NATIONAL ^IBRARV OF MEDICINE NLM 00135Q14A fl &Qy20^®ZOC.C'2.Q'23Q,<3Q.OQGQ>C>QGQC% 0 15 ft Surgeon General's Office &X 11 &A tm, 'M h n No. PRESENTED BY D'&Q'Q&OO'DQOQ: "j'j-BQIOQfOOL'si t) NLM001350488 o} FRACTURE OF THE SPINE: ITS IMMEDIATE TREATMENT BY RECTIFICATION OF THE DEFORMITY AND FIXATION BY PLASTER OF PARIS JACKET. Br HERBERT L. BURRELL, M.D. Surgeon to Carney Hospital; Surgeon to Out-Patients Boston City Hospital; Ass't. Surgeon Boston Children's Hospital; Demonstrator of Bandaging and Apparatus in Harvard University. Read at the Annual Meeting of the Massachusetts Medical Society, June 7, 1887. ^fAK WE 122 7 FRACTURE OF THE SPINE : Its Immediate Treatment by Rectification of the Deformity and Fixation by Plaster of Paris Jacket. From a practical point of view, we may consider disloca- tions and fractures of the spine together, and it will not be a difficult task to represent to the minds of most surgeons the utter hopelessness of this injury in most cases. All authorities1 agree that the prognosis depends largely upon the location of the injury, and the amount of damage done to the spinal cord. It is not the injury to the bony structures or ligamentous union, that renders this injury so fatal, but the pressure or crushing that takes place of that wonderfully constructed spinal cord, which receives and transmits impressions to the various members of the body. The spine itself is so complexly constructed, adapted to so many different movements and purposes, that we can really say, that when it receives an injury, the "back bone" of the human organism is broken. The cord resting as it does in a bony canal, may be pressed upon by bony spiculae from any side, it may be pressed upon or severed completely by some sharp fragment, or simply the anterior buttress or body of the vertebra; may be crushed upon itself, without any serious or permanent 1 Sir Astley Cooper, Fractures and Dislocations of Joints ; Malgaigne, Fractures and Dislocations ; A. Shaw-Holmes, System of Surgery; Gurlt, Handbuch der Lehre von dem KnochenbrOchen, Hamm. 1864 ; Sir Charles Bell, Observations on Injuries of the Spine and of the Thigh Bone, 1824 ; Hamilton on Fractures and Dislocations ; Bryant, Practice of Surgery. 4 FRACTURE OF THE SPINE : injury to the cord having occurred. This is illustrated in Plate X. The higher the injury of the bony column, the greater fatality. Gurlt2 reports that out of 178 cases where the cervical vertebrae were fractured, death occurred in 164, or 90|%. Out of 184 in the dorsal region, death occurred in 146, or 79s<^. Out of 82 in the lumbar region, death occurred in 56, or 68}%. This ratio of mortality is quite what we should expect, as the nearer we approach the res- piratory centre, the more fatal is the injury.3 By the courtesy of the Surgeons of the Boston City Hospital, I have been enabled to collect all the cases (82) that have occurred in that Hospital, and have tabulated them, to ascertain what facts they will show The data thus obtained is represented in Tables D, E, F, G, and H, and the lines represented opposite present a synopsis of the de- tailed account that appears in the tables. First, regarding the mortality of these cases, we find that the fatality is very great, and this is represented by Table A 1. The fatality I have further analyzed to show mortality according to location. This is represented in Table A 2. The striking immediate fatality of the accident is shown in Table A 3. The recoveries have been divided into two classes :—the first, where the patient was useful, in the sense of being self-supporting; the second, useless, where the patient is bed-ridden, and unable to earn a livelihood. So that we really have in these 82 cases of Fracture of the Spine, an apparent recovery of^22%, where really there is only 11% returned as producers in the community. This is shown in Table B. The ratio of frequency of prominent symptoms occurring after fractures of the spine, is shown in Table C. 2 Ibid. p. 72. 3 Bryant, ibid. p. 105. ITS IMMEDIATE TREATMENT. 5 The utter hopelessness which is expressed in the term broken back, pervades the minds of all practitioners, and TOTAL CASES. FREQ&ENGYof SYMPTOMS. Tab/? C CREPITUS. DEFORMITY. UNCONSCIOUSNESS. PA HALTS IS COMPL ETE. PARALYSIS INCOMPLETE. PAIN. PRJAP/SAf. DELIRIUM. CYSTITIS BEDSORES 82 TOTAL CAS£S. REG/ON. r&b/e A-2. CERV/CAL, JtECOV[RJ£J, UPPER DORSAL* RECOVERIES. LOWER DORSAL RECOVERIES. LUMBAR. RECOVERIES- Z2- TOTALCA&FS. MORTALITY. T&4>/t A.I. D£ATH3 18- R£COIf£#/£S. G*t- 39- B- 7" K>. T/M£. TOTAL DEATHS T a 6/e A -3. WJTH/NSDAYS. W/TH/NtOOAYS- WITHIN I MO- AFTER I MO. 18. TOTAl R£COy£-Ki£5 I/SEEUL RESULTS. TAb/e. a. L/SEL.ESS perhaps Erichsen4 expresses the general feeling, when he says that " Fractures of the Spine through the bodies of the vertebrae with displacement, are inevitably fatal." 4 System of Surgery. 6 FRACTURE OF THE SPINE : The treatment of fractures of the spine may be divided into three principal heads :— a. Expectant. Water bed. Air bed. Wire bed. Bonnet's vertebral gutter. Extension and counter- extension. b. Operative. Trephining. Removal of bony frag- ments. c. Rectification of the deformity and fixation of the spine by plaster of Paris jacket or other apparatus. a. Expectant.—The statements made by Cline5 and by Cooper8 that we can accurately determine whether the body, or the arch, or the spine of a vertebra is broken, is not supported by facts. Further, Cline and Cooper be- lieved that death was inevitable, sooner or later, if the frag- ment were not lifted by an operation. This is possibly true, but specimens like Plate I. and Plate II. show only too clearly that, at times, we have to do with an irremediable injury, and our duty in such cases is to pursue the expectant plan of treatment—that is, placing the patient on an air or water bed, and treating the symp- toms as they arise. By this means we can prolong life, and make existence bearable. It is possible that a certain amount of relief may be obtained in these severest cases by permanent extension and counter-extension. Having decided that the expectant plan of treatment must be pursued in certain rare cases, we come to our second division, that of b. Operative.—What further can I say to you than has been said in that bitter controversy between Sir Charles Bell7 and Sir Astley Cooper, as to the expediency of opera- tions on the spine. Only on the parts posterior to the spinal cord, could an operation for a moment be entertained ; for to s Chelius Surgery, Vol. 1, p. 590. & Sir Astley Cooper on Disl. and Fract., 1851, p. 479. 7 Obseiv. on Injury of the Spine and of the Thigh Bone. its immediate treatment. 