UNITED STATES OF AMERICA WASHINGTON, D. C. B19574 / y ^y EPORT POTT'S DISEASE, OR CARIES OF THE SPINE. TREATED BY EXTENSION, AND TUE PLASTER OF PARIS BANDAGE BY LEWIS A. SAYRE, M.D., PROFESSOR OF ORTHOPEDIC SURGERY IN BELLEVUE HOSPITAL MEDICAL COLLEGE, ETC. ETC. EXTRACTED FROM THE TRANSACTIONS OF THE AMERICAN MEDICAL ASSOCIATION. PHILADELPHIA: COLLINS, PRINTER, 705 JAYNE STREET. 1877. %^ ^ X. REPORT POTT'S DISEASE, OR CARIES OF THE SPINE. TREATED BY EXTENSION, AND THE PLASTER OF PARIS BANDAGE. BY LEWIS A. SAYRE, M.D., SNjgj^t . PROFESSOR OF ORTHOPEDIC SURGERY IN BELLEVUE HOSPITAL MEDICAL COLLEGE, ETC. ETC. EXTRACTED FROM THE TRANSACTIONS OF THE AMERICAN MEDICAL ASSOCIATION. PHILADELPHIA: COLLINS, PRINTER, 70 5 JAYNE STREET. 1877. 'rrion. 7»e Since my report was made in Philadelphia, the little fellow has returned from their country seat at Long Branch, and « wants his • jacket' taken off, as it is too tlSW12,lS76,I removed it In the presence of Prof. Darby of this city; Dm. 32 REPORT ON Case XL—Thomas Cochran, aged seven. The mother states that he is a very nervous and excitable child. When three years old befell down a flight of steps, since which time he has com- plained of pain in his stomach, sometimes in his back. The mother noticed a bunch upon his back while he was still confined to his bed. This bunch was painful. Has been under treatment by iron braces for four years, and has gradually grown worse. Has been to a Philadelphia hospital for ruptured and crippled, Forty-second Street, and Dr. Sweet, of Newark, has seen him. Benharn, of Pittsburgh ; Formento, of N. 0. ; Logan and Willman, of Georgia ; Cullen, of Richmond, Va. ; and some others who happened to be in the office at the time. None of the gentlemen present had the slightest suspicion that he was suffer- ing from Pott's disease, or that he was using any support, until his clothes were removed. When stripped, his form was perfect with the '• jacket" on, and at the request of Dr. Darby, he jumped firmly upon his heels without the slightest evidence of any pain. Firm pressure could also be made upon his head and shoulders with the same result. Four months previous he could not bear the slightest jar upon his heels, or pressure upon his head. On sawing down the "jacket" and removing it, his skin was found to be per- fectly healthy. But on turning him over to examine his spine, fortunately we found a black spot the size of a finger-nail over the projecting ninth dorsal spine. This was like a hard corn, and was readily lifted off by the finger-nail, and the integument underneath was sound. This place was still a little tender when strong pressure was made upon the sides of the ribs, or ou crowding upon the head and sacrum. I say " fortunately" we found this one tender spot, for in the language of one of the surgeons present, " if I had not done so, they would all have thought that nothing was the matter with him, and that he had never had the disease at all; but the difference in his actions when the 'jacket' was removed satisfied them that I was correct." I have a letter from his mother dated Ocean Crest Cottage, Dr. Sayre : Long: Branch, July 6, lS7b'. Dear Sir : . . . . You put on your " plaster jacket" on the 1st of March, and from that time George has been steadily improving, and, strange to say, he has never had a single pain in his knee since. About two weeks ago the bandage was changed for a fresh one, and the skin was found to be in a perfectly healthy condition. George has never complained of the "jacket" hurting him, or being uncomfort- able in any way........ Very gratefully Your sincere friend, ELIZA M. CURTIS.' 1 January 15, 1S77. Entirely well. pott's disease. 33 His present condition, March 16,1876, is: tolerably well nour- ished, but unable to stand without support; posterior curvature of seventh, eighth, and ninth dorsal vertebrae. The eighth pro- jecting very prominently (see Fig. 18). Great pain when press- ing on head and sacrum. When suspended, the projection dimi- nished very perceptibly. March 16, 1876. Plaster of Paris jacket was applied. May 20. Boy returned to have jacket seen to. Has been per- fectly comfortable since last date. Has improved considerably. FiS- 18- Fig. 19. Jacket not disturbed, as it is still in good condition, as seen in photograph annexed, and the boy exercises freely without pain or inconvenience (see Fig. 19).1 1 Jan. 8,1877. Perfect consolidation with scarcely perceptible deformity when naked, and imperceptible when dressed. Is in robust health, and very active. 3 34 REPORT on Feb. 10, 1876. Case XII.—Wm. A. Lyon, aged 4 years, 127 Morton Street, Jersey City, sent by Dr. Craig, with Pott's disease, 8th, 9th, and 10th dorsal verte- Fig. 20. Fig. 21. brae of 18 months' standing caused by falling down stairs. Taylor's brace applied July 20th, 1875, has worn it ever since. At that time deformity very slight (as the parents say). Present condition as seen in curved dark line (Fig. 20), has two sores on prominent verte- bra. Eemoved brace, and when extended in sling straightened to dotted line. Applied plaster of Paris dressing, after which could walk and was compara- tively straight. May 10. Has been perfectly comfortable since application of plaster bandage. Exercises freely; has no indigestion or pain ; no pain in bowels, of which he formerly complained constantly. March 27, 1876. Case XIII. —Edith S. Groot, aged 7; father and mother healthy; has three sisters all healthy. About middle of June, 1875, she was thrown from a trotting sulky, and from that time the father dates the disease, and knows that that was the cause. Direct pressure on the knuckle produces no pain, but when lateral pressure is made intense pain is produced. The solid line (Fig. 21) shows deformity when standing; dotted line when suspended. Plaster of Paris jacket applied, with per- fect relief. Child brought to me by her father, Dr. C. A. Groot of Westbury, Wayne Co., New York. Have since received a letter from Dr. Groot saying that he had been able to reapply the jacket with perfect success, and that the child is improving. pott's disease. 35 Fig. 22. March 4, 1866. Case XIV.-Mary S. Ward, aged 4 years, Bloomfield, N. J., was brought to me March 4, 1866, with the following history. Fell out of a child's carriage when 22 months old. Has always been delicate but never sick. Six weeks after fall, parents noticed symp- tomsof lassitude, and disinclination to walk, and in six months she lost all power of walking, when a swelling in her back was discovered. Was bathed in salt water and put on cod-liver oil by advice of Dr. Parker. At the present time she is unable to stand. Has a posterior curvature of 9th, 10th, and 11th dorsal vertebrae. Very tender on ver- tical pressure, and easier by extension by the feet or lifting her by the arms. Advised horizontal posture and applied Taylor's brace, May 20, 1868. With brace on can walk with assistance, and stand without resting her hands upon her knees or any other support. Curvature not quite as prominent. Child was not seen again until April 5, 1876, when she presented the ap- pearance shown in Fig. 23. The curva- ture has increased, although she has worn the supporter constantly. An abscess formed in the back some months ago, which was opened. Several small pieces of bone have escaped. Dark and dotted lines in Fig. 22 show diminution of curvature when suspended. Applied plaster jacket, cutting a fenestra over the abscess, with perfect comfort. May 22, 1876, child has improved very much since jacket has been applied. Abscess has been closed for three weeks. Position as seen in Fig. 24. Jacket removed, and a new one applied without fenestra. The following letter from her father, the Eev. Dr. Ward, will give a very good idea of her present condition, as well as the advantages of the " plaster jacket" over the "Taylor brace." REPORT ON Bloomfield, N. J., June 1, 1870. My Dear Dr. Sayre : Find herewith a photograph of my daughter's back, supported by your plaster corset. You have the one taken previously. She has, you know, worn mechanical braces (Dr. Taylor's) since she was about three years old, until the ap- pearance of a cold abscess on her back, and she could wear them no longer. She is now nearly twelve. Your plaster corset has been a great comfort to her, and we think is proving a permanent benefit to her; certainly she has improved remarkably since you applied it. Several reasons commend your corset to us over the brace. 1. By your pulley the form is lifted, near as may be to its erect position, and the corset retains it in its place. Mary is an inch taller at once by it. 2. The corset so completely fits the form as to distribute its support evenly about the whole body, thus relieving the spine. pott's disease. 