Cooper, Hamilton, Frac- 
tures and Dislocations , Stephen Smith, N. Y. Journal of Medicine, vol. vi, 1859; 
Curling, two cases, London Hospital Reports, vol. 1 ; Van Syck, N. Y. Journal of 
Medicine, vol. iii. 1857 ; Eberman, Am. Joum. of Med. Sci., October, 1879; Arnott, 
Lancet, 1851 ; Bransby Cooper, Lancet, 1828 ; Williamson, Dublin Quarterly Jour- 
nal, vol. 27; Boyer, Surgical Works, vol. 2; C. S. May, Am. Journ. of the Med. Sci. 
Oct. 1876 , Erichsen, Science and Art of Surgery ; Malgaigne, Treatise on Frac- 
tures, Packard’s Trans., N. Y. Jo ir. of Med. and Collat. Sci., Sept. 1849, p. 268, 
Hamilton, Treatise on Fractures and Dislocations, Guy’s Hospital Reports, vol. ii, p. 
480; F. H. Hamilton, Jr., American Medical Times, N. S., vol. 8 ; Berkely Hill, 
Trans. Royal Med. and Chirurg. Soc., Jan. 22, 1867 ; Abernethy, J. Comstock, Bost. 
Med. Jour., 1848 ; William Pepper, Trans. Patholog. Soc. of Phila., 1867 ; T. B. 
Ladd, Boston Medical Journal, 1852 ; A. P. Clarke, Journal of the Am. Med. Ass’n., 
October, 1884; S. D. Townsend, Am. Tour. Medical Sciences, O. S., vol. 22; J. Solis 
Cohen Trans. Patholog. Soc. of Phila, 1878. SURGERY OF THE SPINE. 
17 
Of the 53 cases of resection for fracture and lux- 
ation which have thus far been recorded I find that 
in no less than 21 was there a fracture of the lamina 
or processes, a percentage of 6.2 which, while it is 
undoubtedly in excess of the actual frequency of this form of 
fracture, should yet be studied in the light of the state- 
ment made by the opponents of the operation, viz., that it is 
impossible to tell with accuracy the extent of the damage and 
the particular parts involved. If this impossibility really ex- 
ists it is all the more important that we should not lose sight 
of the fact that the injury may be one quite relievable by op- 
eration. t 
Even when the pressure is anterior, having been caused by 
displacement or fracture of the vertebral body, removal of the 
posterior arches increases the calibre of the canal and increases 
also the chance of avoiding irreparable damage to the cord by 
compression. That it is unsafe to say in any given case that the 
cord is hopelessly damaged would seem to be fairly well estab- 
lished by the results of such cases as Horsley’s, Macewen’s and 
Lauenstein’s, so that operation should scarcely be refused on 
that score alone.1 A still further argument was that the ex- 
JIn his article in Holmes’ Surgery (vol. iv., p. 130), Alexander Shaw says .• 
“ Changes of the most extraordinary magnitude may be effected in the brain and 
cord by encroachments of various kinds, without the sacrifice of their functions, on 
condition that the intrusion is made slowly and gradually.” This opinion has been 
reiterated even by surgeons who like Mr. Shaw, earnestly oppose resection, and is 
used as an argument for trusting the patient to the vis medicatrix natures. Prof. 
Eve has brought together (Am. Jour, of the Med. Sciences, July, 1868) eleven cases 
of supposed division of the spinal cord, in which life was variously prolonged, and 
in one of which recovery was complete. In the lower animals the results of vivisec- 
tion experiments have been somewhat contradictory, but on the whole sustain the 
view that the cord like other nerve trunks possesses extraordinary regenerative 
power. In some animals true nervous matter is re roduced after part of the cord 
has been destioyed ; at least, this is so in tritons and lizards (Muller). As is well 
known in these animals, when the tail is removed it is reproduced, and Muller found 
that a part of the spinal cord corresponding to the new part of the tail is reproduced. 
Morphologically the e'ements were the same, but the spinal nerves were not repro- 
duced, while physiologically, the new nerve substance was not functionally active. 
It corresponds, as it were, to a lower stage of development. 
According to Masins and Vaulain, an excised portion of the spinal cord of a frog 
is reproduced after six months; while Biown-Sequard maintains that reunion of the 
divided surfaces of the cord takes place in pigeons after six to fifteen months. A 18 
/. WILLIAM WHITE. 
posure of the cord and membranes to the air would inevitably 
set up a destructive inflammation, an argument which in these 
days of antiseptic surgery need not further be considered. The 
general conclusions that the operation was too difficult, was too 
prolonged, that there was danger of fatal haemorrhage, etc., 
were, as experience has shown, largely theoretical and al- 
though the operation is certainly not an easy one, and although 
one operator did lose his patient on the table from haemor- 
rhage while attempting to perform it, it is still one which may 
be confidently undertaken by any experienced surgeon. 
In reviewing the statistics of these operative cases it seems 
to me quite proper that those belonging to the preantiseptic 
period should be omitted, or should be regarded in a category 
by themselves. I do not mean that all, or even that a majority 
of the fatal cases, were due to septic disease. In many of 
them the time was too short, in others death resulted from inter 
current disease of other organs, but a sufficiently large propor- 
tion were so distinctly septic as to invalidate any sweeping 
conclusions based upon these results, sepsis after this opera- 
tion being as absolutely avoidable as after any in surgery. 
This would leave then, in a class by themselves, the thirteen 
operations for fracture of Macewen, Morris, Horsley, Lauen- 
stein, Liicke, Albert, Duncan, Pean, and Allingham with three 
complete recoveries, two recoveries from the operation with 
benefit, seven recoveries unimproved, and one death. 
The chief strength of the opponents of operation 
'lies in the argument that the operation per se is of 
great danger or in itself materially diminishes the pa- 
tient’s chances. If, as I believe to be the case, it can 
be fairly claimed that rapid reunion of all the soft struc- 
tures down to the dura mater itself can be confidently expect- 
ed ; if it can be shown, as it has been, that the most extensive 
partial reunion is asserted to occur in dogs by Dentan, Nannyn and Eichhorst, al- 
though Fchieferdecker obtained only negative results, the divided ends being united 
only by connective tissue (Schwalbe). 
Eichhorst and Nannyn found that in young dogs, whose spinal cord was divided, 
not excised, between the dorsal and lumbar regions, there was an anatomical and 
physiological regeneration to such an extent that voluntary movements could be ex- 
ecuted. Vanlain in the case of frogs, and Masins in dogs, found motility restored 
first, and sensation afterwards. SURGEPY OF THE SPINE. 
19 
resections of the laminae do not greatly or permanently weaken 
the spine; if under antiseptic methods the risks of consecutive 
inflammation of cord or membranes are practically ml; if 
haemorrhage is not to be feared, and loss of cerebro-spinal fluid 
is unimportant;1 if it happens not so very infrequently that the 
cord is directly compressed by fragments of the laminae them- 
selves, or if not, that by removal of the arches relief from the 
anterior pressure is afforded ; if these are facts, or even reason- 
ably strong probabilities, it is evident the operation is one 
which should no longer be rejected on the sole remaining ground 
that we cannot be certain in any given case as to the exact 
amount of damage which has been done to the tissues of the 
cord. The argument that if such damage were irreparable, 
operative interference would be useless, while if the cord re- 
tained the power of recovering itself the operation only added 
another complication, has lost nearly all its force. It would 
seem rather to be the duty of the surgeon after a reasonable 
and not very protracted delay to endeavor to relieve any pos- 
sible pressure, to remove any fragments or spiculae of bone, to 
drain thoroughly the canal or even the subdural space if there 
were any oozing and to do so with the consciousness that if he 
meet with none of these conditions, he is at any rate not per- 
forming a necessarily fatal operation.1 
2. As time went on the application of operative methods to 
the diseased conditions of the spinal cord and canal, other than 
those produced by injury or accident was naturally thought of. 
