Pehuenche Indian Calvin.

Annual of the universal medical sciences and analytical index. A yearly report of the progress of the general sanitary sciences throughout the world. [1888-1896.] ... online

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The third case had infrequent and slight attacks during the four
months following the operation, while the fourth remained free
from recurrence for the same length of time.

Taussini ihS?- operated fot epilepsy on a patient who had a



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<SStaU*<^iiSSf;.] SURaERY OP THE BRAIN. A-69

marked asymmetry of the skull. At first he had slight but very
short attacks, but these finally disappeared and had not recurred
for two months.

GENERAL PARALYSIS OP THE INSANE.

Wade^^ calls attention to the great impoitance of operating
on all cases of depressed fracture of the cranium at the time of the
reception of the injury, however slight the depression. In all
cases admitted to insane hospitals careful inquiiy and examination
should be made as to cranial injuries, and where any depression is
discovered an operation is certainly indicated, which in itself is
not dangerous, and which gives promise of some improvement, if
not entire restoration, of the mental faculties.

Goodall,^„^<^^„ believes that a study of the cerebral cortex
fiiUy justifies trephining, followed by drainage of the subarachnoid
space.

I^nphear, ]^ in a paper on trephining for softening following
cerebral haemorrhage, states that if the skull be opened in such
cases the brain and its membranes will often look swollen, and
feel as if there were a sac full of fluid beneath. Puncture allows
the escape of the sofl;ened mass, semi-fluid in consistence, of
purulent appearance, but in reality not pus. Frequently the area
of soft:ening is but a limited one, as in embolism of that branch
of the middle cerebral which supplies the arm-centre and the
speech-area. Such cases are amenable to surgical treatment; not,
indeed, as an operation to be made with the object of improving
a paralysis or other manifestation of destruction of the cortex or
communicating fibres, but of clearing out a quantity of irritating
material and substituting one (like the blood-serum or cerebro-
spinal fluid) which will, within a brief period, fill the cavity and
not give rise to symptoms of irritation. Such an operation is
demonstrated to be practicable in a case which the author describes.

MISCELLANEOUS CEREBRAL OPERATIONS.

Hahn, of Berlin, ^reports the case of a patient, 30 years
old, who had suffered for three years with intense cephalalgia.
He gradually lost the sense of smell, memory became weak, and
two years ago he began to grow blind in the left eye, the right
being affiected later on. Temporary resection of the skull on the



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A-60 PILOHER AND LLOYD. [^^SSSSfe^^TsX**

left side of the frontal bone was performed, and revealed a very
tense, non-pulsatile dura. This was incised, when there was
immediately a walnut-sized hernia cerebri. This was removed, but
a new hernia formed. Puncture with a long needle toward the
anterior horn of the left lateral ventricle evacuated 100 to 120
grammes (3i to 4 ounces) of clear fluid, after which there was
considerable shrinking of the brain. All symptoms of cerebral
pressure disappeared. Eighteen months after the operation power
of vision had improved, and the patient was able to resume his
usual vocation.

Parkin, j^i in a paper on "The Relief of Intra-cranial
Pressure by the Withdrawal of Cerebro-spinal Fluid from the
Basal Subarachnoid Cavity,'' reports a case in which the cerebro-
spinal fluid was drained away through an opening made at the
level of the fifth and sixth cervical vertebrae. In this case the
relief was marked, but there were other points of tubercular dis-
ease which prevented recovery. In a second case there was
evidently a meningeal cyst, which was drained, and the child
decidedly improved. The third case was drained through an
opening made below the superior curved line of the occipital, on
the right side. In passing a curved probe along the under surface
of the cerebellum and sliglitly raising it a very large quantity of
clear cerebro-spinal fluid escaped. A very fine drainage-tube
was inserted, but this child was also markedly tubercular, and
died.

Morton, j^tt in regard to tapping the skull for tubercular men-
ingitis, says that the temporary benefit derived in the few cases
already operated upon might be encouraging, but he is afraid that
the operation will meet with little success.



SURGERY OF THE SPINE.

A most exhaustive treatise on this subject has just been
published by Chipault, of Paris.

Fractni^es, — Hammond Ji^ says that pressure prolonged for any
length of time invariably causes degeneration, both ascending and
descending, of the different tracts in the cord. Relief of the press-
ure is not followed by any diminution of the degeneration. But
relief of the pressure prevents the process of degeneration from



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SfsSSiT] SURGERY OF THE SPINE. A-61

beginning. Hence, the surgeon should operate as soon as possible
after the injury to the cord has been received.

Lloyd, ,,^f,^ after a study of one hundred and three cases, agrees
with Horsley that operation should be undertaken at once " in all
cases where displacement or crepitus indicate compression, and
where extension directly after the accident clearly fails to reduce
the deformity," provided there are symptoms present which indi-
cate interference with the functions of the cord. In other cases
the operator should wait until the shock following the injury has
been overcome. During this time, however, the patient's con-
dition should be most carefully watched, and at the first indication
of any symptoms pointing to an extension of the interference with
the action of the spinal cord, whether that interference be due to
haemorrhage or myelitis from compression, to callus, or to the
exudation of lymph, he should be subjected to operation at once.