37 Fig. 24. 3. It proves comfortable to wear. Its close adjustment seemed confining for a few hours, but after a night's sleep Mary began to speak of the great comfort it gave her—and then of her grati- tude to you—and from that time on her pleasure has been en- thusiastic in it. She breathes easily and naturally with her dia- phragm, without any of that short, jerking respiration she had before it was applied, and has been very unwilling to have the corset removed on any consideration ; she has worn it now more than six weeks unchanged, and in her gratitude wants everybody to know about it. 4. The corset can be removed and replaced to meet any con- tingency or change which may require it, and without so large an expense as to be burdensome to those of moderate incomes. From the day you first applied it Mary has improved in form, in strength, in agility, and in healthful appearance. We have prepared a swing on the principle of your elevator pullev, in which Mary amuses herself daily, and we think with benefit. 38 REPORT ON In conclusion let me reiterate the desire of my daughter, that in some way you should let the world know the comfort and benefit secured to the afflicted by this method of treatment. Very gratefully yours, JOHN WARD. Dr. L. A. Sayre. Fig. 25. Case XV.—Nellie B. Molloy, aged 5, 2202 Third Avenue, New York, was brought to me April 13, 1876. Has always been healthy until about one year ago, when she fell upon her hands and knees. The day following she was seized with a severe pain in the stomach. This confined her to bed, and a physician was called in, who examined her, but said nothing had developed. Re- mained in bed three days on account of the pain experienced when standing or sitting. After this she got up, presenting nothing un- usual, except a stiff manner of walking now and then, which came and went without any apparent cause. During March, 1876, she gradually became worse, and was sent to me by Dr. Farrington, of Harlem, in the follow- ing condition. Large, well-developed child, walks with a peculiar gait. There is a promi- nence in the lumbar region, which is verv painful upon concussion and compression, and which is diminished by extension. Has also hip disease, first stage, of right side. April 13. Plaster of Paris jacket applied to trunk and short hip splint applied to right thigh with perfect relief, and she could walk well immediately. ! 1 May 22. As the child is going to the coun- try for the summer, a new jacket was applied, and new plasters and bandages to leg and thigh. As soon as the plaster had become set she walked with perfect ease, but when the jacket was removed she could not walk a step or stand without support. April 17, 1876. Case XVI. —Anthony Ryan, aged 8, 84 Tenth Avenue, of healthy parents, and always strong. When pott's disease. 39 two and a half years old had a slight fall from a bed. Noticed trouble in back almost immediate^. Was taken to Dr. Knight's Hospital in September, 1870, and wore a brace from October, 1870, ever since. Notwithstanding this, curvature has gradu- ally increased until it is as represented in (Fig. 25) dark line. Opposite X is a small opening, into which a probe passes three and three-quarter inches to the right, two and a half inches to the left, one and a half inch in an upward and downward direc- tion. Dotted line in Fig. 25 is that of suspension; dark line of standing. Fig. 26". April 18. Opened abscess very freely; dressed with oakum and balsam Peru. 19^/i. Applied plaster of Paris dressing, cutting fenestra for the escape of pus, giving him perfect relief, and enabling him to walk without support.1 Case XVII.—Annie T. Camak, aged 13 years, Athens, Ga., was brought to me March 16, 1876. Father and mother dead; cause of their death unknown. The following history is obtained from her aunt: "At 5 years of age she had a fall, followed by 1 Jan. 8th, 1876. Has continued to improve; abscess healed iu November. Still wearing the plaster jacket, but without fenestra. 40 REPORT on intense pain in the back and bowels; this continued for some months, when the pain ceased; soon after a bunch appeared on her back. She was taken in Aug. 1868, to a Dr. Mann, of New York; he rubbed the spine, and made a brace, which, however, the child could not wear constantly, as it gave her great pain- Then a Banning's brace was procured, but this seemed to press the breast out so much that it was thrown aside. Kolbe's brace, of Philadelphia, was then recommended, and worn for two years; an ulcer then appeared on each leg at the top of the thigh, which prevented any brace from being Avorn for some time. Oct. 1874. Dr. Knight, of 42d Street, applied a brace which was much lighter and more comfortable than any before used, but the curve in her back continued to increase, and her breast bone become more prominent." Her present condition, March 16, 1876, is as shown in Fig. 27. Fig. 27. A fistulous opening exists on the right thigh just below Pou- part's ligament, discharging quite freely all the time The aunt says this opening has discharged constantly for four years- she also had a similar opening on the opposite side, but this has been closed for two years. A flexible probe passes into the sinus on pott's disease. 41 the right side below Poupart's ligament upward and backward eleven inches without touching bone. The tracing of the back by the flexible lead tape, while stand- ing, is represented by the dark line. The dotted line represents the tracing of the curve when suspended, March 16, 1876 (see Fig. 28. Fig. 28). After suspension, the plaster of Paris jacket was ap- plied and worn with perfect comfort till April 22, when it was removed on account of the child having measles. During the time of her wearing the jacket, the pain in the stomach after eating, which before had been a constant trouble, had not annoyed her at all, and her breathing was much freer and deeper when the jacket was on than when she was without it. May 12, 1876. Reapplied plaster of Paris bandages; child much straighter than when first applied; this jacket is still worn with perfect comfort; she can run up and down stairs without support, and suffers no incon- venience whatever. Present condition, June 1, 1876, is well represented in Fig. 29, taken from a photograph just sent me by her aunt, with the following letter. Glen Ridge House, Coknwall, June 1st, 1876. Dr. Sayre. Dear Sir: I write to tell you what a wonderful success you have made of the plaster jacket that you applied to my little niece; she finds it entirely comfortable and pleasant, sleeps and exercises in it without any difficulty whatever. She has Avorn a variety of braces of the best kind, but I think this the best 42 REPORT ON application. Before wearing the jacket she suffered greatly from dyspepsia after eating; no medicine seemed to relieve it; had to Fig. 29. be quiet for an hour after every meal; as soon as you put the jacket on all that trouble disappeared, but comes on again if she is without the jacket for a day. This relief would be enough if nothing else, but I find her waist longer and the bump on the back flatter. All of our friends here notice the improvement since last summer. I think now I am in the right path, and feel so relieved and happy. Yours most sincerely, ANNIE CAMAK. Case XVIII.—Mary T. Brown, aged 26 years, 348 E. 32d Street. Mother died of phthisis; father healthy. Patient always strong and healthy till two years ago last winter, when she had a severe fall on the ice. Has never been well since, and the least cold would give her severe pain in the back and stomach. Since Jan. 1, 1875, has been unable to do work of any kind, or walk without assistance, it having taken her three hours to come from pott's disease. 43 home to my office, a distance of a quarter of a mile, she having to rest on each step and railing on the way. Patient states that pain is constant in her back, and at times very intense in her stomach. Condition as seen in Fig 30. April 8. Applied plaster of Paris jacket, which gave great relief. 26th. Returned, saying that she could walk a great deal better with this jacket, but that it was-not high enough on her back, and asked to have a new one applied a little higher up. The old one was removed, and a new one applied going well up to axilla; when dry, she walked a quarter of a mile, had photograph, Fig. 31, taken, and returned home, having walked more than one-half Fig. 30. Fig. 31. Mary T. Brown, April 8, 1876. Mary T. Brown, April 26, 1876. a mile inside of one and a half hours from the time this jacket was applied. June 1. Returned, feeling very well, and without the slightest pain or discomfort whatever. Is able to do moderate house- work.1 • Jan. 8th, 1877. Can walk without support, and has but slight deformity ; con- solidation apparently complete, but advised to wear the jacket a few months longer for security. 