In the second group of cases which includes those of spinal 
'Dr. Herbert Burrell in a valuable paper read before the Massachusetts Medical 
Society, June, 1887, has recorded the results of immediate rectifications o the de- 
formity and fixation of the spine by means of a plaster jacket. He details sixteen 
cases, in which three died, three derived no benefit from the method, and ten were 
greatly benefitted. He arrives at the following conclusions: 
1. That in the immediate correction of the deformity and fixation with plaster of 
Paris jacket or other means, we have a rational method of treating a large number 
of cases of fractures of the spine. 
2. That considering the hopelessness of results in fracture of the spine when 
treated expectantly, almost any risk is justifiable. 
3. That the immediate correction of the deformity is imperative, if softening of 
the cord can and does occur from pressure at the end of forty-eight hours. 20 
J. WILLIAM WHITE. 
paralysis due to pressure by pus or by carious vertebrae, we 
have some encouragement to operation held, out in the clinical 
facts i1 (1). That there are very many examples of the relief of 
paralysis in spinal caries, after the pointing of a psoas or iliac 
abscess, or after the evacuation of pus by the side of the 
spine. It is scarcely worth while to give special instances of 
the truth of this statement. It is familiar to all who have seen 
many cases of Pott’s disease. Of course in such instances the 
evacuation of the abscess when it is accessible, or the per- 
formance of Treves’s operation for the removal of the carious 
portion of the vertebrae is clearly indicated. (2) By the fact 
that the disease of the dura mater in Pott’s disease is limited 
to the site of the diseased vertebrae. The change from an in- 
flammatory to a normal area is an abrupt one. Dr. George 
R. Elliott in a valuable paper on the Pressure Paralysis of 
Pott’s Disease (TV. Y. Medical Journal, June 2, 1888) has fully 
developed this point, long ago advanced by others, in an argu- 
ment to sustain the theory that this paralysis is due chiefly, 
almost entirely, to pressure and not usually to grave changes 
in the cord itself. Some of his conclusions, sustained by au- 
4. That the suspension of the patient is only a means of rectifying the deformity; 
that certain fracture could be simply pressed into position while the patient lies 
prone or supine. 
The objections to the treatment are: 
1. That the expectant plan of treatment gives a small percentage of recoveries. 
2. That there are, especially in the cervical region serious risks attending the sus- 
pension of a patient and the rectification of the deformity with a fractured spine—in 
the way of shock, collapse and death. 
3. That in attempting to relieve pressure on the cord, by rectifying the deformity, 
we might either sever the spinal cord or make pressure upon it. This is a matter of 
chance. 
My own belief regarding the status which the procedure should occupy in surgery 
is, that it will occasionally be a life-saving measure; that it should be applied under 
anaesthesia in all cases of fracture of the spine, which are not conclusively known to 
be irremediable; and that apart from the chance of recovery offered to the patient 
by this means, it will almost invariably make the patient more comfortable, in that 
he can be handled more easily. 
'Lidell. Internat. Encyc. of Surgery, vol. iv., ja. 786. SURGERY OF THE SPINE. 
21 
topsies in twenty-one cases, have a direct bearing upon the 
question and may be found subjoined.1 
That these statements, at least in so far as they attributed 
the paralysis of Pott’s disease to an external pachymeningitis 
rather than to direct pressure from the bones themselves are 
not new ones, a few quotations will demonstrate. Hippocra- 
tes, writing of spinal cases, said : 
The palsy of the legs and arms, the wasting of the body, and the re- 
tention of urine happen chiefly in those cases where there is no 
spinal deformity, nor any projecting bone forward or backward; and 
paralytic affecaons take place the least frequently in cases of gibbous 
or angular projections 
Mr. Percival Pott, writing in 1720 on “The Useless State of 
the Lower Limbs in Consequence of a Curvature of the Spine,” 
says: 
Since I had been particularly attentive to the disorder, I thought 
that I had observed that neither the extent nor degree ot the curve 
had in general produced any material difference in the symptoms, but 
that the smallest was, when perfectly formed, attended with the same 
consequences as the largest, and that the useless state of the limbs is 
by no means a consequence of the altered figure of the spine, or of the 
’It seems to him demonstrated: That we have present a simple mechanical pres- 
sure in the form of abscess products, thickened dura or bone; that the inflammatory 
process is invariably a limited one, the inflammation of the dura mater being restricted 
exactly to the site of the diseased vertebrae, exhibiting no tendency to extend in the 
membrane—nature’s medullary protection; that the medullary surface of t .e dura 
mater is almost invariably normal. It follows, then, that the pressure lesion is sim- 
ply mechanical, possessing no tendency to involve the spinal cord through any in- 
herent specific characters of the carious process—a bland mechanical lesion—and 
the damage it inflicts commensurate with the pressure exerted. 
Experimental physiology gives no evidence of an inflammatory lesion following 
experimental compression of the cord. A careful examination of the pathalogical 
findings of reporte 1 cases reveals to us, in the light of recent pathological knowl- 
edge, but few instances where we have reason to believe the original lesion to have 
.been inflammatory. These were cases where the process was virulent, leading to a 
perforation of the dura mater, thus allowing the purulent products to come in direct 
contact with the cord, giving rise to a lepto-meningitis. 
Finally, then, Dr. Elliot concludes, our researches have led us to the belie! that 
the original lesion is, as a rule, non-inflammatory, an opinion supported by path- 
ology and experimental physiology, and corroborated by clinical manifestations. 22 
/. WILLIAM WHITE. 
disposition of the bones with regard to each other, but merely of the 
caries. 
Michaud, in 1871, completely elucidated the mechanism of 
this form of paralysis. (Sur la Meningite et la Myelite dans le 
mal vertebral.) 
Dr. Thomas Buzzard, reporting a case of Pott’s paraplegia 
(The Transactions of the Clinical Society of London, vol. 13, 
1880), says : 
The spinal cord was curved abruptly at an angle ot 125°, but the 
cavity in which it lay, although encroached upon to a certain very 
small extent by the thickening of tissue external to the dura mater, 
did not appear to be sufficiently narrowed to affect the calibre of the 
cord. There was no pinching or obvious compression, except what 
was due to the bending of the cord upon itself. The soft membranes, 
the surface of the cord, and the internal surface of the dura mater 
were entirely free from traces of inflammation. 
Gowers says (Diseases of the Nervous System, 1886, vol. 1, p. 
169): 
The inflammation extends to the loose cellular and adipose tissue 
between the bone and the dura mater, and often to the dura mater it- 
self, the outer layer of which becomes irregularly thickened in the 
neighborhood of the disease. The inner surface of the dura mater is 
often normal when the outer surface is much changed. Inflammatory 
products, cheesy material, pus, etc , accumulate between the bone 
and the dura mater, and often in such quantity as to com- 
press the cord. Inflammation is frequently set up in the cord, but 
usually only when it is compressed. The damage to the spinal cord 
depends on the secondary consequences of the caries, and both its oc- 
currence and character are variable and uncertain. The mechanism 
of the damage is twotold—compression and inflammation. The me- 
chanism ot compression varies. The most frequent is the collection 
of inflammatory products outside the dura mater, and the thickening 
of this membrane. Less commonly the cordis compressed by the dis- 
placement of the bone, or by fragments of bone that are pushed into 
the canal. SURGERY OF THE SPINE. 