7 attempt to remove the body of a vertebra after fracture of the spine from behind, would necessitate the division of the spinal cord ; to attack it in front would be equally inad- Plate I. (No. 1229 Wakrkn Museum.) The patient fell 30 feet. Wild and irritable, complete paralysis, bed sores, cystitis and death from exhaustion in two months. There has been a complete rupture of the intervertebral substance between the 6th and 7th vertebras, the upper edge of the ?th being carried away to the right side with the 5th and 6th vertebrae. The state of the spinal cord in this case may be imagined. Plate II. (No. 139 Wakeen Museum.) T., aet. 19, run over by a fire engine. Complete paraysis, bed sores, cystitis, and died of exhaustion. There is a very extensive fracture and displacement of the 1st and 2d lumbar vertebrae. Cord completely destroyed. (Table D.) TABLE OF OPERATIONS. j. c. Aug. 20,'l884, vol. 121, p. 175. Dec. 28, 1884, vol. 126, p. 72. 53 M Gay. Gay. Fell few hours before entrance Standing in a cart, horse started, patient thrown, striking on back. Fell 3 stories. Attempted to get out of bed quickly; feet caught in sheet; fell, striking on neck and shoulders. 5 & 6 dorsal. Tenderness, 7th cervical, 1st dorsal. 6th cervical, dislocation. 4th dorsal. 5th cervical. yes yes yes m D !« O p. *S yes yes yes yes, at first. Complete. Complete below nipple. Complete of legs; partial of upper extremities. Complete below 5th rib Complete. yes yes yes yes yes yes, next day. yes, 48 hrs. yes, with- in 24 hrs. 4th day. In 30 hrs. REMARKS. An incision six in. long through muscles to spine. The spinous processes of 2, 3, 4, 5. d. vert, were found broken off, aftid were easily removed. Tortious of laminae of 3 and 4 removed with trephine and " Hmgeur » forceps. All spiculae and sharp points removed. Cord exposed from 2 to 5 d. vert.; opposite the 3d, slight laceration of cord. Emphysema was now first noticed on r. side, and soon covered it. Pulse and respiration better than at beginning of operation. Pupils contracted; surface warm ; cold compress on wound. Conscious that night; took nourishment well. Paralysis continued. Urine did not flow until pressure was applied: priapism nearly gone. Comfortable until noon of next day, when dyspnoea became marked.; Became unconscious; died at 2 P.M. An incision over 1 and 2 d., arid 7 cerv. vert, was made. found, but no crepitus. Some abnormal mobility was 9 P M. same day, Dr. C. saw pltient, and found cavity at nape of neck. Just above 7 cer- vical, spinous processes of 4, 5,16 cerv. vert, could not be felt. Patient could rotate head, but pain over 7 cerv. vert. Dedided to wait until morning. On A.M. following, Dr. C. made incision 3 in. long, extending from 7 cervical upward, without ether. 6 cerv. vert. found dislocated forward; no force could bring it into place. Spinous process and r. lamina and part of left lamina of 6th vert, and part of lamina of 5th removed by trephine; cord laid bare for 1 in. in lengthland nearly its whole breadth: membrane not ruptured. During operation, slight pressure was accidentally made on the cord; immediately patient would show signs of severe pain; pulse was slowed, and became intermittent; the moment pressure was removed, the pulse returned to its former condition. Application of cold produced the same effect. Little blood lost, and strength good: brandy twice. From this he failed rapidly; temp. 110° in axilla at 5 P.M.; and died 6 P.M. -£«*<>psy.—1 he 6 cerv. vert was dislocated forward, its) articular processes being in front of those of the 7th. JNo fracture of bone, or laceration of ligaments; an abrupt depression in spinal canal at point of dislocation. Post. lig. stretched lightly over upper margin of 7 cerv. vert. Cord and membranes normal to the eye. An incision was made over siines of upper dorsal vert. Spinous process of 4th was found to be broken off, its body tilted and dislocated inwards, the articular processes of the vertebra visible. Extension, njovements of neck and body, and traction by forceps, all failed to accomplish replacement. Dr. Gay cut down on to the deformity, but failed to reduce it. (Table E.) TABLE OF AUTOPSIES. B H E < -< s ft fl « J. W. Aug. 29, 1870, vol. 30, p. 138. P. C. Aug. 31, 1872, vol.43, p. 118. CM. March 23, 1873. vol. 45, p. 230. J.B. Sept. 10, 1875, vol. 61, p. 3. C. E. Sept. fl, 1879, vol. 84, p. 240. W. P. Sept. 26, 1880, vol. 92, p. 24. W. W. Aug. 12, 1881, vol. 98, p. 87. S. D. June 3, 1882, vol. 103, p. 164. H. B. W. March 22, 1882, vol. 101, p. 94. T. T. June ao, 1882, vol. 103, p. 254. M. C. May 27, 1885, vol. 128, p. 176. G. F. Nov. 24, 1886, vol. 181, p. 125. H.S. Aug. 10, 1886, vol. 138, p. 136. < S 02 22 M 30 M 45 M 67 M 39 M 52 M 45 M 83 M 68 M 27 M 44 F 74 M 45 F Thorndike. Gay. Thorndike. Gay. Fifield. Fifield. Fifield. Ingalls. Ingalls. Ingalls. Homans. Cheever. Burrell. Fell from staging on back. Fell 5 days before entrance, striking on back of neck. Fell quite a dis- tance ; did not enter hospital for 6 days. Struck on head, and knocked to ground. Struck by a raihoad train. While drunk, fell 15 feet. Fell 18 feet. Fell 15 feet, striking on back. Fell 15 feet. Fell down stairs Fell 30 feet. Fell 10 feet. Tenderness, 7th cervical. Cervical dislocation. 4th & 5th cervical. 5th cervical. Dislocation of atlas. Multiple inju ries; fracture of 2 or 3 vert. in dorso-lum- bar region. 7th dorsal. 4th cervical, 7th to 12th dorsal. 6th cervical. 8th dorsal. 12th dorsal. 12th dorsal. yes yes yes yes yes yeB slight yes yes yes yes yes yes yes drunk < Ph Complete. yes Complete aelow nipples yes Complete below nipples yes Complete. yes Complete. yes No. yes Complete. yes Complete. yes Complete. yes Complete. yes Complete. yes Complete. Incomplete. yes B 33 < M « Ph B D 5 3 O w H 03 -0 02 0 M « H S fl 50 0u O b yes 4 days yes 7 days yes yes next day yes no yes yes yes 8 days 28 hours yes yes no no 2d day yes yes yes in 119 days yes no no no next day yes no no no in 12 hours yes yes yes yes in 69 days yes 'yes yes yes in 3 mos. in 18 hours yes yes s © E £ i< ■- yes albu-men. in 2 days yes REMARKS. (See Table of Operations.) Abdominal breathing; consciousness in special senses preserved to the last. Autopsy.— Heart, lungs, spleen, liver, kidneys, congested; 5th cerv. vert, dislocated for- ward \ in.; spinous process sunk downward nearly J in. from spinous process of 6th vert.; cord considerably softened from 3d to 7th cerv. vert.; effusion of blood under dura mater, at level of 7th cervical and 1st and 2d dorsal nerves, but not enough to compress cord or nerves. The canal was narrowed from 1-8 to 3-16 of an inch. Autopsy showed 5th and 6th cerv. vert, dislocated; softening of cord corresponding to seat of injury. Attempts were made in this ea*e to reduce the deformity, without avail. Autopsy —Examinations of organs not remarkable; 3, 4, & 5 cerv. vert, fractured ; cord pressed upon and softened. On pressure upon these vertebrae, post mortem, tile deformi- ty could be reduced, and pressure of cord relieved. Autopsy.—Granular kidney; cystitis; left pleuritis with effusion ; slight lepto-meningitis. There was a fracture of r. transverse process, and part of the body of the 5th cerv. vert., with injury of the inter-vertebral substance. Extreme perspiration and cyanosis. Autopsy.—Dislocation of atlas, with rupture of lateral ligaments. Autopsy.