44 REPORT ON Fig. 32. April 14, 1875. Case XIX.—Charles E. Webster, aged 19, Binghamton, N. Y. When about 3 years of age, first complained of pain in back. Does not know of any injury; was then placed under care of a Dr. Wood, of Boston, and has been treated with corsets constantly until two or three years since. Curvature was then nearly about the same as dark line; corset was then left off. A year ago last fall, again roticed trouble in the spine; has since worn corset. The dark line indicates his defor- mity while standing; the dotted line after being suspended five minutes (see Fig. 32). While suspended I applied the plaster of Paris dressing with a piece running up under the occiput, which gave perfect relief.1 His height increased three-fourths of an inch by actual measurement. April 26. The plaster under occi- put having cracked, the jacket was reapplied without head extension piece. May 17. As the jacket causes pain over the hips, it was removed, and a new one applied, with pads over the anterior superior spinous processes. The pads were removed when the plaster set, and he said that the jacket gave him perfect relief from pain. Patient returned to his home to-day. By comparing the annexed photographs before and after the application of the plaster-jacket, the change in his curvature will be seen to be quite apparent (see Figs. 33, 34). The following case is a very instructive one, as showino- the importance of an early diagnosis before any deformity has oc- 1 Since that time I have devised an apparatus for extension of the head, which is much more satisfactory, and which is fully described in the latter part'of this paper. pott's disease. 45 curred, and yet a number of very eminent gentlemen examined the case without detecting the disease. Fig. 33. Fig> 34 I think a careful study of the earlier symptoms and mode of examination, as I have endeavored to illustrate in the earlier part of this paper, would render such an error almost impossible. I quote the mother's letter entire, as it is a type history of the majority of such cases, merely omitting the names of the medical gentlemen referred to. No. 19 East 46th Street, New York, May 4, 1876. Dr. Sayre: Dear Sir—According to promise I will try to give you a minute detail of the illness and treatment of my little girl up to the present time. Florence Boyle is the second child of William F. and Fannie L. Boyle, of St. Louis, Mo. The parents and grandparents were particularly free from any bone or blood diseases. The other two children are unusually stout and healthy. Up to the time of her injury I never saw a more active, stout, healthy child. When two years and three months of age, on July 4, 1868, while playing on the stoop, shefell one step, and I think she fell across an iron 46 REPORT ON foot scraper, as she cried out as if in great agony ; did not cry long, and went out again to play, but played with very little spirit, wanted to be held. The next day she had a slight fever and was very cross; complained of no pain. In the next few days complained that her wrists and ankles hurt her. Then when playing would stop suddenly and put her hands to the lower part of her bowels and say it hurt her; it would not last long, but occur often during the day. I had a friend whose child had spinal curvature, and these symptoms rather alarmed me. I examined her spine one night, at the end of three weeks after the injury, and she winced decidedly when I touched two places, one at the waist and another between the shoulders. Next day I Jook her to town and had her examined by four physicians separately, neither knowing tne other had seen her, each one said these were symptoms of spinal trouble, but must wait for further development, so I took her home and waited for four months, symptoms getting worse, and at last a small knuckle appeared between shoulders. Then I called in two of our leading surgeons ; one advised use of a brace, the other advised that child be confined to bed for one year. Then went to another physician, who had recently come from Brooklyn, and made diseases of the back a specialty ; advised his brace and to keep the child on her back too. I placed her under his care because this plan agreed with both the others, and at the end of ten months she was totally paralyzed from hips down, feet drawn back till they almost touched the calves of her legs; curvature much worse, and spot at waist much more sensitive. Leeches were applied at that spot, which gave perfect relief from all soreness. She never complained of pain anywhere, and was very fleshy while confined on her back. The Dr. then wanted to put both limbs in iron braces, but I could not approve of it, so took her out of his hands. She was paralyzed for three years. I next took her to Boston, where she remained a year; she was so much relieved that she could crawl, but not stand an instant, or walk. This new Dr.'s brace failed also to arrest the increase of the curvature ; she still did not suffer. Becoming discouraged, I took off this brace. Her paralysis became worse until the end of three months, when she one day pulled up by the window and walked across the room, and has walked some ever since. She did not wear a brace for two years, walking and running around like other children, only bending forward terribly, the curvature getting pott's disease. 47 worse. Then I took her to a Dr. from Indianapolis, who applied his brace, which has been of great and positive injury to her ; she has suffered a great deal this past winter; would have to take off the brace and stay in bed three or four days at a time. The muscles in back would swell up and be exceedingly sensitive to the touch. I sincerely regret I delayed so long coming to you. The im- provement by to-day's treatment far exceeds the wildest hope I ever had of her recovery. The straightening of the curvature by this one " hanging up" is really just twice as much as I expected to have accomplished in three years' treatment. Whether you believe in prayer or not, I shall most certainly ask God's blessing to rest upon you and reward you eternally, as well as in this world. FANNIE L. BOYLE. April 28, 1876. Case XX.—Florence Boyle (see Fig. 36). Dark line shows deformity while standing. Dotted line shows the decrease of the deformity dur- ing suspension (see Fig. 35). While the child was thus suspended a plaster of Paris jacket was applied, which did not give perfect relief; it was removed and a new one applied, but had to be removed, as it caused pain over the prominent points of spine. As there was a very sensitive point over the second dorsal vertebra, leeches were applied, with marked relief. A new jacket was applied on the 4th of May, and, as the disease was so high up, a Davis's head supporter in conjunction with it, affording perfect relief. Child walked two blocks, and can sit up, stand, and run round, which she had not been able to do for months. (See Fig. 37.) May 1. She has continued to wear the last "jacket," in connection with the Davis's head support, without any dis- comfort. She has improved in flesh and spirits, has become rosy cheeked and playful ; in fact, is so completely changed 48 REPORT ON as to attract the notice of all her friends. She was three-fourths of an inch higher by accurate measurement immediately after the suspension, and the "jacket" and " head rest" have retained it. Fig. 36. Fig. 37. May 15, 1876. Case XXL—Elvira Arango, aged 12 years. Father healthy; mother's history passable. Cause unknown. When eight years old complained of more or less pain about the spine. Noticed nothing till two years ago, when mother found a small knuckle about last dorsal and first and second lumbar vertebra?. She has been treated by the prone position more or less ever since the deformity was noticed, and the uncle, Dr. Arango, says "that the deformity has increased, notwithstanding she has been most of the time in the horizontal position." Pre- sent condition as seen in Fig. 39. Dark line indicates the curve when standing. Dotted line shows deformity during suspension (see Fig. 38). May 20. Plaster of Paris jacket applied after suspension of the body, which gave perfect relief, and a marked improvement in her figure. June 3. Has been perfectly comfortable since last date. Has pott's disease. 