23 
On May 9, 1883, Mr. William Macewen, in a case of com- 
plete sensory and motor paraplegia, with incontinence of 
urine and feces, and of two years duration, the result of angu- 
lar curvature of the spine, removed the laminae of the 5th, 6th, 
and 7th dorsal vertebrae. Between the theca and the bone he 
found a fibrous neoplasm one-eight of an inch in thickness firmly 
attached to about two thirds of the circumference of the mem- 
branes ; this was carefully dissected off; 24 hours later improve- 
ment began, and in 6 months the patient was able to walk. In 
5 years afterward he was attending school and joining in all 
the games including foot-ball. Mr. Macewen’s cases of para- 
plegia in Pott’s disease, included four others, two of which 
were successful, one of them being of the most aggravated 
character imaginable. The connective tissue tumor was very 
dense, intimately adherent to the theca, and the cord beneath 
was shrunken, to half its dimensions, and lay like an inani- 
mate rod. Several laminae were removed, but at no time dur- 
ing the operation were there any distensile pulsations of this 
part of the cord. It was thought that there was no hope of 
the patient, a female, recovering from her paralysis, but she 
did so, walked a quarter of a mile eight months later, and 
now does house-work and enjoys life. A third case was also 
successful. The two fatal cases died, one a week af:er the 
operation, the other eight months later, of general tuberculosis. 
Recently Mr. Horsley has operated upon a case of complete 
paralysis of all four limbs from caries of the 2nd and 3rd cervi- 
cal vertebrae, and reports the case as rapidly regaining power. 
The wound healed without the slightest complication. 
In December, 1888, I operated upon a paraplegic patient 
with Pott’s disease and angular curvature. The patient had 
grave visceral lesions which together with the shock of the op- 
eration caused his death. The case will be found fully re- 
ported in the last number of the Annals of Surgery. 
Dr. Robert Abbe, of New York, has recently (Medical 
Record. P'ebruary 9, 1889) reported a case which he describes 
as an extra-dural tumor of the spine, but, which seems to 
have been a case of caries of the dorsal vertebrae followed by 
localized suppuration with inflammatory thickening and dessi- 24 
J. WILLIAM WHITE. 
cation of pus, rather than a tumor causing caries by pressure. 
In this case the spines and laminae of the 8th, 9th, and iotli 
dorsal vertebrae were cut away by the rongeur and the mass 
of dense tissue above the spine removed. The patient made a 
rapid recovery, regaining the ability to walk while pushing a 
chair. In another case of intractable brachial neuralgia the 
laminae of the vertebrae from the 5th cervical to the 3rd dorsal 
were removed upon the right side, and the posterior roots of 
the 6th, 7th, and 8th cervical nerves were divided. The pa- 
tient made a quick recovery. 
Mr. Duncan has reported (Edinburgh Medical Journal, 
March, 1889) a case of paraplegia of nearly a year’s standing 
and due to Pott’s disease, relieved by the removal of the 
spines and laminae of the 4th, 5th, 6th, and 7th dorsal verte- 
brae. 
Mr. W. Arbuthnot Lane reports (British Medical Journal, 
April 20, 1889) a case of Pott’s disease with angular curvature 
in a child aet. 7*/2 years. The curvature was about the middle 
of the dorsal region. For 11 months he had been paralysed. 
The spinous process and laminae of the fourth, fifth and sixth 
dorsal vertebrae were removed with bone forceps. The body 
of the fifth appeared abnormally near the laminae of the ad- 
joining vertebrae, and the cord seemed to have been forcibly 
compressed between those bony points. The wound healed 
under two dressings. A month later he was able to move both 
legs freely, and at the time the case was reported seemed on 
the road to recovery. 
The cases of Macewen give strong corroborative evidence in 
favor of the theory of extra-dural pressure rather than inter- 
stitial cord change as the cause of the paraplegia in these cases 
as does that of Horsley, the cord recovering there from the ef- 
fects of the pressure of the tumor, which had been exerted with 
sufficient firmness, and for so long a period, as almost to liemi- 
sect it. Duncan’s case and Horsley’s other case (of Pott’s 
paralysis) are also valuable evidence in the same direction. 
We thus have another small series of secondary operations, 
i. e., those for spinal caries performed during the era of scien- 
tific surgery, and including the ten operations of Horsley, SURGERY OF THE SPINE. 
25 
Macewen, White, Abbe, Duncan, and Lane, with three com- 
plete recoveries, four recoveries from the operation with ben- 
efit, and three deaths, one eight months after the operation, 
and from systemic disease. 
The evidence seems to be fairly conclusive that the cause of 
the paralysis in Pott’s disease is not, as a rule, a transverse 
myelitis or a hopeless degeneration, and is not due to the 
pressure of the carious or displaced vertebrae, but is in the ma- 
jority of cases the result of an external pachymeningitis 
which results in the formation of an extra-dural connective tis- 
sue tumor.1 
This fact taken with the above clinical evidence at 
any rate seems sufficient to my mind to warrant the sug- 
gestion that in the future in all cases of paralysis from 
spinal caries, we should, after (ist) evacuating pus when- 
ever it is accessible, and (2nd) having treated the 
patient by the extension process with a plaster jacket, proceed 
at once to a resection, if these prove unsuccessful after a fair 
trial. 
Resection of portions of the body of a vertebra has been 
performed in paralytic cases on the 6th and 7th cervical verte- 
brae by Podres {Russkaja Med. No. 19. 1886) with recovery; 
on the dorsal vertebrae by Boeckel with excellent results 
Tn an admirable paper by Weir Mitchell on The Treatment of Pott’s Paralysis 
{The American Journal of Medical Sciences, May, 1889), the following conclu- 
sions are reached: 
That suspension should be used early in Pott’s disease; that used with care it 
enables us slowly to lessen the curve; that in these cases there must be in some 
form a replacement of the crumbled tissues; that unless there is great loss of power, 
the use of the spine-car or chair, etc., of John K. Mitchel, enables suspension, es- 
pecially in children, to be combined with some exercise; that no case of Pott’s par- 
alysis ought to be considered desperate without its trial; that suspension has suc- 
ceeded after failures of other accepted methods; that the pull probnbly acts more 
or less diiectly on the cord itself, and that the gain is not explicable merely by ob- 
viotis effects on the angular bony curve; that the well-known influence of exten- 
sion in Pott’s palsy makes it probable that in other forms of spinal disease, not due 
to caries, extension in various forms may be of value, as has apparently been of late 
made clear; that the methods of extension to be used in these and carious cases mav 
be very various, only provided we get active extension; that the plan and the length 
of time of extension must be made to conform to the needs, endurance, and sensa- 
tion of the individual cases. * 26 
J. WILLIAM WHITE. 
(,Schmidt's Jahrbiicher, Phil. Med. Times, Sept. 8, 1883). Janies 
Israel, (Berliner Klin. Wochenschrift, March 6, 1882) resected 
the arch and body of the last dorsal vertebra for caries and 
spinal abscess. The patient died of coincident tubercular 
disease on the 37th day, the wound having almost entirely 
healed. Mr. Treves has formulated the operation as applied 
especially to the lumbar vertebrae or to the last dorsal, and 
has reported a successful case of removal of a sequestrum from 
the body of the first lumbar vertebra. (British. Med. Journ. 
Jan. 12, 1889). 
3. Passing now to the third group of cases, and taking up the 
surgery of the neoplasms of the cord unassociated with trauma- 
tism or caries, we may very briefly review the history. In the 
50 cases of spinal tumor tabulated by Drs. Mills and Lloyd, 
and among 50 cases tabulated by Horsley, the two including 
practically all those of which we have any satisfactory 
knowledge from the surgical and pathological standpoints, no 
mention is made of operation in a single instance. 