—There was a fraclture of 2 or 3 ribs near thn dorso-lumbar region. The spine itself was broken transversely through the body of the first lumbar vert., and a segment of the last dorsal vert, was brbken off. Next day after entrance, sense of constriction about waist. Autopsy.—Pleuritic with effusion ; emphysema of lungs; cystitis; pvelitis; fatty liver; fracture of anterior part of 7th dorsal, with compression, and complete disintegration of cord. i Autopsy.—Fracture of bodt of 4th with dislocation forward; fracture of transverse processes of the 3d and 4th ce>v- vert. Complete disorganization of the cord. Apparent depression at 7th and 9th dorsal, and dislocation, with prominence of the 11th and 12th dorsal, with deflection to the left. Extension to legs; counter-extension by rais- ing foot of the bed. Autopsy.—Fracture of the 12th dorsal, with part of the body of 11th; compression of the cord; fractured rib; pyelo-nephritis. Tympanitis. Autopsy.—Fracture of the body (transverse) and articular processes of the 6th cerv. vert.; amyloid degeneration of spleen, liver and kidneys. Autopsy.—Fracture of 8th jdorsal, with crushing and displacement backwards; trau- matic myelitis at seat of fracture. Spinal cord at seat of injury reduced to J the size, and on section it was found to consist of a tube, the wall formed by pia, with a small amount of nervous substance adherent^ and a cavity the size of a lead pencil, filled with a thin puriform fluid. The cord, for about 1 cm. above and below the above site, was softened, yellow and opaque, there beini no distinction between the gray and white portions. At this point, the 8th dorsal was Jressed backward so as to reduce the spinal canal one half. Autopsy.—Fracture vertebral; red softening of cord; hemorrhage into pia, plural cavi- ties, lung and mediastinum. Autopsy.—Twelfth dorsal vert, was fractured in upper portion, giving rise to an arching backward of spine, and a projection backward of a plate of bone, which in turn had pressed on the cord. This pressure had led to red and white softening for a distance of about 15 mm. Above this was an extravasation between the dura and periosteum. (Table F.) Cases treated by Immediate Correction op Deeormity, and Fixation by Plaster} oe Paris Jacket. 17 g S H fl Ph W. B. April 6, 1881, vol. 119, p. 57. July 15, 1884, vol. 121, p. 80. F. O. Aug. 24, 1886, vol. 138, p. 181. J. J. Sept, 21, 1886, vol. 139, p. 67. T. S. Nov. 26. 1886, vol. 140, p. 244. M Ingalls. Bolles. Burrell. Gavin. Burrell, by courtesy of Dr. M. K. Gavin. U ve in bed without pain. Ddlirium. Djath on 11th day, refusing nourishment and stimulants. ' Splint of plaster of Paris at once applied. Discharged Oit 17, 1884, relieved. Sept. 23, 1886 letter: Paraplegia; can feel a few inches dow.i from trunk. Legs are crooked and draw up spasmodically. Constipation. Uses catheter. Sits up 4 to 5 hours daily. No medical advice for a year. Nojr in New Brunswick. Pat. suspended; deformity reduced as much as possible by pressure; "crunching" of vertebra felt on redaction; p. j>f P. jacket applied; sensation in limbs returned iratne. diately. Deformity reduced 11 jhours after accident; retention and constipation ceased on 3d day. S-pt, 2d, patella reflexj soimwhat exaggerated; no ankle clonus; urine normal. '87 examined by Dr. P. C. Knajpp; 1. thigh and leg, no galvanic reaction; all muscles re- act to faradic current; r. thigh ani leg, no faradic reaction; walks with halt in r. leg. May 4, '87, went home, 129 Cnejsea St., C!iarlestow.i, M iss. May 5, '87, bar-tender. Pat. weighed over 200 lbs.; si*p?nded; great pain and dyspnoea; had to be let down; p. of P. applied while suspended; jacket required to be cut up on 2d day, owing to diffi- culty in breathiig; gaping nearly 1 in.; no improvement fron jacket; remived on 6th day abdominil breathing. 31 day, "girdle" sensation. 8th d ly, paralysis of arms; slou«'h of ear from pressure. 7th day, incantinenoe of urine and fae^s. At end of one month, dribbling of urine. Bid sores, marked emaciation, delirium, death. Treated by irmiidiate correction of deformity and fixation by p. of P. jacket. Dec. 5th, plaster splint 2 stntp< applied, i Djc. 8th, jacket removed owing to defective padding; knuckle foanl at 10th dorsal; jacket reapplied; no paralysis. Dec. 9, discharged,own re- quest a-'Minst a Ivice, w.;a.-ing jinket. Feb. 14, »S7, walked into Biston City Hosp. for reapplicitioa of jaccet: no paralysis or pain; slight deformity at 10 to 12 dorsal vert. C M. May 17, 1887, vol. 147, p. 76. CASE UNDER TREATMENT JUNE 7, 1887. Gay. Struck by a falling derrick. 10th dorsal. yes angle 45° yes Complete. yes yes yes under treatment Within a few hours of the accident; pat. was etherized ; suspended; deformity was par- tially reduced, and a p. of P. jacket with shoulder straps was quickly applied. Jacket was uncomfortably tight; 3d day split up over abdomen; 4th day completely, owing to tym- panites. Moved toes 2d dav, slightly right foot. Has had and lias now hyperaesthesia of the legs; this is diminishing. Moved right leg voluntarily the 13th day; left leg as bad as ever. Bed sore over sacrum, also over calf of r. leg. Turns on either side; the jacket very comfortable; cystitis better. FRACTURE OF THE SPINE. 9 missible, for the thoracic viscera, aorta, solar plexus, and vena cava would forbid; and an attempted removal from the side would be equally inexpedient. Five cases have been operated upon at the Boston City Hospital, and they appear in Table D of Operations. All ended fatally. It may be of interest to see the status that this procedure should occupy in Surgery. Pare, Heister, and many of the older authors discussed the propriety of excising portions of the vertebras or trephining, but Henry Cline8 first per- formed the operation at St. Thomas's Hospital, June 16th, 1814. The patient lived seventeen days, and Mr. Cline admitted that the operation hastened the end. Lidell9 failed to find a single well authenticated successful case. It is certainly true, that Legoust,10 Jobert,11 E. Gurlt,18 Hamil- ton13 and Sir Charles Bell14 all condemn the operation in unqualified terms. Gun-shot injuries, however, may be excepted from this sweeping condemnation, and all the reported successful cases of operation, closely resemble that done by Louis16 in 1762, where bony fragments were removed after a gun- shot fracture of the spine. The removal of fragments after gun-shot injuries to the spine is perfectly justifiable, and will, I believe, give a fair measure of success. In the War of the Rebellion16 "there were twenty-four cases of removal of fragments of the vertebras after gun-shot fracture, with fatal results in only 8 New England Journal of Medicine and Surgery, Vol. IV., No. 1, January, 1815. 9 On injuries to the Spine, American Journal Medical Sciences, October, 1864 ; Vol. XLVIII. p. 320. 10 Chirurgie d'Armee, pp. 341, 352. 11 Plaies d'Armee a feu, Paris, 1833, p. 125. 12 Handbuch der Lehre von dem Knochenbruchen Hamm. 1864, p. 186. 13 Treatise on Fractures and Dislocations, p. 187. 