49 taken a great deal of exercise, and has had no pain. Has men- struated for first time, and the mammae have increased so much that the top part of the plaster had to be eut out to Fig. 38. accommodate them. Position as seen in Fig. 40. with protrusion of the spinal process, and deviation of the spine to the right; when hanging the angle diminishes greatly, as well as the deviation of the spine to the right. "After the bandage has been applied she walks with perfect ease, and is straight (see Fig. 40). D. A. ARANGO." The following case is one of such extraordinary interest that I wish to add it to my report, but have delayed in sending it to the publishing committee until I could get a confirmatory diag- nosis of his case from the different physicians who had had him 4 50 REPORT ON in charge during the past four years. As the result of the treat- ment has been so nearly marvellous, any one would be liable to the charge of having made an error in diagnosis, unless sustained by competent witnesses who had also personally examined the case. I therefore wrote to each of the medical gentlemen who had tended him, asking for their diagnosis of his case. Unfortunately Dr. Otis was absent from the city for some months, and the books of the Strangers' Hospital, where the case was first treated, cannot be found since that hospital has been destroyed. But I have received replies from a sufficient number of competent judges confirming my diagnosis, that I felt justified in giving the case to the profession, particularly the opinion of Dr. Gibney, who probably examines more cases of Pott's disease every year than all the physicians in the city. On May 10, 1876, A. J. Hessler called at my office with the following note:— My Dear Doctor: This man will tell you his story, and I feel sure you will admit him to your wards at Bellevue. I would willingly furnish him with a brace, but he has not where to lay his head. You would prefer plaster of Paris, and consequently I have taken no measure for a brace. Yours respectfully, Dr. Sayre. V. P. GIBNEY. When the man came in the office his countenance was expres- sive of great pain ; he could not stand erect, but was very much bent forward, resting both hands upon his knees, and had a very hurried and short respiration. He was so exhausuted in coming from Forty-second Street to m}r office, that I had to give him brandy a,nd let him lie down for some time before he could be examined. His history was as follows, as written out by himself:— " Arthur Alex. Hessler, native of Paris, France; aged 32 ; musician by profession; of healthy parents, and myself always robust, and very active until the spring of 1872, when I was playing with a comrade, apd got struck heavily in the abdomen and back. At the time I was struck lost my breath, and felt a very painful sensation going through the backbone, and since that day have been complaining all the time of great weakness in my back, that has compelled me to keep my bed for many months, on several occasions feeling powerless in my legs and paralyzed in my back. pott's disease. 51 "In February, 1873, I was admitted by application in the Strangers' Hospital in Tenth Street and Avenue D, under the treatment of Professor Otis, visiting physician; Dr. Kearny, house surgeon of the ward. The treatment I received was cup- ping and blistering on my back, and constant confinement to my bed. This relieved me to a certain extent, and I was discharged as cured in May, 1873, by Prof. Sands (then visiting surgeon to the hospital). I went to my business for a few days, but had to go to bed again, and have been unable to do anything for the past three years. " I was under treatment of a great many doctors until I spent all my money, and then went to Rosevelt Hospital, Fifty-ninth Street and Tenth Avenue, in March or April, 1876, and put in Ward No. 4, and treated for diseased kidney for about one month, when Dr. Thompson, then visiting physician, examined me, and told the doctor I was not a case for the Medical Ward, but the Surgical; telling him that I had an enlargement or projection of the lower dorsal vertebra. "I was immediately transferred to Surgical Ward No. 2, Dr. Rice, house surgeon, and Prof. Wier, visiting surgeon. I was put to bed and cupped on my back, and extension was made of my feet, which gave me considerable relief. After some time they sent me to Dr. Shaffer, 52 West Twenty-eighth Street, for a steel brace, but as I could not pay him $35 for it I returned to the hospital. "Two days after this Dr. Rice informed me that it was useless for me to remain in the hospital any longer, as my case was incurable, and advised me to go to Dr. Knight's Hospital for Cripples in Forty-second Street, and Dr. Gibney sent me to you." This is the man's history as written by himself, and, of course, must be received with all due allowance. I have endeavored to make it correct as far as possible by corresponding with the sur- geons in the various hospitals referred to, and the letters in response are hereto annexed. When he came to my office he was unable to stand erect, and was complaining of an intense pain in the back, and "as if a hot wire was binding him around the lower part of his belly." Upon stripping him, the tenth, eleventh, and twelfth dorsal, and the first lumbar vertebrae were found very prominent; the two last dorsal and the first lumbar making quite a sharp angle with each other. 52 REPORT ON When he was suspended in the sling he expressed the greatest delight as soon as his heels were lifted from the floor, and said the hot band around his bowels was loosened, and that he could breathe much easier than he had done for months. The extension was continued very slowly and gradually until his feet swung clear, when he almost instantly exclaimed, "that's the first full breath I have had in two years; if I had my cornet now, I could play as well as ever." It is very probable, that if I had applied the plaster bandage at that time and retained him exactly in the position in which he was, he could have played his cornet that evening as he stated he would. And from what I have seen of him since, I am quite convinced he could have done so. Being anxious that Dr. Gibney should see the application of the plaster dressings, 1 took him from the suspending apparatus and laid him on the floor on an air-bed, and immediately sent my servant for Dr. Gibney, who returned in a few minutes with the following note: — Out-door Department, Hospital for the Relief of Ruptured and Crippled, N. W. Cor. 42d St. and Sixth Av. My Dear Doctor: This has proved to be one of our "field days," and I will not be able to get through before one o'clock, consequently have to ask you not to save anything for me to day. Thanking you for your kindness, I am hastily yours, Prof. Sayre, May 10th. GIBNEY." The man still insisted, that, if I could only fix him in the posi- tion that he was in while hanging and keep him so, he could play his cornet as well as ever, and could then earn his $10 a night and need not go the Hospital. He was so positive on this point, that he refused to go to the Hospital, and, as I was anxious that Dr. Gibney should be present, I refused to apply the dress- ings until the following day. The man said he had not a cent of money, but he had a friend in Washington Street near the Battery, where he could stay for one night, and if I could fix him like he was when hanging he could make money enough to take care of himself. I therefore arranged to apply the dressings on the following day at 12. This was an unfortunate mistake, as the exercise of "going to the Battery and back was too much for him, and when he&returned pott's disease. 