In 1882 Mr. Byron Bramwell, of Edinburgh, in his work on 
“Diseases of the Spinal Cord” made the following important 
suggestion in regard to this subject: 
“The removal of extra-medullary tumors is not yet a recognized 
plan of treatment. This is partly owing to the uncertainty of diagno- 
sis, and partly to the serious nature of the operation. The difficulties 
in diagnosis are disappearing, and thanks to antiseptic surgery, we can 
now conduct operations which were formerly unjustifiable. I would 
advise an operation in any case in which the symptoms were original, 
in which the diagnosis clearly indicated the presence of a tumor, in 
which there was no evidence of malignant disease, in which the exact 
position of the growth could be localized, and in which a Vigorous an- 
ti-syphilitic treatment had failed to produce beneficial results.” 
Other neurologists, notably Mr. Gowers, expressed the same 
general views, but the strong prejudice existing among sur- 
geons against the operation of resection, and the uncertainty 
of diagnosis on the part of the neurologist combined to pre- 
vent operative interference in such cases, patient after pa- 
tient perishing without even an attempt at treatment. 27 
SURGERY OF THE SPINE. 
In June, 1887, Mr. Victor Horsley operated upon a case, the 
symptoms of which had begun immediately after a severe 
traumatism in 1884, and were thought to indicate an intercos- 
tal neuralgia, localized beneath the lower part of the left scap- 
ula. For a long while the pain was the only marked symp- 
tom, but in February and March, 1887, there came on distinct 
loss of power in the legs, and by June the symptoms were 
those characteristic of a transverse lesion of the cord a little 
above the middle of the dorsal region. 
. Mr. Horsley operated very much after the method employed many 
years previously by Gordon, McDonnell, Hutchison and others, tre- 
phining the lamina of the fifth vertebra after having first cut off the 
fourth, fifth and sixth dorsal spines. After the removal of the trephine 
button the rest of the laminae of the fourth, fifth and sixth dorsal verte- 
brae were then removed with the bone forceps and knife. The dura 
mater was opened but nothing abnormal was discovered. The 
third and seventh laminae were then removed, and finally the lamina 
of the second dorsal vertebra, disclosing an oval or almond shaped 
tumor which subsequently proved to be a fibro-myxoma. This was 
easily removed when the lateral column on that side was found to be 
so notched by pressure that the bottom of the groove nearly reached 
to the middle line of the cord. The patient made an excellent and 
fairly rapid recovery, and one year later was able to do a day’s work 
of 16 hours, including much standing and walking about. 
In July, 1888, Dr. John B. Deaver operated upon a patient of 
Dr. Hendrie Lloyd’s who had a swelling involving the left lat- 
eral region of the cervical spine which was thought to be a 
tumor extending outward from the spinal canal. She had pa- 
resis of the left arm, paralysis of the left leg, exaggerated re- 
flexes, etc. There were no paraesthesiae and no anaesthesia. 
At the operation the laminae of the third and fourth cervical verte- 
brae were cut th r » l but nothing abnormal in the cord or membranes 
was found. The cord was explored with a needle. During the latter 
part of the operation the respiration altered and continued to be gasp- 
ing and irregular at intervals until her death, three days later. At the 
autopsy there was found an old extravasation of blood with advanced 
degeneration a short distance below the decussation of the pyramidal 28 
/. WILLIAM WHITE. 
tracts. Death was thought to be due to phrenic inhibition, the 
result of the exploratory procedure. 
In October, 1888, I operated on a case of paraplegia thought 
to be due to focal spinal lesion, possibly to a tumor, in a pa- 
tient of Dr. F. X. Dercum. The case will be found reported 
in the June number of the Annals of Surgery. Although 
no tumor was found, the removal of peri-dural connective tis- 
sue which had undergone some thickening and the separation 
of sub-dural adhesions were followed by very marked im- 
provement in sensation and mobility, which improvement is 
still continuing. 
We may now consider the possible indications for opera- 
tion in this third group of cases, or those in which, fractures 
and dislocations having been excluded, there is reasonable 
ground for suspecting the existence of a removable neoplasm ; 
Naturally, this group will, more than any other, try the diag- 
nostic powers of both surgeon and neurologist, and no broad 
view of the subject can be taken without a brief enumeration 
of the various sources of error. 
In approaching any case of paraplegia for the purpose of 
diagnosis it will usually be easy to exclude the first group of 
cases or those in which the paralysis depends upon fracture or 
dislocation. In such cases the history of traumatism, the 
rapid onset of the symptoms, the deformity which usually ex- 
ists, or at any rate the distinctly localized swelling and tender- 
ness will almost invariably lead at once to a correct diagnosis. 
The question which will remain in doubt will usually be that 
of the extent of damage done to the cord and the possibility 
of its taking on reparative action. As to this, the safest rule 
with which I am familiar is that which has been formulated by 
Lauenstein and already alluded to, namely, that if after the 
lapse of six or ten weeks there is incontinence of urine with 
cystitis or incontinence of faeces, and especially if there is also 
the development and spreading of bed-sores, but little is*to be 
hoped for from the unaided efforts of nature. If, however 
these symptoms are absent, and if there be the least improve- 
ment in either sensation or motion, it may be justifiable for the SURGERi OF THE SPINE. 
29 
surgeon to delay operative interference still longer, though I 
am far from being certain as to this point. 
The second group of cases may also as a rule easily be rec- 
ognized by the history of caries and the existence of deform- 
ity. In this group the presence or absence of an abscess must, 
if possible, be carefully determined, as in some instances, pres- 
sure from pus alone has produced the characteristic paralysis, 
which was therefore unrelieved by the removal of portions of 
bone, while in others such purulent collections have existed as 
serious complications, only to be discovered at the autopsy. 
Arguments have already been advanced to show that the par- 
alysis of Pott’s disease is, as a rule, a pressure paralysis, dis- 
tinctly localized, and not attended with such degenerative 
change in the structure of the cord itself as necessarily renders 
the case hopeless. While there are exceptions to this rule, as 
will be seen in one of the cases reported by Dr. Dercum and 
myself, it may, nevertheless, I believe, be taken as a safe 
working hypothesis, which should encourage the surgeon to 
attempt to relieve pressure even after the long continuance of 
a complete paraplegia. The temperature of the patient which, 
during the existence of suppuration, or especially while acute 
changes are going on in the vertebral bodies, will probably be 
moderately elevated, the presence of coexistent tubercular dis- 
ease in other organs, the history of the same disease in parents 
or near relatives, together with the well-known and easily rec- 
ognized symptoms of spinal caries will make an error of diag- 
nosis in this class of cases well nigh impossible. 
It, however, we have to deal with a case of paraplegia 
which is distinctly not one of either of the foregoing varieties, 
the diagnosis will at once become much more difficult. A 
consideration of this subject will lead me upon ground prop- 
erly belonging to the neurologist, but I may perhaps be par- 
doned if I give a brief outline of the general diagnostic points 
which it will be necessary to bear in mind before deciding 
upon or rejecting operative interference. In the first place it 
will be requisite to determine whether the symptoms are due to 
pressure upon the cord or to inflammatory or other changes 
involving primarily the structure of the cord itself. If, in a 30 
J. WILLIAM WHITE. 
case of paraplegia, we have the history of a very gradual onset 
beginning with pain and followed first by motor paralysis, and 
then by sensory paralysis; the symptoms being irregularly uni- 
lateral ; the pain having first seemed to be neuralgic or rheu- 
matic and burning and shooting in character; if the pain and 
anaesthesia in the lower limbs ascend gradually from the soles 
of the feet towards the trunk; and if at the same time there is 
a constant dull ache in a distinct segment of the spinal column 
accompanied by a feeling of weakness at that point, 
much heightened by fatigue, we have a group of symptoms 
pointing strongly in the direction of a neoplasm. In addition, 
it would be found that at first the reflexes, both deep and su- 
perficial, were much exaggerated, becoming gradually lost as 
destruction of the cord with descending degeneration and 
wasting grew more marked, the abolition of the reflexes be- 
ginning as in the case of the pain and anaesthesia in the plan- 
tar region and passing gradual.y upward. 