14 Observations on Injuries of the Spine and of the Thigh Bone, 1824. lb Remarques et Observations sur les Fractures et la Luxation des Vertebrae, Mem. Path. Arch. Gen. de Med., 1836, LXI. 2 Serie, p. 417. 16 Hist, of the War of the Rebellion, Pt. 1, Surg. Vol., p. 459. 10 fracture of the spine : ten instances." In nine instances, however, of the fourteen examples of recovery, the spinous process, or fragments of it, only were removed. In the five cases of recovery, in which portions of the laminae or the transverse processes were removed, the results were much less satisfactory, nearly all of the patients having serious disability. On the other hand, the operating on fractures of the spine, not compound, is not a justifiable measure, and with- out further evidence supporting this operation, it will have to be placed among the impracticable efforts of experimental or venturesome surgery. Plate III. c. Immediate Rectification of the Deformity in Fracture of the Spine and Fixation by Plaster of Paris Jacket.—On the 10th of August, 1886, I saw the autopsy of a woman who had been under my care, with a fracture of the spine, in the Boston City Hospital (Plate III. Case 78), and found that a plate of bone from the posterior wall of the body of the 12th dorsal vertebra had been broken off, in addition to an arching backward of the whole spine. This plate had pressed upon the cord, and had, in 38 hours, its immediate treatment. 11 led to red and white softening for a distance of 15 mm. The presence of the plate anterior to the cord showed me that an operative procedure would have been of no avail, and the softening occurring so early in the cord, led me to believe that, if aught was to be done to remedy the damage caused by a fracture of the spine, it must be at once.17 The arching of the vertebrae suggested that the difficulty might be overcome by immediately pressing back the deformity, and fixing it in this corrected position. I determined to apt upon this principle in the next case. On Aug. 24th, 1886, Case 17 was admitted, and was seen within twelve hours of the time of his fall of 40 feet. The risks of immediate rectification and suspension having been explained to him, he was suspended, as represented in Plate IV., with this difference, that the tripod was placed over the head of the bed, a ward-master was placed upon a small table at either side of the patient to lift up on the body at the axillae. This, when one has many assistants, is a great aid to the patient. The back of the patient, while being changed from the horizontal to the perpendicular position, should be carefully supported, and when 'the patient is brought into an erect position the buttocks are free from the table. The deformity, which was at an angle of at least 30° and included the 12th dorsal vertebra, was reduced, and a plaster of Paris jacket was quickly applied. An anaesthetic was not given, for I did not wish to have any danger masked. The patient's sufferings during the suspension, rectification and application of the jacket, were more intense than anything I have ever seen ; he nearly collapsed, but the jacket was finished, and stimulants were given. On recovering him- self, he said that there had been an immediate return of sensation in his limbs, directly following the reduction of 17 Case 80. Red softening in cdrd. Death in 18 hours. Table of Autopsies, E. 12 FRACTURE OF THE SPINE : the deformity. His recovery proceeded uninterruptedly. On April 23d, 1887, for the first time he walked out. Dr. P. C. Knapp examined him on May 1st, 1887, and found Plate IV. in the left thigh and leg no galvanjc reaction. All muscles react to faradic current. The right thigh and leg have no faradic reaction. He now walks with a halt in the risrht leg, and on May 5th, 1887, was found acting as a bar tender. Plates V. and VI. represent his present condition. This procedure at the time I supposed to be an original thought, but soon found that other gentlemen in the same hospital had preceded me. Plate V. ftoj^n&f, £ weeks; paralysis, bed sores, cystitis. (Table G.) TABLE OF DEATHS. Z B H ?. E-< fe < < a fc ft M 19 | J- S. 28 March 21, 18C6, vol. 7, p. 8. fc o B 0 X B 0 as a f pain Jn neck ; physical exam, negative. In 3 hours legs be- came paralyzed; abdominal respiration; later, complete paralysis; great thirst; death. Distinct crepitus felt after death, between 6 & 7 cerv. vert. (See Table of Autopsies,) TABLE G (Continued). 38 39 41 45 46 47 48 50 53 M. M. June 12, 1874, vol. 56, p. 26. J. T. Aug. 13, 1874, vol. 53, p. 113. Sept'2, 1874. vol. 53, p. 141. E. T. May 3, 1875. vol. 57, p. 270. J. W. Sept. 12, 1875, vol. 39, p. 271. W. F. Nov. 10, 1*75, vol. 64, p. 84. J. M. Sept. 2'n, 1873, vol. 52, p. 14. B. M. Jan. 1, 1877, vol. 68, p. 227. Oct. 30, 1S77, vol. 74, p. .132. J. K. Aug. 25, 1878, vol. 42, p. 126. J. M. June 30, 1879, vol. 84, p. 77. M. P. Aug. 13, 1879, vol. 83, p. 170. M. D. Oct. 10, 1879, vol. 86, p. 58. J. H. May 22, 1880, vol. 87, p. 252. P. B. Oct. 14, 1880, vol. 91, p. 21. P.W. G. Feb. 10, 1881, vol. 91, p. 120. J. S. Aug. 22, 1881, vol. 98, p. 109. 38 M 50 M M 33 M 34 M 15 M M M 45 M 32 M 23 M 40 M 45 F 51 M 42 M 41 M 32 M Jlomans. Gay. Gay. Ingalls. Gay. Thorndike. Fifield. Thorndike. Fifield. Thorndike. Homans. Gay. Fifield. Ingalls. Gay. Thorndike. Fifield. Tossed by a bull. Fell 30 feet. Fell 18 feet. Fell 8 feet. Wheel of cart passed over chest. Fell 2 stories striking on back. Struck by a falling basket of sand Struck on head by chain of coal scuttle; fell some distance. Fell into a vessel's hold. Fell down 10 Fell 3 stories. Fell 35 feet. Fell 15 feet. Elevator struck patient on back, " doubled him up." Fell 30 feet. Cervical. 3d or 4th cervical. Lumbar, fracture of pelvis. 7th or 8th dorsal. Mid. dorsal. 4th and 5th dorsal. 2d and 3d lumbar. Multiple injuries 4th lumbar. Lumbar; Multiple injuries. 12th dorsal. 7th dorsal. Lumbar. Lumbar. Upper lumbar. 12th dorsal. Multiple injuries, 2d lumbar. yes yes no yes yes no yes yes yes yes no yes yes yes yes yes y»s yes yes yes yes no yes yes no yes yes no yes in lower cerv. yes yes yes no i yes yes no yes yes no yes yes no Below 2d ribs. yes no no no Complete. yes Absent. yes Complete. yes yes yes Complete. yes yes yes Complete. yes Complete. no Complete. yes Complete. yes Complete. yes no yes yes Complete. yes no no no Complete. yes no no no Complete. Complete. yes no no no Complete. yes yes yes yes Complete. yes 24 hours. no yes Same day. no Next day. no 52 days. no Tn 1 month. no no 18 hours. no 4 hours. no | hour after admission. 4th day. no yes Following day. no yes 9 days. no yes Next day. no yes 6 days. no Next day. no 3d day. no no 79 days. no 5 days. no Respiration abdominal; thirst, Died suddenly, speaking 5 minutes before death. Incontinenee of urine and faeces, Exhaustion. (See Table of Autopsies.) Fract. 