53 the following day he was so completely exhausted, that it was with great difficulty that my assistant Dr. Taylor and myself could get him in the suspending apparatus, and before the dress- ing was completed he swooned, and we were compelled to lay him down, with an insufficient amount of plaster on him to support, and in taking him down a little too soon it cracked, so that our experiment of having him blow the cornet that night was a failure. After resting some hours I took him to Bellevue Hospital; but the following day, the "plaster jacket," having cracked, pained him so much that it had to be removed. He was placed upon a water-bed, and freely cupped over the tender portions of the spine, with great relief. The cups had to be renewed once or twice, and the recumbent posture on the water-bed with extension at the feet kept up for some weeks. After this another " plaster jacket" was applied; but the plaster not being good, it did not afford him the relief I expected, and was removed. Another one was put on him at the hospital, which enabled him to walk around tolerably well; but did not give him the supjwrt requisite to make him perfectly comfortable. He therefore came to my office about the 1st of July, and I removed it. After washing him thoroughly and putting on him a very tightly fitting flannel shirt, I suspended him and applied another dressing. In this case I used, as I now always do, the bandages made of "crinoline" or "cross-barred wiggin," the meshes of which, being much larger, will hold more plaster than the ordinary hospital roller bandages. This suspension and application happened to be exactly right, and as soon as the plaster had hardened or "set" he jumped up on his feet, and capered around like a wild man. He could take the deepest possible inspiration, and concuss himself upon his heels without the slightest pain or incovenience. A short time after, this "jacket" was sawed down the front, and eyelets put in it, so as to be laced like a corset, and could be removed and reapplied at will. With this jacket properly laced he could play his cornet as well as he ever did, and no one looking at his ruddy face, and watching his elastic step, would ever dream that he was suffer- ing from " Pott's disease," or any other infirmity. How long before anchylosis will take place, and a cure be effected, of course I cannot answer; but that the man is changed 54 REPORT ON from wretchedness, pain, poverty, and intense suffering, to perfect comfort, and an ability to earn his living with cheerfulness and pleasure, is apparent to every one who has seen him. Hessler called to see meat the West End Hotel, Long Branch, on the 13th of July, and I did not recognize him. His form was erect, and his face florid, with the ruddy hue of perfect health. He stated that he was returning from Philadelphia, where he had played the cornet in Gilmore's Band, at the Centennial the night before until 12 o'clock at night, and that he was then on his way to fill his engagement to play at the Hippodrome in New York, at 8 o'clock that evening. I have seen a number of persons who were present at the concert, who told me that, with the exception of Levy and Arbuckle, they never heard the cornet played better than by him. I am well aware that this sounds more like a " fairy tale" than a statement of actual facts, and therefore have corroborated the statement by the annexed letters of other well-known physicians who are familiar with them. When we consider the unsatisfactory results hitherto of all our treatment of this disease, and compare them with this case and a number of others that I have seen, we are perfectly justified in using the language of Prof. Alfred C. Post in saying, " it marks an era in the history of Surgery." Hospital, 135 East 42d Street, July 27, 1876. Lewis A. Sayre, M.D. My Dear Doctor: At the time I saw Arthur A. Hessler, May 9, 1876, I had no hesitation in diagnosticating caries of the spine. The history and the signs would admit of no other diagnosis. He had great difficulty in walking, was stooped far forward, and the spinous processes of the last two dorsal and first lumbar ver- tebrae projected about three-fourths of an inch. I regarded him as unfit for out-door treatment, and sent him to you, who kindly admitted him to Bellevue, and returned him to me for inspec- tion, July 9th, or thereabout. He then walked erect, was active, and had so changed in appearance that I failed to recognize him. From him I learned that on the morning of May 10, you applied a plaster of Paris jacket in your office, and sent him to the hos- pital ; that you called the next day, and found him in such pain that the jacket had to be removed; that leeches and ice were pott's disease. 55 applied to his spine, and that he lay on a water-bed for three weeks; that a jacket of poor plaster was applied, and no benefit followed; that two weeks later another was applied (better plas- ter), and perfect relief was afforded ; that he had been improving in every particular since. Two weeks later I saw him at Gil- more's Garden, no sign of relapse having, occurred. He still wore the jacket. Very truly yours, V. P. GIBNEY. 35 West 33d Street, Aug. 9, 1876. Dear Doctor: I am sorry that I cannot enlighten you con- cerning the patient referred to in your note ; but I think you will find his case recorded in a case-book which is in Dr. Otis's possession. When the Strangers'Hospital was disbanded, the records were divided among the attending staff, and I am pretty sure that Dr. Otis got the book belonging to his service. You will have no difficulty in consulting the records at the " Rose- velt." Yours, truly, Db. L. A. Satre. H. B SANDS. No. 19 East 32d Street, July 24, 1876. Dear Doctor: Dr. Rice is absent in Europe, and my recollec- tion of Hessler's case is very imperfect. From the Hospital records I find that he was admitted to my ward May 2, and dis- charged from the hospital May 8. I only remember the point that attention was attracted to the apparently rapid progress of the dorsal tumor. Dr. Rice will probably return in August. Yours, very truly, Dr. L. A. Sayre. R- F- WIER. Arthur Hessler, musician, France; single; aet. 31; admitted April 27, 1876. Up to 1871 patient says he was a healthy man. Does not know whether he had the lump on his spine before that time or not. At that time he had the gonorrhoea, but denies all other venereal symptoms. Soon after had a severe pain in his shoulders, back, and arms, which he attributed to exposure to cold. The pains all settled in his back, and he was compelled to go to the Strangers' Hospital. He was there some months, 56 REPORT ON and was then discharged cured. From that time he has been comparatively well at times up to the 3d of April, when he was attacked with shooting pains along the spine, and had night- sweats at the same time; has been growing weaker ever since. On admission, find a prominence of the spine of the eleventh or twelfth dorsal vertebra, and patient unable to stand. Com- plains of weakness and pain in the back. Cups were applied, and patient much relieved. May 2d. Patient transferred from the Medical to the Surgical Division. Can now walk, but still complains of the pain and weakness. Cups again applied. 8th. Patient discharged unimproved. S. W. BUDD, Sen. Assistant Surgeon Rosevelt Hospital. Bellevce Hospital, July 31, 1876. Dear Doctor: Your note was duly received, and in accordance with your request I inclose Hessler's history as recorded by ray senior assistant, who is the historian. I think it is an excel- lent case; such a marked improvement. He came to see me a few days ago ; he was as lively as a cricket; no one would ever suspect Pott's disease; he was looking very well. Very respectfully, HENRY M. SILVER, M.D., House Surgeon. Arthur A. Hessler; aat. 30; single ; French; musician ; admitted May 10, 1876; residence 194 Varick Street. On admission patient had on a splint, which had been applied at Dr. Sayre's office. He was able to walk, but was suffering from pain in the chest, back, and thighs. This splint was cut down on the day after admission to relieve the irritation, and that evening six cups were applied by the side of the spine at diseased point; this treatment afforded much relief. About a week after another exacerbation of pain was overcome by similar treatment. The patient was then placed on a water-bed, upon which he lay for five weeks, feeling more comfortable, as he said, than he had for some time. At the end of this period another plaster splint was applied; this fitted the patient well, and while wearing it he was able to walk in an upright position without difficulty.0 This was taken off in two weeks, as it had broken down, too little plaster having been placed in the bandage. The patient was pott's disease. 