Later in the disease we have the development of spasms with 
clonus, most marked in the intra-dural cases. The same remark 
is true of the symptom of rigidity. Local nutrition is not us- 
ually impaired ; tenderness of the spine on percussion when it 
occurs in the dorsal region appears to be lower than the tumor 
producing it; in the cervical region, according to Horsley, 
this generalization does not seem to hold so closely. The 
feelings of stiffness and weakness will usually be found to cor- 
respond to the position of the tumor. Lateral curvature of the 
spine is a secondary result of the tonic spasm of the spinous 
muscles and therefore the concavity of the bend is on the same 
side as the growth. The pupils are not affected except when 
the cord is pressed upon above the level of the second dorsal 
nerve. 
The age of the patient, judging from Mr. Horsley’s tables, 
throws but little light upon the diagnosis of tumor, as we find 
lipomata occurring at an average age of 2*/2 years, sarcomata 
at 18 years, ecchinococcus at 34 years, tubercle at 39 years, 
scirrhus and myxoma at 48 and 53 years. These figures ap- 
ply to extra-dural growths. In the case of intra-dural growths 
we have tubercle at 18Y2 years, myxoma at 43 years, fibroma SURGERY OF THE SPINE. 
at 44 years, sarcoma at 41, psammoma at 51 years. It will be 
seen, therefore, that while age may be of use in eliminating cer- 
tain forms of growth, as, for example, tubercle in intra-dural 
growths in persons beyond 30 years, it is of but little value in 
deciding the general question as to the presence or absence of 
a neoplasm. 
This sketch of the principal symptoms makes a tolerably 
distinct clinical picture, but one which is, nevertheless liable to 
great variation and therefore difficult to differentiate from that 
of certain conditions of the cord due to causes quite beyond 
the reach of operation. 
The chief of these, with the most obvious diagnostic points 
are as follows: 
31 
Spinal Hcetnorrhage. Intra-medullary. Onset sudden; history of traumatism, 
or of disease associated with profound blood changes; symptoms bilateral; pain in 
back; rapid disappearance of reflexes connected with the affected segment; spasms 
and rigidity and paralysis appear rapidly; girdle symptom; bed-sores; incontinence 
of fames; retention of urine very early in case; rapid course; often fatal. 
Extra-medullary. Pains in limbs, spasms, etc., more marked; paralysis super- 
venes more slowly; course of case much slower and much more favorable. 
Pachymestingitis Externa, from Caries. Common cause, caries of vertebrae; fam- 
ily history of phthisis, scrofula or tubercle; personal history fair; patient weak and 
feeble; usually history of injury also; onset slow; first symptoms often rigidity of 
spine, with tenderness on pressure or on tapping top of cranium, or on flexion or ro- 
tation; muscular palpitation and weakness rather than spasms or paralysis; irreg- 
ular hectic fever; characteristic deformity; spinal abscess; bladder and rectum rarely 
affected; emaciation. 
Chronic Transverse Myelitis. Frequently a history of acute myelitis; slow in 
onset; bilateral; first symptom apt to be an impairment of motion, ranging from 
paresis to an absolute paralysis ; increased reflexes ; ankle clonus; rigidity common, 
but paresis, contractions, etc., more marked than paralysis ; pain in back and girdle 
symptom common; anaesthesia and parassthesia proportionate to motor paralysis ; 
bladder and rectum not greatly involved; stow course. 
Primary Lateral Sclerosis; Spastic Paraplegia. Often attacks robust adults 
between 30 and 50; slow in its onset; bilateral; begins with a feeling of weight and 
weakness in lower limbs, preceded by a peculiar and characteristic gait; spasm 
chiefly of muscles of lower extremities; manipulation of those limbs throws them 
into tonic spasm; paralysis not very common early; paresis with rigidity are charac- 
teristic symptoms, together with arched spine during peculiar locomotion. 
Hypertrophic Cervical Meningitis. Symptoms affect chiefly the upper limbs 
with upper part of spine and thorax; bilateral; marked pain and rigidity involving 
all these regions; paralysis occurs in second stage, and affects first and chiefly arms, 
shoulders, etc.; no atiophy of lower extremities; no bed-sores; no bladder or rectal 
trouble. 32 
J. WILLIAM WHITE. 
These points may perhaps be better shown in the accom- 
panying table which, however, it must be remembered, is, like 
the foregoing remarks, intended simply to aid in giving com- 
pleteness to my consideration of the subject, and to present a 
sort of bird's eye view of it to the practical surgeon, who will 
without doubt call a neurologist to his aid in the vast majority* 
of these cases: 
Having decided in any given case that the symptoms are 
probably due to tumor, the interesting question, whether it is 
intra-medullary or extra-medullary will still remain to be 
settled. The best general guide will be found in the fact 
that the symptoms of intra-medullary growths are chiefly those 
of motor and sensory impairment, while the extra medullary 
growths produce much more markedly irritative symptoms, as 
for example pain, spasms, etc. In the presence of a paralysis 
of gradual development, preceded by long-continued signs of 
nerve irritation, and with a distinct unilateral element, the 
transference of paralysis from one to the other limb having 
been effected slowly and after a considerable interval, the 
diagnosis of compression of the cord by some cause outside of 
its own structure would seem warranted. Aneurism might be 
excluded in the absence of the characteristic physical signs 
and of evidence of erosion of the spinal column; gumma would 
be accompanied by a history of syphilis, would often be asso- 
ciated with other and recognizable specific lesions, and would 
possibly yield to the use of iodide of potassium ; a growth (cancer 
or tubercle) of the bodies of the vertebrae themselves usually 
causes a perceptible deformity. By attention to the points which 
I have mentioned a reasonably correct opinion may be arrived 
at, but I would strongly advise that in no case shall the sur- 
geon undertake a spinal resection based on a diagnosis of tu- 
mor without having called to his aid a skilled neurologist and 
carefully studied the case with him. The same remark applies 
with even more force to the question of localization. The 
broad general principles, long applied in cases of traumatism, 
are of course equally applicable to tumors, but there are num- 
erous refinements of modern diagnosis which belong especially 
to the province of the neurologist and which are of vital import- 
ance in selecting the site of operation in cases of supposed  
Tumor, 
Spinal Heemorrhage. 
Ca' its and Pachymengiti. 
Externa. 
Hypertrophic Internal Cer 
vtcal Meningitis. 
- Chronic Transverse Mye 
litis. 
- Primary Lateral Sclerosis 
Spastic Paraplegia. 
Family History. 
; Of no especial signifi- 
cance . 
Not important. 
History of phthisis 0 
(tubercle or scrofula. 
Not important. 
i Not important. 
Not important. 
Personal History. 
Often perfect health up to 
beginning of symptoms. 
Occasionally history o: 
strain, exposure or trauma- 
tism. 
History of traumatism, 
aneurism; scurvy or pur- 
pura. 
Health has always been 
poor; patient young, often 
under 20; history of injury, 
evidences of scrofula 
Occurs in middle-agec 
persons as a rule. 
j Frequently a history 0 
jacute myelitis; often a his 
jtoryot some form of com 
ipression; occurs in adults. 
Often attacks robust, 
healthy adults between 30 
and 50. 
Onset. 
Almost universally grad- 
ual. 
Very sudden. 
Slow. 
Moderately slow. 
i Slow. 
Slow. 
Distribution of 
Symptoms. 
Irregularly unilateral; es- 
pecially so in intradural 
growth. 
Bilateral. 
Bilateral as a rule; may 
be unilateral if abscess be 
present. 