3 ribs on right side, Incontinenee; spinous processes of lower lumbar vert, deflected to one side, and a space existed between 4 and 5 lumbar large enough to lay finger into tympanites; no dejection, even from ol. tiglii gtt. iv. ] Tympanites; abdomen tapped w|Ith relief. Tympanites relieved by rectal tube. (See Table of Autopsies.) Tympanites relieved by reotal tube. Death sudden. (See Table of Autopsies.) Death said to be due to oedema of the lungs. Etherized, and by extension, coijnter-extension and pressure over deformity, the de- formity was nearly reduced; kept in position by pads; 10 lbs. extension and tight cmvaa belt; incontinence; 40 days after entrance, plaster of P. jacket applied; pat. grew steadily worse; death from exhaustion. (See Table of Autopsies.) Cause of death obscure. TABLE G (Concluded). 59 (See Table of Autopsies.) 00 E. W. May 6, 1882, vol. 104, p. 91. 38 M Homans. Fell 65 feet. Multiple injuries, middle dorsal. no no Complete. yes yes 8 days. no Died suddenly, without cause being known. **" if 61 D. C. May 10, 1882, vol. 104, p. 106. 39 M Homans Fell 30 feet striking back. 1st lumbar. yes Complete. yes yes yes yes 21 days. no (Edema of penis; girdle sensation; tympanites. 62 63 (See Table of Autopsies.) (( H «( is 64 J. S. Aug. 8, 1882, vol. 106, p. 246. 39 M Thorndike. Struck on back by a boom. 8th dorsal. no yes semi Complete. yes yes 8 days. no Severe pain, with girdle sensation; vomiting. 65 J. C. Aug. 10, 1883, vol. 114, p. 219. 17 M Thorndike. Fell 40 feet. Multiple injuries, double frac-ture mid. dorsal. yes yes yes j Complete. yes yes yes 4 months. no No special treatment; deathfijam exhaustion. 66 (See Table for Immediate Rectification of Deformity and Fixation by P. of P. Jacket.) 67 J. C May 22, 1884, vol. 122, p. 8. 30 M Homans. Struck by a boom. 4th and 5th dorsal. yes yes yes Complete. 24 hours. no Concussion of brain; respiration diaphragmatic. 68 F. D. June 12, 1884, vol. 119, p. 269. 25 M Post. Railroad accident Multiple injuries, tract. of mid. dorsal. yes yes yes Complete. yes Few hours. no Pulseless at time of admission. 69 W.E. Aug. 2, 1884, vol. 121, p. 132. 65 M Gay. Fell down stairs. 6th cervical. no yes no Complete. yes yes yes 6 days. no yes Cyanosis; diaphragmatic respiration. 70 71 (See Table of Operations.) 72 J.C. Jan. 5, 1885, vol. 126, p. 92. 65 M Gay. Fell from wagon, struck on face. Cervical. yes ! Complete. yes yes yes yes 11 days. no no 73 (See Table of Autopsies.) 74 C. S. Sept. i5,*1885, vol. 130, p. 234. 25 M Bolles. Fell from 2d story window. Dorsal. yes ' Complete. yes Same day. no 75 E C Jan. 6,1886, vol. 132, p. 261. 42 M Bolles. Carriage fell on patient. 4th cervical. yes yes yes i Complete. f Next day. no Asphyxia. 76 Dec. 3, 1886, vol. 142, p. 12. 45 F Bradford. Fell 2 stories. Cervical. yes no at first Absent. 15 hours. Spoke five minutes before death. 77 M. C. July 31, 1886, vol. 138, p. 108. 21 M Bolles. Railroad injury, multiple. 6th dorsal. yes yes no Complete. yes 3 days. no No re-action from shock. 78 (See Table of Autopsies.) 79 B. F. E. Oct. 26, 1886, Carney Hosp. 50 M Burrell. Fall from coal bridge 18 feet, striking on back. . 9th and 10th dorsal. yes yes no Complete. yes yes yes yes 212 days. no no Was transported from Lake Suberior to Koston on an air bed': cystitis so- severe that it perforated the recto-vesical septum,-causing recto-vesical fistula. Complication of drib-bling-of urine from anus, relieve4 by glass rectal urinal. 80 (See Table of Autopsies.) 81 (See Table for Immediate Rectification of Deformity and Fixation by P. of P. Jacket.) 82 A.M. April 11, 1887, vol. 145, p. 176. ..... 44 M Gay. Fell 15 feet. Lower cervical and upper dorsal. no no no Complete. yes no 40 hours. no yes Fracture bed; tympanites; diaphragmatic respiration. This may be a case of hemor-rhage into or about the cord. ITS IMMEDIATE TREATMENT. 15 doubtless to his bringing; this method of treatment of Pott's disease18 before the profession is due the present application of plaster of Paris jackets in fresh fractures of the spine. • On June 25th, 1879, J. R. Weist, of "Richmond, Indiana (see Appendix I.), reduced a fracture of the 9th Plate X. (No. 1376 Wakren Museum.) Diagram of a fracture of the body of a vertebra, not narrowing the canal materially. dorsal vertebra during suspension, and applied a plaster of Paris jacket. This was followed by a great relief to the pain, uninterrupted improvement, and a recovery of the patient on the 67th day. " Succinct History of the Plan of Treatment of Pott's Disease by Sus- pension and the use of Plaster of Paris Bandage, p. 4. 16 FRACTURE OF THE SPINE : Dr. Weist says that when he applied the plaster dressing in this case, he was not aware that it had been used in such cases; but he learned from Dr. Sayre that it had been Plate XI. (No. 911 Warren Museum.) Fracture of 1st lumbar vert. Female, aet. 19; fall, 20 ft., striking on nates. Spinal eanal encroached upon. Symptoms.—Complete paralysis, immediate. Results,— Moderate improvement after 3 weeks; power of sphincters regained. ITS IMMEDIATE TREATMENT. 17 used several times in a similar manner at Bellevue Hospital with very satisfactory results, and says that probably others also have used the plaster jacket in this way. However this may be, Dr. Weist made the report at the Plate XII. (No. 4629 warren Museum.) Old fracture 12th dorsal. Upper edge has been broken away from body of centrum. 12th dorsal vertebra is crushed anteriorly. Considerable narrowing of canal, oppo- site upper edge of 12th dorsal vertebra. C. a!, a;t. 18; fell ori plank floor. Paralysis, bed sores, cystitis; death after 2 8-12 years, 'cord considerably disorganized at seat of injury. request of Professor Sayre, and with the exception of an allusion to a case of Spratley's by Reginald Harrison, shown at the Liverpool Medical Institution,19 Dr. Weist's case is the earliest published record of the procedure that I have been able to find. is Surgical Diseases of the Urinary Organs (Lectures on), p. 51, by R. Harrison, at the season 1878-9. 18 FRACTURE OF THE SPINE : In the remainder of the year 1879, I find five cases treated in this manner. Konig, of Gottingen, in 1880 said that having used suspension and plaster of Paris jackets for caries of the vertebra?, where there was paralysis, Plate XIII. (No. 938 Warren Museum.) Fracture 4th dorsal: longitudinal section, showing backward displacement and narrowing of canal. Female, a;t. 25; fall, 15 feet; paralysis (complete); bedsores; death, 9 weeks. ITS IMMEDIATE TREATMENT. 