57 obliged to go to bed again, as he could only stand by placing his hands upon his knees. The third splint, which was applied a few days later, was cut down on the third day, as it was too long below, hurting patient's hips. During its application he fainted. The fourth was applied at Dr. Sayre's office; and four days after- wards this cracked, and was removed. On July 7th, the fifth and last splint was put on at Dr. Sayre's office; this was a good fit, the patient being perfectly easy in it; goes about the grounds at will; is up all day, and has improved wonderfully in general condition. This splint was cut down in front, and a piece taken out; eyelets were then made, and the splint converted into a plaster corset. When he came in patient was suffering greatly at all times, and was unable to stand erect except when supported by a splint; he was pale, and showed the marks of great suffering. He is stout and healthy, and free from pain. Now, even when the splint is removed, he can stand erect and walk; the splint being now used rather as a precaution than from necessity. He was discharged July 14, and is now playing a cornet at Gilmore's Concert Garden. HENRY M. SILVER, M.D., House Surgeon. ARTHUR BELL, M.D., Senior Assistant. MARTIN BURKE, M.D., Junior Assistant. Third Sdrgical Division Bellevue Hospital. ADDENDA. Since the above Report was presented to the Association, I have abandoned the use of the " Davis head support" in cases of disease of the cervical and upper dorsal vertebrae, as seen in Fig. 37, and have accomplished the object desired, namely, suspension of the head and extension of the vertebrae, by means of an iron rod, which is secured to two pieces of malleable iron, which are placed on either side of the spine, and which can be bent so as to accurately fit any curve in the plaster jacket, which has already been applied to the entire trunk of the diseased patient, and retained accurately in position by having attached to them two narrow strips of perforated tin, which should be long enough to very nearly encircle the entire trunk, leaving only a central 58 REPORT ON line of an inch or so in width in front of the body, for the pur- pose of cutting or sawing down the plaster jacket whenever it may become necessary to remove it. The, central bar is at- tached by two cross-bars to the upper portion of this malleable framework, and is curved over the top of the head to the ver- tex; and to its extremity is attached a swivel bar, an inch or two in length, from which the head is suspended by adjustable straps, secured under the chin and occiput. This upright bar is made in two pieces running into each other at the straight portion behind the neck, and capable of being extended to any desired length, and firmly secured in position by screws. To apply the appa- ratus the patient is suspended in the usual way, from the axillae, chin, and occiput, and the plaster bandage applied, as usual, over a tight fitting knit or woven shirt. After the bandage has been accurately applied, the patient is removed from the suspending apparatus and carefully laid upon an air-bed until the plaster has hardened or " set." The patient can then stand up, and the appa- ratus for suspending the head is applied in its proper position, over the back of the plaster jacket, and the lower portion of it bent and moulded until it accurately fits all its various curves. The loose tin strips, being very flexible, can then be smoothly moulded around the jacket which has already been applied to the trunk, and another plaster bandage having been wetted in water is to be carefully and tightly applied over the apparatus and jacket first applied in sufficient number of layers to make it perfectly secure. The tin being rough and perforated, a suffi- cient amount of plaster will be incorporated into its holes and meshes to prevent any possibility of displacement. We have now a secure point of support from the pelvis and trunk from which the head can be sustained by properly adjusting the move- able rod and securing it by screws. Its practical application is seen in Figs. 41 and 42. The ease and comfort to the patient, together with the perfect freedom of mobility to the head, make it very much more satisfactory than any contrivance that I have yet seen used. I will simply add one more case out of a number in which this treatment has been applied, as it is a good illustration of the immediate relief that is given to the patient when the support has been accurately adjusted. Case XXII.—Lewis Easton Flournoy, aged nine years, resi- dence St. Louis, Mo., was brought to me on 27th October, 1876, pott's disease. 59 by his father, with the following history: Father and mother both healthy, and boy always healthy and strong until the 25th of Fig- 41. Fig. 42. December, 1873, while playing in a hay loft he fell, head first, down a hole in the hay mow to the barn floor, a distance of eight feet. He cried for an hour after the fall, saying his back hurt him. He was tolerably well for some three or four weeks; then began to complain of pain in the shoulder; was treated for rheu- matism for some weeks without any relief, and it was then dis- covered that he had a lateral curvature. Drs. Schoaley and Payne applied a brace. This brace was worn fourteen months, when it was discovered that he had a double lateral, and a very prominent posterior curve. Dr. Franklyn, of St. Louis, applied a new instrument, which gave very little relief. This was worn for six months; but the posterior deformity continued to increase, and his " breast bone" to be more prominent. The father noticed about ten days since that he had great difficulty in walking, and for the past three days could not walk at all, or stand without support. When he attempted to stand he had a very short, grunting respiration, and very marked convergent strabismus of both eyes. I suspended him and applied a plaster of Paris jacket on 28th October, 1876, and in half an hour after, when the plaster became "set," he could stand without assistance. The next day the father stated that he had slept better than he had done for two years, and had eaten a better breakfast than he had known him to since he was hurt. He could walk without assistance, and 60 REPORT on could poise himself on either leg by simply steadying himself with one hand on a chair, and could raise the other limb so as to put his foot in a chair. He still carried his head forward in a constrained position—had a peculiar catch in his respiration, and the convergent strabismus continued. I placed my hands under his chin and occiput, and, lifting his head very slightly, the strabismus immediately disappeared, and he exclaimed " that's what I want." As soon as I released my support, the strabismus returned. I sent him to Mr. Rynder's, 309 4th Avenue, to measure him for an outside support, or "Jury mast," such as I have described, to be applied over the " plaster jacket." On the 8th of November, before a large class of physicians and students in the amphitheatre of Bellevue Hospital, I applied this outside support for head suspension, as seen in Figs. 43 and 44; and, as soon as the plaster was "set" and the head properly Fgi. 43. Fig. 44. suspended, his respiration became natural, the strabismus disap- peared, and he expressed himself as being perfectly comfortable. In less than half an hour after the adjustment of the apparatus, he ran up and down the stairs in the amphitheatre without the slightest inconvenience. He went to Philadelphia the following pott's disease. 61 day, and his father states that he spent nearly two days in walk- ing around the Centennial buildings without fatigue or inconve- nience. He left for his home in St. Louis on the 13th of Novem- ber, but before he left I persuaded him to go to O'Neil, the photographer, and have his picture taken, from which Figs. 43 and 44 are engraved. I regret that I have not a picture of him on the 27th October, but it could not be taken, as he was unable to stand for it. EXTRACTED FROM THE MINUTES OF THE SECTION" ON SURGERY AND ANATOMY. Tuesday, June 6, 1876. The Section met at 3 P.M. Dr. Alonzo Garcelon, of Maine, Chairman : Dr. E. T. Easley, of Arkansas, Secretary. The Chairman. We have assembled the Section on Surgery. As yet I have not been able to confer with the members of the Section, and do not know whether any definite arrangement has been made with regard to the matters to be introduced. I am aware that there was a paper which was referred to this Section; but the Secretary has not reported to us yet. I hope that all gentlemen who have papers to read, or who have any special subject to bring before the Section, will do so early, in order that we may know somewhat of the nature of the business we have to attend to. We are in hopes to make this meeting profitable. In order to do that we must all be active and prompt, and lose no time; and if any gentleman proposes to introduce any sub- ject to the Section, or who has any paper to read, and will have the goodness to forward it to the Secretary, we will endeavor to have the matter arranged so as to give each an opportunity to be heard. We will hear from Dr. Sayre, if he is ready to read his paper. Dr. L. A. Sayre, of New York, then read his paper on Pott's disease of the spine. During