Bilateral. 
Bilateral. 
Bilateral. 
First Symptom. 
Pain; insidious; very rare- 
ly sudden; neuralgic or 
rheumatic in character; lo- 
calized; usually in the 
course of one nerve; some 
times felt in the spine itself 
as a dull ache. 
Pain in back, with shoot- 
ing pains in limbs if haem- 
orrhage be extramedullary. 
Rigidity of spine. 
Shooting pains in back ol 
neck, arms and upper part ol 
chest, with rigidity of same 
region. 
Impairment of motion or 
sensation; weakness in lower 
extremities; difficulty in 
emptying the bladder or 
obstinate constipation, 
numbness, “pins and need- 
les,” etc. 
A feeling of weight, weak- 
ness and stiffness in lower 
limbs, with slight rigidity 
and increase of the deep re- 
flexes. 
General Course 
of Disease. 
The pain is iollowed after 
a variable interval—months 
or years—by the develop- 
ment ofparalysis; sometimes 
preceded by paresis; often 
unilateral in the beginning 
(particularly in intradural 
growths); often extending 
irom above downwards. 
This is followed by sensory 
paralysis, later by symptoms 
ol inflammatory soften- 
ing and descending degen 
eration. Total duration ot 
symptoms in extradural 
growths, about 13 months; 
in intiadural growths, about 
29 months. 
The pain is followed by 
the very rapid development 
—a few hours—of paralysis 
in cases of intramedullary 
haemorrhage; more slowly— 
a few days—in extramedul- 
lary haemorrhage. This is 
often preceded by spasms 
and followed by a rapid dis- 
appearance of the reflexes. 
The rigidity of spine is 
followed by the develop- 
ment of localized tender- 
ness; painful flexion or ro- 
tation; pain on tapping on 
cranium; evidences of sup- 
puration; irregular muscular 
action; jactitation or spasm 
occasionally; later the 
development of paraplegia. 
During the first stage the 
pains are very severe in the 
upper extremities or in the 
head and neck; these are 
followed by symptoms of 
motor irrtation — spasms, 
rigidity and contraction. 
There are grave sensory 
distuibances due to pressure 
on the posterior roots; pa- 
ralysis, anaesthesia, etc., oc- 
cur later. 
There is gradually in- 
creasing motor weakness, 
which after a time becomes 
paralysis; but this is not 
marked as a rule, paresis, 
rigidity and contraction be- 
ing more common; often 
rigidity of muscles and in- 
crease of deep reflexes are 
associated with loss of mo- 
tor power. The general 
health is not greatly affect- 
ed until late in the disease. 
Average duration of life 6 to 
15 years. 
The first vague symptoms 
are soon followed by ihe 
development of the charac- 
teristic locomotion; this 
stage may last for years and 
is followed by the develop- 
ment of complete spastic 
paraplegia, the patient be- 
ing confined to bed with the 
legs rigidly extended; then 
still later there may be pa- 
ralysis, with muscular atro- 
phy, bed-sores, cystitis, etc. 
Special Symptoms. 
Motor— 
Reflexes. 
Invariably exaggerated at 
first; later lost, the plantar 
first disappearing. 
Early disappearance in 
the muscular area of tl.e af- 
fected segment in intrame- 
dullary haemorrhage. 
If paraplegia occurs are 
at first exaggerated then 
lost 
Increased, but especially 
in upper extremities, neck, 
etc. 
Always increased in parts 
below the lesion. 
The deep reflexes are in- 
creased at first very mark- 
edly. 
Spasms. 
Occur in large majority of 
cases; ankleclonus present. 
Common, especially in ex- 
trameaullary haemoirhage. 
Not very common; some- 
times tonic spasms of 
psoas and iliac from pressure 
of abscess. 
Twitchings,slight spasms, 
etc. ; most marked in mus- 
cles of aim and forearm. 
Ankle clonus, etc., same 
as in tumor. 
Chiefly of muscles of low- 
er extiemities, which are 
easily thrown into tonic 
spasms by- manipulation. 
Rigidity. 
Occurs in about one-third 
of cases; more frequent 
with intradural growths. 
Very common; appears 
early. 
Uncommon. 
Common as to neck; less 
frequent elsewhere. 
Common. 
Very marked in lower 
limbs. 
Paralysis. 
Sensory— 
Pain. 
Constant in later stages; 
at first u ilateral. Transter- 
ence to outer limb occurs 
soon in extradural growths; 
after some weeks or even 
months in intradural 
growths. Often involves the 
higher groups of muscles 
first. 
Very common; occurs very 
early in intramedullary 
haemoirhage; more slowly in 
extramedullury haemor- 
rhage. 
Very far from constant. 
Develops during second 
stage, but at first is limited 
to affected areas. 
While it occurs late, is not 
usually very marked, gen- 
eral paresis, with rigidity, 
contraction, etc., being 
more characteristic. 
Only present late in dis- 
ease. Paresis and rigidity 
are characteristics. 
» 
Described as burning, 
shooting, etc. Almost al- 
ways, when in the lower 
limbs, ascends from the 
soles of the feet. 
Felt in back, with shoot- 
ing pains in limbs; more se- 
vere and more constant in 
extramedullary haemor- 
rhage. 
Felt chiefly in back or 
radiating to lower limbs if 
abscess is present. 
Severe in head, neck, 
arms and upper part of 
chest. 
Dull, heavy pain in back 
constant. 
Very little pain. 
HyPER/ETUESIA. 
A zone of hyperaesthesia 
above the upper limit of the 
anmsthesia. 
Mild or absent in intra- 
medullary haemorrhage; fre- 
quent and severe in extra- 
medullary haemorrhage. 
Uncommon. 
Very marked during first 
stage; confined chiefly to 
neck and upper extremi- 
ties. 
Rare. 
No true sensory disturb- 
ances. 
An.es thesia. 
Almost constant; begin- 
ning, like the pain, in the 
soles pf the feet and ad- 
vancing- upwards. 
Common; occurs early in 
intramedullary haemor- 
rhage; later in extramedul- 
lary haemorrhage. 
Rare. 
Develops during second 
stage, but at first is confined 
to areas supplied by cervi- 
cal nerves. 
Not often present to any 
marked degree; when it oc- 
curs it is proportionate to 
the motor paralysis. 
None. 
Parajstheria, 
Girdle symptoms com- 
mon . 
Girdle symptoms com- 
mon . 
None as a rule. 
None as a rule. 
Girdle symptoms com- 
mon . 
Sometimes cramp-like 
feeling, due to spasms; no 
girdle symptoms. 
Fever. 
None. 
None. 
Irregular; hectic. 
None. 
None. 
None. 
The Spine. 
Sometimes a dull ache, 
localized. Occasionally lo- 
calized tenderness. In a 
few cases a slight lateral 
curvature, the concavity of 
the curve being towards the 
tumor. 
Possibly evidence of trau- 
matism; often a localized 
pain. 
Characteristic deformity; 
tenderness on pressure; ina- 
bility to flex, etc. 
Cervical spine may be 
stiff, from rigidity of mus- 
cles; but there is no tender- 
ness on pressure or percus- 
sion of the vertebral spines; 
no curvature. 
Not noticeably affected, 
never any curvature unless 
the myelitis is secondary 
to cancer, tumor, etc. 
Often strongly arched 
forward during locomotion. 
Nutrition— 
Gfneral. 
Not much affected. 
Not materially affected. 
Emaciation. 
Impaired. 
Not greatly affected. 
Fairly good. 
Local. 
Decubitis, and wasting 
late in the disease. 
Bed-sores common in in- 
tramedullary haemorrhage; 
rare in extramedullary haem- 
orrhage. Muscular wasting 
frequent after intramedulla- 
ry haemorrhage. 