19 with great improvement, he was led to apply a similar treatment to fresh fractures of the spine. He did not advocate its employment in all cases, but in his three cases the results were favorable. (See Appendix II.) He said that doubtless the method had been employed in other hospitals, and he wrote the paper as a contribution to the subject. Wagner, of Konigshutte, reported two cases with which he was not at all satisfied. In both cases he was obliged to remove the jacket. (See Appendix III.) He advised caution in the use of the jacket, had seen it produce paralysis, and felt that the replacement might produce alarming or dangerous symptoms. He advocated its application at the expiration of fourteen days. The whole subject was discussed at the German Congress of Surgeons in 1881,20 and was evidently considered a measure worthy of trial in picked cases. Langenbeck mentioned a case which he had treated in this manner in 1862, and which ended in failure. Since then I have accounts of the following cases : one by Berkeley Hill (see Appendix IV.); one by Edouard de Reynier (see Appendix V.) ; one by Carson (see Appen- dix VI.) ; two cases by H. O. Marcy, private letter (see Appendix VII.) ; and the five cases included in Table F. No attempt has been made to investigate cases where a jacket has been applied after the tenth day following an injury. This gives us sixteen cases, in which three died, three derived-no benefit from the method, and ten were greatly benefited. The subject may be summarized, and 1 submit the following conclusions : First__That, in the immediate correction of the de- formity 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. 20 Berl. Klin. Wochen., 1881, p. 247. 20 FRACTURE OF THE SPINE. Second—That, considering the hopelessness of results in fracture of the spine when treated expectantly, almost any risk is justifiable. Third—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. Fourth—That the suspension of the patient is only a means of rectifying the deformity; that certain fractures could be simply pressed into position while the patient lies prone or supine. The objections to the treatment are,— 1st. That the expectant plan of treatment gives a small percentage of recoveries. 2d. That there are serious risks, especially in the cer- vical region, attending the suspension of a patient and the rectification of the deformity with a fractured spine, in the way of shock, collapse and death. 3d. 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. In conclusion I wish to acknowledge my indebtedness to Drs. II. W. Cushing, E. G. Brackett and W. H. Prescott for valuable assistance rendered in preparing details of this paper. (Table H.) TABLE OF RECOVERIES. 12 16 < < N K. Jan. 30, 1866, vol. 8, p. 152. j. R. June 20, 1867, vol. 11, p. 136. H. W. Oct. 2, 1874, vol. 53, p. 211. D. F. 55 Dec. 3, 1874, vol. 55, p. 102. J. E. Feb. 26, 1878, vol. 70, p. 130 P. W. June 21, 1881, vol, 95, p. 136. F. D. Sept. 2, 1882, vol. 106, p. 221. T. K. Sept. 13, 882, vol. 108, p. 18. R. B. Oct. 5, 1882, vol. 108, p. 87. S C Oct. 5, 1883. vol. 116, p. 92. M. C. Nov. 23, 1883, vol. 115, p. 165. W. R. Julv 7, 1884, vol. 122, p, 159. F. W. Sept. 20, 1885, vol. 130, p. 256. W.C. Oct. 18, 1885, vol. 132, p. 06. 30 W. K. 19 Oct. 2», 1870, vol. 32, p. 24. 50 38 32 34 32 33 40 45 36 25 M M M M M M M Coolidge. Cheever. Fifield. Gay. Thorndike. Ingalls. Thorndike. Thorndike. Fifield. Fifield. Cheever. Homans. Bolles. Post. X ^ Fell 3 weeks before entrance. Fell from mast head. Fall from ladder. Fall 25 feet. Burled in debris by giving way of a floor. Fell down 4 steps, striking on head and shoulders. 5 weeks before entrance fell quite a distance. Fell 2 stories. Fell from team, striking on face. Was caught between tin- si at of a team and the top of a driveway. Fell 14 feet, striking head. Thrown from a team. Thrown from raiiroad biidge. Fell 3 stories. Fell 35 feet, 1 week before entrance. Lumbar. Fracturo of spinous pro- cess in lum- bar region. 1st dorsal. Lower dorsal. Lower dorsal. Cervical. Lumbar. Lumbar, 4th. Cervical. Lumbar, 1st & 2d. Spine of 6th cervical. Upper Lumbar. Dorsal, 4th &5th. Mid dorsal. Dorsal, 4th. yes yes yes yes yes yes yes yfcs yes yes yes yes yes yes yes yes yes yis on For a few minutes. Retention, Constipation Yes. Complete. Complete. Partial, at first. Complete. Complete. Absent. Absent at first, slight numbness later. Absent. Complete. Absent. Complete. Complete. yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes ye.' Treatment—rest in bed. Disci targed relieved, Feb. 16, 1866 Discharged well in one month. Discharged Dec. 24, 1870, nearl y well; nothing especial done Some nausea and vomiting; tions; bed sores on left flank Heavy drinker. Discharged re clean and small. Tympanites; incontinence of t improvement in paralysis Paralysis of arm, hand and leg probable fracture of spinous prot REMARKS. tympanites; paracentesis abdominis ; involuntary dejec- d thighs, exposing muscles; catheter kept in bladder. lfcved, Dec. 30, 1874. No record of paralysis; bed sores rine; diarrhoea; became fretful; circulation poor; no Discharged relieved. at once, lasting 12 hours; gradual return of sensation; ess. Discharged March 23, 1878, relieved. Discharged in one month, cone ition unchanged; incontinence of faeces and urine. li'ht ■ctions; reflexes increased; considerable twitching; Treatment, fracture bed. Oct. 14, 1882, motion in legs. rged, condition relieved. Seen on Oct. 1, 1886. Staid in u crutches ; retention for 5 mos.; incontinence of faeces ncontinence; can go down stairs fairly well with )ut subjectively heavy ; almost complete motor paralysis fat for a time, now weight nearly normal. neck became stiff. Examination—head carried low; nsverse processes of 5tli & 6th cerv. vert. Sept. 14, 1882, lead; back fixed with ham splint, attached with shoulder val of plaster. Sept. 29, 18>2, '-bound to go"; plaster & 6 cerv. spines; some tenderness : moves head easily. Tympanites; involuntary dej "girdle" t-ensation ; urethritis. Nov. 9th, sat up. Nov. 13, di^ch house 3 yrs. 8 mos., going about < 2 years. Present condition—sli crutches; can move r. leg fairly, of 1. leg; appetite fair; was very Mounted team and rode home crepitus on lateral pressure of trt p. of P. jacket, with a hood about. cap over h< ad, lifter partial rem< removed; pi-ejection felt over 5 No further symptoms. Delirium tremens on 4th day. (Discharged Nov. 1, 1882, nearly well; projection plainly felt. Discharged well in 6 weeks; plaster hood applied 3d day. Letter, May 16, 1887, doea light work on a farm. Dec. 22 1883 thinks he can do as well at home as in hospital; discharged, own request, unrelieved. Lobar pneumonia 36 davs after entrance. Treatment—fracture bed, swathe round body. Discharged, well, Aug. 30, 1884. May 18, 1387, walks about, and does a Utile work. (See Table for Immediate Rectification of Deformity and Fixation by P. of P. Jacket.) I etter from patient Sept. 15, 18i?6. Can move legs slightly, but not to any practical ex- tent" sensation fairly good; catheter constantly; scrotum and penis often (Edematous; general condition improving, but bed-ridden. Discharged incurable. (See Table for Immediate Recti5cation of Deformity and Fixation by P. of P. Jacket.) APPENDIX. I. From the St. Louis Medical and Surgical Journal. Fracture of" the Spine, with Cases. By T. R. Weist, M.D., of Richmond, Indiana, March, 1880, p. 295. On June 25, 1879, called to see Mr. B.. farmer, aet. 30, whose back, messenger said, " was broken." When accident oc- curred, he was on top of a load of hay, that was being driven under a shed across which some beams were placed. While passing through, he found that he was likely to be caught