the reading of the paper he exhibited an apparatus for suspending the patient, and presented several cases which he had treated of this disease, and added, at the end of his paper, that doctors, instead of sending their cases to spe- cialists, ought to treat them themselves. His object in bringing it before the Section was to show the profession that each and 62 REPORT ON every one could treat this disease as well as he or any other specialist could. Patients can be kept at home and cured, thus saving the inconvenience and expense of travelling. The treat- ment of the cases here reported has been that of far advanced cases. He had a number of other cases, where the disease has been treated in this way from the outset, and that is an important point; for, if the disease is taken in its earliest stages, before the deformity has occurred, by this treatment prompt restoration occurs without deformity. A Delegate. I would ask if there is any other treatment to be observed—that is, constitutional treatment. Dr. Sayre. The best constitutional treatment is: Roast beef, beefsteak, mutton chop ; generous diet and fresh air, and as much of it as-you can get; and if the patient is subject to indigestion, make him digest. A Delegate. I understand that he said he applied this jacket without applying anything else. I wish to inquire whether he applied it to the naked skin ? Dr. Sayre. I did not apply it in that way, and I think it would not be a good thing to do. A Delegate. Did you make use of linen ? Dr. Sayre. I take a woollen shirt, one without seams, that will fit as tightly as possible, and am careful to have no puckers in it; that is as necessary as anything. The ordinary bandage is too closely woven and too heavy, and will not hold plaster enough; mosquito netting is almost too loose, and, as I say in my paper, it should be a cloth that is loosely woven. Dr. A. C. Post, of New York. What you call crinoline ? Dr. Sayre. Yes. Dr. Post has got it. Dr. Post. I move that this paper be referred to the Commit- tee of Publication. I consider that this principle introduced by Dr. Sayre constitutes an epoch in the treatment of this very dis- tressing form of disease. A Delegate. I would ask Dr. Sayre if this paper has not already been published ? Dr. Sayre. In my book just recently published, the ideas are laid down; but, as I have had so many cases since proving its practicability, I thought it my duty to bring it before the pro- fession. pott's disease. 63 A Delegate. I was under the impression I had read the article in a medical journal. Dr. Sayre. The first article was a clinical lecture. Dr. Jones, of Illinois. I recommended the same treatment. Dr. Sayre. It was spoken of in that lecture. I believed the profession would be benefited by it. The idea struck me as a correct one, but I had not had a sufficient number of cases to practically prove it. I always bring my new ideas to the first class I can show it to; whether it be a medical class, it gets it; if it be the State society, it gets it; and when the ideas are impor- tant, I give them as fast as they come to me, so that the rest of the profession can enjoy the benefit of them as they like. The doctor refers to a lecture published two years and a half ago. That was the first suggestion. It was published by a reporter, and that is the way many things get to the profession through the medical journals. Then when my book came out a few months afterwards, I spoke prophetically of it, saying I believed that sooner or later we should see good results from it. Since that time I have had one hundred and twenty cases, which is certainly a very different thing. And now I speak with a posi- tiveness that the thing has been demonstrated. Another point:— Sometimes you have a projecting sternum, or projecting points at other places; these you will have to guard. If there is a pro- jecting sternum, it is better to let the patient lie on an air-bed. Before I used it I had some trouble, but since I have used the air-bed I have had none whatever. You can put in little pads and pull them out afterwards; and if you squeeze it over the hips before the plaster gets set, it does not press on the ilium. The Chairman. The motion before you is that made by Dr. Post, that the paper read by Dr. Sayre be referred to the Com- mittee of Publication. Dr. Benj. Lee, of Pennsylvania. I wish to second the motion which has been made, and in doing so to express the deep interest I have felt in listening to this paper of my friend, Dr. Sayre. The idea which underlies this mode of treatment is undoubtedly the true principle for the treatment of Pott's disease. We have done wrong in considering it a purely constitutional affection. We must look upon it as a surgical disease, and treat such cases much as we treat a fractured limb. It is this that Dr. Sayre has done in applying his plaster bandage. He has treated a carious spine as any one of you would treat a broken leg, 64 REPORT ON and in doing so has achieved the results which he has shown you, which we must all admit to be wonderfully successful. I have not yet myself put this plan in practice. I have been so long making use of other appliances,, having the same end in view, have become so accustomed to them, and so well satis- fied with them, that I have hesitated to make a new experi- ment ; but after hearing the demonstration of to-day, I feel that I shall be wanting in justice to my patients if I do not at least make the effort to use it. Important, Mr. President, as is the mode of treatment that Dr. Sayre has introduced, his hints with regard to the diagnosis of the disease in its earliest stage are, it appears to me, even more so. I think he will bear me out in saying that a case rarely comes under his care which, had he seen it in the early stages, he could not have saved absolutely from the deformity which it presents. But the mischief is that these cases are allowed to go on from month to month, and sometimes even from year to year (so slow is their development) unrecognized. The doctors say: The child has gastritis or dyspepsia, or worms. I think, sir, that nine-tenths of my cases " have had worms," and they have been dosed with pink-root and santonin for months before the physician had any idea of the true pathological con- dition, so persistent does this idea appear to be in the minds of the profession. Too often it is left for the parents to discover that the child has a spinal affection, while the physicians ignore it. Now, sir, I wish every member to carry away with him the very important hints which Dr. Sayre has given in reference to this matter of the diagnosis. If I may make a personal allu- sion, I will allude to one point in this connection to which the doctor referred: He mentioned the fact that pressure upon the spinous processes, in a case of true spinal caries, rarely produces pain, owing to the fact that the disease is almost invariably con- fined to the anterior portion of the bodies of the vertebrae. In fact, if you place a patient on his face, and make pressure upon the projecting portion of the spine, you naturally separate those vertebral bodies whose inter-pressure produces the suffering, and therefore, so far from causing pain, you relieve pain. Now, before Dr. Sayre, and others of his progressive tendencies, began to write on this subject, we all were taught—I know I was taught— that the diagnostic symptom in Pott's disease was that pain was produced if you pressed upon the spine. We must disabuse our- selves entirely of this impression. That classical pain does not pott's disease. 