Muscular atrophy. 
As a rule some muscular 
atrophy; not affecting legs. 
Not greatly affected; oc- 
casionally atrophy of cer- 
tain muscular groups. 
No atrophy until very late. 
Bladder and 
Rectum. 
Retention of urine and 
cystitis common. Incontin- 
ence of feces common. 
Retention of urine and in- 
continence of feces common 
in intramedullary haemor- 
rhage; less so in extramedul- 
lary haemorrhage. 
Rarely affected. 
Not affected until very 
late. 
Not commonly affected to 
any marked degree until a 
ate period—the time vary- 
ing with the site of the 
esion. 
Usually quite normal. 
Prognosis. 
Unfavorable. Usually 
death from interstitial ne- 
phritis; pyaemia from bed- 
sores; exhaustion fiompain, 
etc. 
Unfavorable in intrame- 
dullary haemorrhage, which 
is often fatal or ends in in- 
complete recovery; less so 
in extramedullary haemor- 
rhage. 
Fairly favorable as to life; 
frequently an arrest ofj 
symptoms; often a perma 
nent cure. 
Not infrequently ends in 
recovery which may be 
complete; as a rule some 
atrophy and loss of power 
remain. 
Very unfavorable unless 
the case is syphilitic. 
Good as regards prolonga- 
tion of life; unfavorable as 
regards recovery; when 
death occurs it is usually 
from intercurrent bron- 
chitis or pneumonia. 
Pathology. 
Lipoma, sarcoma, echi- 
noccus and tubercle are the 
most common varieties of 
extradural tumor; myxoma, 
fibroma, sarcoma, psam- 
moma,tubercle are the most 
common intradural growths 
Effusion of blood into orjCaries of vertebral bodies is! 
around the cord duetorup-jby far the most frequent 
ture of vessels or to passive cause of external pachy- 
haemorrhage from disorgan-|meningitis. 
ization of blood. 
A chronic inflammation of 
the inner surface of the cer- 
vical dura, with great thick-1 
ening from the formation ofj 
new fibrous tissue. 
Chronic inflammation of a 
whole transverse section of 
;he cord, usually in the lum-j 
liar or dorsal region; in- 
crease of connective tissue 
elements. 
A symmetrical sclerosis 
of the crossed pyramidal 
tracts. 
TABLE. 33 
SURGERY OF THE SPINE. 
tumor. Horsley’s experience in the patient of Dr. Gowers is 
ample evidence of the unavoidable uncertainty as regards the 
particular vertebra or vertebrae to be attacked, but there is 
every prospect that these diagnoses will become more and 
more scientifically exact in the near future. In the meanwhile I 
would reier the surgeon who desires carefully to study for 
himself this side of his cases to the articles referred to below.1 
Having arrived at a conclusion and having decided that the 
probability is in favor of the existence of a tumor, and having 
also fixed upon its probable seat, the surgeon is confronted 
with the important question of the advisability of operation, and 
of its probable result; in other words, with the question of 
prognosis. 
All the evidence which we now have points to extraordinary 
reparative power on the part of a cord which has simply been 
suffering from compression and to an almost equally remark- 
able tolerance to operative interference. The material for 
finely differentiated prognoses can hardly yet be said to exist, 
but in a general way it is safe to say that the diagnosis of tu- 
mor (if it be non-malignant) carries with it a reasonably favor- 
able prognosis, which is strengthened if, in addition the tumor 
is thought to be extra-medullary. 
In conclusion I desire briefly to speak of the operation 
itself, which has been variously described as “ formidable,” 
“ appalling,” “ well nigh impossible,” “desperate and blind,” 
and in other similar extravagant terms. In one case the pa- 
tient is said to have died upon the table from haemorrhage; in 
another the operation was abandoned on account of the sup- 
posed impossibility of its completion. It has not seemed to 
me that these descriptions are in the least justifiable. The op- 
eration is, indeed, as was said by Dr. McDonnel, apt to be 
on Localization of Spinal Lesions, Pepper's System of Medicine, vol. v. 
p. 77. Starr on the Localization of Functions of the Spinal Cord, Am. Journ. of 
Neurology and Psychiology, vol. iii, 1889. Gowers, Diseases of the Nervous System, 
vol. i, p. 142. Thorburn, The Medical Chronicle, April 1889, p. 1, and The British 
Medical Journal, Dec. 22, 1888. Ranney, The Applied Anatomy of the Nervous 
System, p. 355. Ross, Diseases of the Nervous System, p. 356. Charcot, Localiza- 
tion of Cerebral and Spinal Disease. Bramwell, Diseases of the Spinal Cord, 
Mills and Lloyd, Pepper's System of Medicine, vol. v. 34 
J. WILLIAM WHITE. 
tedious and tiresome; but, so far as any major difficulties are 
concerned, it is not to be compared with many much better 
known, and much more frequently practiced, operative pro- 
cedures. I base this opinion both upon experiments on the 
cadaver, and upon my experience with two cases in which I 
have performed resection. It may be useful to give the de- 
tails of the method which seems to me to be preferable : 
The patient having been placed in the prone position and a 
gentle curve having been given the spine by means of a firm, 
small pillow placed under the lower ribs, a long incision should 
be made directly down to the tips of the spinous processes, the 
middle of the incision being opposite the supposed site of the 
tumor, the apex of the angle, or curve, if the case be one of 
Pott’s disease, or the deformity, or displacement, if the case 
be one of fracture or luxation. The muscles should then be 
freely separated from the sides of the spinous processes and 
the posterior surfaces of the laminae, the edge of a stout, thick- 
backed scalpel being used for this purpose. One side of the 
spine should be cleared and all haemorrhage arrested by the 
use of haemostatic forceps before the other side is approached, 
and the wound should be filled with sponges, or a towel wrung 
out of a hot antiseptic solution. This having been done the 
other side may be treated in the same manner. By the time 
the spine is thoroughly exposed on the second side most of 
the bleeding will have permanently stopped on the other; but 
any distinct spirts or free oozing following the removal of the 
catch forceps should then be permanently arrested by liga- 
ture, after which the periosteum may be reflected by making 
a firm incision through it along the angle between the spinous 
processes and the laminje, turning up its edge at this point 
with the help of dissecting forceps and then scraping the sur- 
faces of the vertebral arches with a curved periosteal elevator. 
This being completed the haemorrhage should be similarly ar- 
rested, and the periosteum reflected on the opposite side. 
Cline and Tyrrel used broad angular plates as retractors on 
each side; Gordon divided the attachment of the muscles to 
the articular processes, which, he said, gave plenty of room, as 
one end of each muscular bundle being separated from its at- 
tachment it retracted of itself and needed little holding back SURGERY OF THE SPINE. 
35 
with the fingers; Horsley divided the deep fascia at right 
angles to the line of the incision opposite its middle, in order 
to prevent its resisting a proper separation of the sides of the 
wound, and adds that it may be found necessary to divide this 
aponeurosis at more places than one. In my cases I found 
that retractors of moderate size, not large or clumsy enough 
to be in the way, were all that was needed to keep the mus- 
cular masses from interfering with the subsequent procedures. 