by the timbers above. He was sitting on the hay; he threw his body forward and lowered his head; still there was not sufficient room, and the upper part of his shoulder and spine came in contact with the obstruction above, and he was badly crushed. Was unconscious for some time after the accident. There was a serious injury and great deformity of back. A few hours later he was in great agony, complaining of violent pain in his back, and of great diffi- culty in breathing. Examination:—Shock, pulse 140, feeble, skin cool and perspir- ing, resp. 35, difficult; deformity of spine at 9th and 10th dorsal vertebrae. On each side of the spine there was a decided swelling near the point of curvature. On shoulders, skin abraded and much bruised. Loss of sensation below seat of injury, more marked on right than on left side. No paralysis of motion. Slightest movement caused great pain. Spinous process of 9th dorsal vertebra was much displaced backwards, it being possible to place the finger under it. Evidently there was fracture of 9th dorsal vertebra, with slight dislocation backwards. Efforts were made by extension and pressure to reduce the displacement, without success. During these manoeuvres distinct bony crepitation was felt. ...... Fifteen hours after accident paralysis about the same. He was then suspended h la Sayre. I then made strong extension with slight rotatory movements, and pressure with the other hand over the projecting parts of spine. Crepitation was again felt. 22 fracture of the spine : Plaoter jacket was now hastily but carefully applied, then he was put to bed. Breathing greatly improved; was left in comparative comfort. Next day he was much improved; sensation below injury restored; bladder again normal. On 7th day he could turn in bed without assistance; on 12th was carried on a stretcher to his father's house 2 miles distant; on 15th day was able to get out of bed himself; on 20th day a new jacket was applied, and worn until September 1st. November 2d, 67 days after accident (?), his back is as strong as before the injury..... II. From Gentralblatl fiir Chirurg., Leipzig, 1880, vii. pp. 97-100. Der Thoraxgipsverband bei Fracturen der Wi-rbelsaule, von Prof. Konig. (3 cases.) (1) Male, set 20. Had a fall from second story window, Aug. 14th, 1879 ; unconscious when found. Rallied at hospital. On examin., found a fracture of the 8th dorsal vertebra; there were no symptoms of motor paralysis, no paralysis of either bladder or rectum. On Aug. 16th the plaster of Paris jacket was applied, patient being suspended; the jacket extended from the axillae to the trochanters. The suspension and application of bandage were well borne, and immediate improvement followed. Patient was able to walk at the end of three weeks. On the removal of bandage, about the middle of the following September, deformity had disappeared, and there were no symptoms of com- pression of the spinal cord. (2) Patient, male, aet. 28. Had a fall of 40 feet, Oct. 21, 1879 ; was unconscious for half an hour, then complained of violent pains in back, and formication in lower extremities, with numbness; no paralysis of bladder or rectum. Back very sensitive in region of first dorsal vertebra; angular deformity at that joint. Oct. 22d, the gypsum bandage was applied, in the same manner as in the preceding case. The nervous phenomena had dis- appeared by the next day, and the patient was able to move about by the 22d of November. Nov. 29th bandage was removed ; the cyphosis had disappeared, and patient was dismissed perfectly well. (3) Male, jet. 38. Had a severe fall, Nov. 28th, 1879, from roof of a rail-road car ; suffered fracture of 8th, 9th and 10th rib, near vertebral insertion, with hsemo-pneumo-thorax deformity (gibbosity) in back, corresponding to the 9th and 10th dorsal ITS immediate treatment. 23 vertebra. On account of symptoms of embarrassed respiration, the correction of this deformity had to be abandoned. Cervical neuralgia. When the symptoms of embarrassed respiration had about disappeared, the gypsum corset was applied, as in the preceding cases. Nervous phenomena had disappeared the next day; patient continued to improve, and by the end of the year had perfectly recovered. In all these cases recent fractures were dealt with, and only in such cases would I recommend the application of the gypsum corset. III. From Centralblatt fur Chir., Leipzig, 1880, vii. pp. 737-739. Zur Behandlung der Fracturen der Wirbelsaule mit dem Sagree schen Gipskorsett, von W. Wagner. (2 cases.) The author refers to the good results obtained by Prof. Konig in his 3 cases, and then reports two cases with which he is not satisfied: — (1) Male, set. 38. On Oct. 16th, 1879, was buried beneath a mass of coal, which fell upon his back; was immediately removed to hospital. There was evidently fracture of the 11th dorsal vertebra. Paralysis of bladder, which was temporary, and dis- appeared within 24 hours; no motor or sensory disturbances ; " gibbosity," or displacement of fragments, in back. The next day patient was suspended " to toes only " (!) ; the " gibbosity " dis- appeared somewhat, but the patient complained of violent pains near the seat of fracture during the suspension. The plaster of Paris jacket was applied. During the next twenty-four hours, the pain had so greatly increased, that the patient was actually frenzied, so that the bandage had to be removed, when the pains immediately abated, and the patient afterwards recovered. (2) Male, aet. 25. Jan. 31, 1879, sustained a great pressure while in a bent position ; fracture of the 10th dorsal vertebra ; no disturbance of mobility; deformity in back. The plaster of Paris jacket was applied 24 hours after reception of injury, and was well borne at first; deformity disappeared; no increase of pain. The next day the patient complained of numb- ness in his lower extremities; when examined, perfect paralysis of extremities was found, also paralysis of bladder, necessitating use of catheter; decreased sensibility of extremities also found. The bandage was at once removed; all the disturbances men- tioned disappeared in the course of a week. At the end of that time, patient complained of severe pains at seat of fracture when he attempted to sit up in bed. Another bandage was applied; this was worn for three months, when the patient was dismissed with slight deformity. 