65 exist in the majority of cases. Now the point to which I wish to call Dr. Sayre's attention is that I have insisted upon that fact for many years past myself, in print, and I thought that he alluded to it as not having been heretofore published. Dr. Sayre. I did not intend to be so understood. The fact which I announced as original was that by pressure on the ribs we could detect the existence of inflammation of the articular facets. Dr. Lee. I am glad to find that the misunderstanding was my own. This additional point in regard to the production of pain by pressure upon the ribs communicated to the facets of the articular processes, is certainly of very great importance, and Dr. Sayre is entitled to the merit of having been the first one to intro- duce it. I confess that it had never occurred to me to make use of it as a point of diagnosis in cases generally, although occasionally a case of Pott's disease has presented itself complicated with so much lateral deviation that my attention has been called to the fact that there must be destruction of the articular facets. Another point which is also somewhat personal: one of the doctor's cor- respondents, quoted in his paper, complimented him on his in- vention of the hanging machine as he termed it, the suspension apparatus. The doctor himself does not make any such claim, as I understand it. Dr. Sayre. Mr. Rynders, the instrument-maker, is entitled to credit for that. Dr. Lee. The idea of making a suspension apparatus for the purpose of suspending the body in the treatment of spinal distor- tions was first introduced into this country by Prof. J. K. Mitchell, of the Jefferson school, whose lectures many of you attended and enjoyed. Although most successful in his hands, it fell into entire disuse, until, acting on the suggestion of Prof. Mitchell's son, Dr. S. Weir Mitchell, of Philadelphia, I began myself to make use of it with certain modifications. I am now, and have been for ten years, in the habit of using suspension by the occiput and chin, not as a means of placing the patient in position for the applica- tion of other apparatus by the use of the instrument of support, but itself as a means of treatment; allowing the patient to suspend or extend himself daily for a certain length of time by means of a rope passing over a pulley. I will endeavor to have one of my apparatuses here to-morrow for Dr. Sayre's use; and if I may be allowed, will introduce a patient who will demonstrate the feasi- 5 66 REPORT ON bility of suspension in such a way as to make effective extension of the spinal column, thus relieving the pressure at the seat of disease. Dr. I. N. Quimby, of New Jersey. I would like to make a fur- ther remark, and that is that it does seem to me that Dr. Sayre draws a pretty strong conclusion in saying that he believes that these cases are all traumatic. I do not know but that the Doctor is correct, and yet it seems to me that there are some spinal affections that are strumous, whatever that means; whether it has its origin in a syphilitic taint or something else, deponent saith not at present, but it seems to me to be so. I may be rather bold in presenting my opinion, but if Dr. Sayre will allow it— Dr. Sayre. Certainly. Dr. Quimby, of New Jersey. To say that all spinal affections are the result of blows or of some force, it does seem to me is wrong. I have had but few cases, but I could not at all detect by examination or by inquiry that there had been any injury whatever; and the patient or the parents of the patient were stru- mous themselves, and we know, of course, that as father so is son constantly; and hence it seems to me that there are some cases really of a strumous character that have spinal difficulty. I would like to ask Dr. Sayre whether he has been always pretty sure, from the investigation made, that all of these cases were traumatic, and whether there was not some little suspicion that they were of a strumous diathesis or cachexia? Dr. Sayre. I believe I tried to make myself quite clear on that point, and I know that you can have Pott's disease and have swellings of the joints in strumous patients. I never taught such nonsense in my life as that they could not exist together, and yet I have been represented as being a teacher of that doctrine. I tried to make it as clear as I could that a strumous child would have disease developed in his spine by very much less injury or force than a robust, vigorous, strong child ; but that even in these strumous children, the disease requires an exciting cause for its local development. Whether from inherited syphilitic taint, or from some tubercular diathesis of his ancestors, or whatever constitutional cause there may be, I take it that if it is a constitu- tional affection inherited from the father or mother, it involves the whole system, eyes, head, heels, back, bones, blood, yea, his whole constitution ; it is all tainted with whatever constitutional taint he has inherited. Now, what has developed it in one par- pott's disease. 67 ticular point more than in another as a localized development of this constitutional taint, is the kick, blow, rack, strain, thump, bump, or some other traumatic trouble which has been the ex- citing cause: that is the way I look at it. Dr. Quimby. I would like to ask the doctor if he finds that cases where there is a taint of struma are as easily cured as where there is no struma, or where he has positive evidence there is a traumatic cause ? Dr. Sayre. It is hardly necessary to answer such a question as that; as a matter of course every one knows it is not. The paper was then referred to the Committee of Publication. Dr. Sayre. On Saturday last I received a letter from Dr. Jones, of Maryland. I do not see him here yet to-day; he may be here to-morrow. He stated in his letter that he had a child with a diseased back. Some one recommended the Taylor's brace ; finding it inconvenient, he had sent it to a physician in Washington, a young doctor who had attended cases with me. On taking up my book in one of the bookstores, he had read my treatment of Pott's disease, and applied it, but not with entire satisfaction, and so he wrote to me in New York, speaking of coming there and having it applied. I wrote to him that if he would come here, he being a medical man, I would make a prac- tical application of it in his child's case, and by coming here he would save the trouble and expense of going to New York. Yesterday morning I received a letter from him expressing great gratitude that I was willing to meet him half way ; he would be hereto-day or to-morrow. If the Committee of Arrange- ments will find a place, I will hang the apparatus right in this room at some hour not during the session of the Section. The Chairman. It will be proper to state, as many of the gentlemen attended the Convention at Louisville, that Dr. Sayre applied, in the presence of some members of the profession, this supporting bandage to a child that was presented there to the Association. If there are any gentlemen from Kentucky who know anything of the results of that case, we would be glad to hear from them. Dr. Martin, of Boston, Massachusetts, is present in the room, and informs me he has a few remarks to make in reference to a splint which he has applied several times. Is it the pleasure of the Convention to give Dr. Martin a hearing upon this subject? 68 REPORT ON POTT'S DISEASE. A gentleman has just made a remark to me that the next paper is one by Dr. Dowell, of Texas. Dr. Quimby. I would like to make a motion just at this point. I move that if Dr. Sayre's patient arrives, we give way, and allow the doctor to apply the bandage before this Section. This was agreed to. Dr. Easley, of Arkansas, said : I have listened with great interest to the paper. Dr. Sayre, and Mr. Bryant, of London, have shown us more clearly than anybody else, that there is no necessary connection between scrofula and diseases of the bones, and for this service we owe them a large debt. We have been taught that morbus coxarius, as well as Pott's disease, was always associated with the so-cajled strumous diathesis. We are now prepared to say that their occurrence is only a coincidence; in a word, that struma is to be considered a predisposing cause of the trouble, as it is of so many other pathological conditions. Highly as I esteem the gentleman's opinions, however, I fear that he is disposed to go too far in regard to the traumatic origin of the malady. It is not hard to understand how a wound, blow, or concussion may light up the disease, provided a predisposi- tion already exists, and no doubt spinal curvature often occurs in this way. We grant that violence may bring it on, even in the absence of a predisposing cause; "but we have undoubtedly a large class of cases in which the osseous lesion is an essential disorder, a condition described as Rachitis, Osteo-malacia. Here you will find the abdomen protuberant, the patient emaciated, great malaise, and vitiated tastes. The important fact is, that there is mal-nutrition of the entire osseous system, spinal curva- ture resulting as a part of the common distress.1 EXTRACT FROM THE MINUTES OF THE ASSOCIATION. On motion of Dr. W. C. Jacob, of Ohio, it was Resolved, That this Association is under marked obligations to Professor L. A. Sayre, for his admirable practical demonstration of his appliance for Pott's disease, which, indeed, marks a new era in surgical science. « Dr. Sayre applied the plaster Paris bandage to two cases of Pott's disease before the Section, with the most satisfactory results, both children being able to walk as soon as the plaster was " set."