The next step, and one which greatly facilitates the remainder 
of the operation, consists in the division of the spinous pro- 
cesses close to their bases by means of large, strong bone for- 
ceps set at an obtuse angle. That was not done by most of 
the earlier operators, but certainly adds nothing to the severity 
of the operation while affording a much freer exposure of the 
laminae, which are the next parts to be attacked. In perfor- 
ating these Cline advised the use of a small crowned trephine 
to cut through the vertebral arches, if requisite, that is, if they 
were not already broken into more than two pieces. Tyrrel 
found Hey’s saw most convenient. In Gordon’s case one side 
of the arch was broken and the yellow ligament torn through, 
admitting the entrance of his finger so that he merely divided 
the other side of the arch with a pair of stout bone forceps ; 
Lauenstein employed a chisel; Horsley returned to the use of 
the trephine, but says that if more than one arch is to be re - 
moved it will be better by means of an angular saw to cut 
partly through the laminae along the lines of the sides of the 
neural canal, and then the division of the bones can be com- 
pleted with the bone forceps. I have found that both the tre- 
phine and the saw are unnecessary, and that the laminae can 
be most expeditiously, and with equal safety, divided by the 
use of a pair of very strong bone forceps, either straight or 
having a large obtuse angle as may be preferred by the op- 
erator. The vertebra at the center of the incision should be 
selected, and the vertebral spaces above and below its lamina 
should be recognized with the tip of the finger. The points 
of the bone forceps should then be placed above and below 
its edges and the lamina cut through by successive short nips, 
the line of section being as close to the transverse processes 
as possible. This gives the greatest exposure of the cord and 36 
J. WILLIAM WHITE. 
canal, with the least risk of wounding the spinal nerves. It will 
be known when the section is complete by the easily recog- 
nized increased mobility of the vertebral segment which is 
being operated upon. The opposite side of the same vertebra 
is then attacked and treated in the same manner, after which 
the remaining ligamentous connections of the vertebra may be 
divided in the middle line by the same forceps, the final liga- 
mentous attachments being separated from the under surface 
of the arches with a knife or a pair of curved scissors. The 
anatomical circumstances which make this method of operating 
comparatively safe are as follows: 
The cord only partially fills the spinal canal and swings free 
in the arachnoid fluid, gravitating forward when the patient is 
in the prone or semi-prone position necessitated for the per- 
formance of this operation; it normally is held closer to the 
anterior than to the posterior wall of the canal by the anterior 
roots of the spinal nerves ; in cases of posterior curvature and 
in cases of fracture or luxation the inflammatory elements 
which are produced tend to be in excess in the space between 
the posterior surface of the dura and the wall of the canal 
thus lessening the risk of wounding either membranes or cord. 
A certain degree of risk of the accident must be admitted, but 
it is probably at least equal, whether the trephine, the saw or 
the forceps are employed and would seem to be distinctly 
greater if a chisel or gouge be used. 
Other laminae above and below the first one may then be 
even more rapidly removed in the same manner, and the dura 
mater exposed by incising in the middle line, or, better still, 
gently separating, with a curved director, the thin layer of fat 
which sometimes covers it. At this stage much danger has 
been predicted by the theoretical objectors to the operation 
on account of haemorrhage from the spinal plexus of veins and 
from the spinal arteries; as a matter of fact, however, in 
hardly any of the reported cases has this been alarming, and 
in nearly every instance it has been easily and permanently 
arrested by moderate pressure. At this point in the operation 
the appearance of the dura should be carefully noted, and the 
presence or absence of thickening of the connective tissue be- 
tween it and the posterior wall of the canal, or of thickening S UR GARY OR THE SPiNE. 
37 
of the membrane itself. Its color should also be noted, par- 
ticularly with the view of determining in cases of traumatism, 
whether it is or is not necessary to open it. If it be dark or 
purplish, from the presence of exuded blood beneath it, or 
yellowish from the presence of pus, it will, of course, be 
proper to incise it in order to empty and to explore the subdu- 
ral space. My own feeling is that in all cases in the future in 
which this operation is performed for supposed tumor, and the 
growth is not found lying upon or external to the dura that 
membrane should be freely and fearlessly opened for explora- 
tory purposes. The resulting escape of the cerebro-spinal 
fluid has been found to be merely one of the bug-bears of the 
subject and is certainly not to be weighed against the 
chance of terminating the operation without discovering a pos- 
sibly existent and relievable condition. If it is determined to 
open it it may be picked up in the median line and at the mid- 
dle of the incision with a pair of delicate-toothed forceps, 
nicked with a knife or the scissors and then divided either 
upon the director or with a pair of blunt pointed scissors to 
any required extent upward or downward. It can be easily 
and gently retracted to either side, so as to expose the whole 
posterior surface of the cord to both inspection and palpation, 
permitting the gentle insertion of the tip ot the finger between 
its inner surface and the lateral aspect of the cord, and per- 
mitting, also, if need be, the investigation of the anterior and 
antero-lateral subdural spaces by means of a blunt curved in- 
strument, such as a pedicle needle or aneurismal needle. The 
inspection having been completed, the tumor having been re- 
moved, the pus or blood evacuated, or it having been deter- 
mined that no indication for further operative interference ex- 
ists, the incision in the dura should be stitched up with fine 
interrupted catgut sutures. These may be introduced very 
readily and speedily by means of a pair of staphyllorraphy 
needles, the one not in use being threaded by an assistant 
while each stitch is being put in place ; the stitches should be 
inserted at intervals of about one-eighth to one-sixth of an 
inch, and when all are in place can be easily tied, the ends 
being cut off short. After this a small rubber drainage tube 
and a dozen strands of chromicised catgut should be laid 38 
J. WILLIAM WHITE. 
throughout the entire length of the wound; the muscles being 
then united above them by means of chromicised catgut 
sutures, after which the skin and aponeurosis are brought to- 
gether by silk or silver wire, as may be preferred. It is hardly 
necessary to say that the most rigid antiseptic precautions 
should be observed from first to last. 
Finally, I may briefly summarize the conclusions which seem 
to me warranted by this survey of the history of spinal operation 
from early times to the present day : 
ist. The objections urged against operative interference in 
spinal traumatisms were partly theoretical, hemorrhage, fre- 
quency of absolute destruction of the cord, pressure from inac- 
cessible fragments of bone, etc., and have been shown to be 
unsupported by clinical facts ; and were largely due to a well- 
founded dread of a, the shock, in those cases operated on in pre- 
ansesthetic times, and, b, consecutive inflammation, suppuration 
and pyaemia in pre-antiseptic periods. The later results, which 
now constitute our only safe basis for generalization, are dis- 
tinctly encouraging and resections of portions of the vertebrae, 
in fractures, possibly even in dislocations, should be recognized 
as an eminently proper operati'on and in suitable cases alto- 
gether warranted by the facts in our possession; and further 
such cases are by no means rare or exceptional. 
2nd. There can be still less doubt that the testimony of 
both pathologists and practical surgeons indicates that the 
cause of the paralysis of Pott’s disease is in many instances an 
extra-medullary proliferation of connective tissue, assuming 
the density and proportions of a neoplasm, occupying the 
space between the dura and the anterior surface of the laminae, 
not apt to be associated with intra-medullary changes or with 
destructive degeneration of the cord, and very frequently re- 
movable by operation. 
3rd. Every case of focal spinal lesion, thought to depend on 
a tumor and not distinctly a malignant and generalized dis- 
ease, should be regarded as amenable to operative interference, 
no matter how marked the symptoms of pressure may be, nor 
how long continued. 
4th. The method of extension as recently revived is well 
worthy of preliminary trial in the first two classes and in ob- SURGERY OF THE SPINE. 
39 
scure cases thought to belong to the third class. It has not 
yet been tried in a sufficiently large number of cases to es- 
tablish its exact limitations, but it is unquestionably a thera- 
peutic measure of vast importance in spinal injury and 
disease. ♦ 
5 th. It is customary and proper in deciding upon any serious 
surgical procedure, involving risk to life, to consider well the 
prospects of the patient in the event of non-interference, and to 
be largely influenced by them. Looked at in this light, the sur- 
gery of the spine, as regards traumatisms, caries and neo- 
plasms may fairly be said to have a rapidly widening field, and 
to deserve more serious and careful consideration by practical 
surgeons than it has received for many years.