24 fracture of the spine : IV. From Transactions of Clinical Society of London, 1881, vol. xiv. pp. 144-147. Case of Berkeley Hill, read March 11th, 1881, before Clinical Society of London. John Richards, on Dec. 1st, 1880, fell 20 feet down an elevator. He was unconscious until he found himself in the hospital. On his way to Univ. College Hosp. he had two fits. Never remembers having any before the accident. Suffered for 24 hours from concussion of brain and spinal cord, and was unconscious for half an hour after admitted to the hospital. Pupils dilated and insensible to light; skin hot and sweaty ; pulse 120. Respirat'on frequent, shallow and puffing. A severe con- tusion behind the right parietal eminence was the only sign of injury to skull. In the back, there was prominence of the spinous processes from the 10th dorsal to 2d lumbar vertebra ; a large swelling occupied the vertebral grooves. No symptoms of visceral injury ; urine drawn from bladder, normal ; no paralysis of lower extremities, but great pain on movement. At 7 A.M., next day, temperature 103° ; no retention of urine, no paralysis, but great pain in back. At 2 P.M., same day, the jacket (plaster of Paris) was applied; it gave great pain until it had firmly set; patient was kept until then on air-bed. The temperature then fell, patient asked for food, and then slept. Third day after application of jacket patient could roll himself in bed from side to side without pain. Dec. 4th, patient complained of sharp pain on dorsum of left foot; no loss of sensibility anywhere. Dec. 5th, could not move the lower extremity at hip, knee or ankle, though he could flex the toes slightly. Right limb normal; but sensation of " pins and needles " in fingers of right hand. In two days control of left limb was regained, hyperaesth. of foot disappeared. Jan. 27th, jacket removed, patient allowed to walk about the ward. Feb. 2d, patient left for Eastbourne Hospital (a long railway ride). Feb. 24th, completely cured and able to walk three (3) miles. V. From Deutsche Z'schrift.f Chirur., Leipzig, 1885, xxii. pp. 356, 386, by Edward de Reynier. Fracture of 7th Dorsal Vertebra. Patient was suspended "k la Sayre;" perfect reduction of dislocation in this position ; plaster of Paris jacket was then applied, in order to insure " permanent reposition" of spine. ITS immediate treatment. 25 The injury had caused paralysis both of motion and sensation in lower extremities, which had completely disappeared eight days after application of jacket. One month later patient was able to rise and walk, with the aid of crutches. He wore the jacket for two months, at the expiration of which he left the hospital cured. Title of article is: Einige Bemerlciingen iiber 17 Falle von Wirbelfracturen, die auf der Chir. Klinih zu Bern vom Jahre, 1865-1884 vorgekommen sind, von Edouard de Reynier. Patient, male, aet. 19. Admitted to hospital, Sept. 20th' 1881, for fracture of spine (exact location not mentioned); had fallen into a well head first, had his back suddenly thrust back- ward ; states he "heard his back crack." He was then unable to rise or move and was brought to the hospital in this condition. Author regrets to say that he was only thoroughly examined five days after the infliction of the injury. Plaster jacket was not applied until Oct. 3d ; the next day the sensibility and power of motion had returned, and retention of urine disappeared (no priapism). VI. From St. Louis Courier of Medicine, Jan. 1885, p. 71. Meeting of " St. Louis Medico-Chirurgical Society." Dr. Carson (N. B.); "It may be interesting to the gentlemen here who were present several weeks ago, when I reported a case of fracture of the spine, to hear the result. I saw the patient shortly after the receipt of the injury, within a very few hours, and applied a plaster jacket; the patient was at that time devoid of sensibility and ability to move the extremities. I stated that immediately after the stretching he felt relieved from the pain, and all the other symptoms were also relieved; the fracture was in the lower portion of the dorsal region. The patient gradually recovered, and the bad symptoms disappeared within a few days after the application of the splint, as did the other disagreeable symptoms, and he said to me to-day that he felt as though he could go out. I don't think he could run a race, but I think he has done very well indeed. We have had, since that time, another case, which happened very much in the same manner, and the injury is very nearly at the same site. The patient came to the hospital several days after the injury was received, in a much worse condition. We applied the jacket in this case, but not with any decided improve- ment, so far. The patient was unable to talk or feel the intro- duction of the catheter at the time he entered the hospital. At 26 fracture of the spine : the present time, whenever the catheter is introduced, he feels it, but there is total loss of sensation in the lower extremities, and his condition is not a favorable one, nor has there been any material benefit by the application of the splint. In this case, however, we did not suspend him as we did in the other ; we tried extension and counter-extension from the hip and shoulder in the horizontal position." VII. W. L., set. about 50. Carpenter, strong and vigorous. Fell from staging, about thirty feet, May 21, 1881. Was doubled up and taken home in a hack. I saw him soon after. Fracture of spine near middle dorsal. Paralysis com- plete. Priapism, retention of urine. Motion of fragments marked at point of injury. After a careful explanation of the danger, extension was made and a plaster splint applied, aided by Dr. Samuel N. Nelson. For a few days there was a marked improvement, both sensation and motion in a slight degree return- ing to both extremities. Soon the patient grew worse, with rapid pulse, elevation of temperature, delirium, sinking into a coma, and death supervened June 4th, fourteen days after the injury. Autopsy showed a transverse fracture through the body of the vertebra with local softening of the cord at the place of injury. The fragments were in direct apposition. Case 2d.— P. R., horse doctor, aet. about 50. In good general health, except suffering from multiple strictures. Had been a hard drinker. In August of 1882, was thrown backward from carriage, striking violently on shoulders. Paralysis not complete. Sensation and motion of lower extremities, to a limited extent; retention of urine. Not seen for some days after injury, owing to absence from city; under care of another physician. Was a distinct projection with marked tenderness over the second and third dorsal vertebrae, with slight motion on firm pressure. In consultation with t)r. F. A. Holt, of Cambridge, it was determined to attempt exten- sion and reduction, after a careful explanation, of the condition and its danger, to the patient. Upon extension a certain amount of displacement was effected and a plaster splint applied. The patient fainted, with entire loss of consciousness at its completion, but rallied at once upon being placed horizontal on a water bed near at hand. Owing to pressure and disturbed respiration the splint was carefully opened anteriorly, and retained by tapes. Was kept on water bed three ITS immediate treatment. 27 weeks, and then carefully removed to a firm hair mattress. Par- alysis slowly lessened, until patient could walk, at the end of about six months. Now is able to attend to business. Can stand upon either foot and has no pain or tenderness at seat of injury. The patient is stooped, with a considerable prominence at site of injury, and carries the head somewhat forward.