Hammond reports three cases : In one of these, operated upon
by Powell, there was paralysis of the sphincters of the bladder and
anus, but no other muscular paralysis ; knee-jerk was present in
both legs, but was sluggish. The gait was slightly ataxic ; all
forms of sensibility were nearly normal in the feet, legs, and thighs,
but he was not always accurate in locating a touch on the but-
tocks and thighs, and the muscular sense below the knees was
slightly diminished. There was an area of absolute loss of all
forms of sensibility, circular in extent, with the anus as a centre
and a diameter of three inches. There was a fracture of the eleventh
dorsal vertebra ; a piece of the bone pressing against the posterior
columns of the cord was removed. At the end of two months the
patient seemed to be perfectly well. Villar ^^ reports the case of
a man of 23, who was struck on the back and immediately felt
great pain in the lumbar region. When examined, soon after the
accident, a depression was found corresponding to the twelfth dor-
sal vertebra. He had complete paralysis and ansebthesia of both
legs. He was trephined on the fourth day, and the cord was found
pressed between the plates of bone. These were removed, and
three weeks later he had recovered motion in the right leg, but
sensation had not returned. The man's condition has continued
to improve, but the left side is still paralyzed. Pain has disappeared
and he is able to control urination.

Bird ^u operated on two cases. In the one, as was to be



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A-62 PILCHBR AND LLOYD. j-Fr»ctii«»



_ of Spine.



expected from the nature of the mjury, no improvement followed.
In the other, the patient gradually recovered both sensation and
motion to a very great extent, but he still occasionally has to use
the catheter and has troublesome constipation.

Davies,„f, a reports the case of a man who, in a sudden fit of
suicidal mania, made a rush, head-foremost, against plate-glass a
quarter of an inch thick, and later against a wall. He became
partially unconscious, had pain on movement and pressure over
the cervical spines, but no deformity ; paraplegia and anaesthesia
extending upward to a line three inches above the nipples, dia-
phragmatic respimtion, retention of urine, reflexes absent. Tem-
perature gradually rose, until at the time of death it was 106.6° F.
(41.5° C). At the autopsy a T-shaped fracture of the body of
the fifth cervical vertebra was found splitting the body into three
parts, with a V-shaped fracture of both laminae at a pomt near
the junction of the posterior laminae with the transverse proc-
esses. No displacement of the fragments was noticeable. On
opening the vertebral canal the spinal meninges bulged out, and on
incising these a large amount of dark blood escaped, being suffi-
cient in amount to cause some compression of the cord. The
spinal cord at the seat of fracture was not examined. Korte ,^u also
relates a case, which he attempted to relieve by trepanning, but
the cord was too severely crushed. The majority of the^e cases
end fatally. Of 270 cases collected by Genet, only 53 recovered.

In a case operated upon by Pantzer, ^i^ the patient was still
perfectly well thirteen months after the operation. The same
author also reports an unsuccessful case. Warren a^. also presents
the history of a case, operated on in the Massachusetts General
Hospital over twenty-five years ago, which resulted fatally.

Chipault,^,jtJ states that in performing laminectomy for the
relief of traumatic lesions it is not now considered sufficient for
the operator to content himself simply with the removal of a
greater or lesser number of arches, but in order to make the pro-
cedure complete it is essential that the dura mater should be
opened and the intra-dural and medullary lesions treated. By this
means the value of the operation has been enhanced. Out of 160
cases analyzed by Chipault, 20 were cured, 33 were improved, 22
gave no improvement, and there were 65 deaths and 15 unknown
results. This proportion of successes to deaths is decidedly dis-



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Pottfs



J SURGERY OF THE SPINE. A-63

couragiDg. The deaths were all due, however, with the exception
of two cervical cases that died from operative hsemorrhage, to one
of the three following causes: 1. The extreme gravity of the
traumatism, the injury soon affecting the respiratory centre, or else
there were lesions of other organs also present, 2. Infection
through the operative wound, which was so grave and so frequent
an accident in pre-antiseptic days. 3. Infection through the lungs,
bladder, or bed-sores consequent upon the injury of the spinal
cord. The first class is naturally beyond surgical assistance, the
second should not be considered at the present time, while the third
can be controlled somewhat by antisepsis of the bladder and the
ulcerations.

Phelps?^ has performed laminectomy for Pott*s disease in two
cases ; both patients died, — ^the first of pneumonia after thirty-seven
days, the second from exhaustion at the end of a month. He
states that the mortality from operations for Pott's disease is About
40 percent. He has compiled all the cases published since Lloyd's
paper (see Section H, this volume), about forty in number, and
finds that the percentage varies but little. A safe rule to follow in
any case would be to treat the patient mechanically for a time, —
say, two months, — and if the pamlysis continue to increase, or if
it become complete, operate. Cases with complete paralysis, with
incontinence either of urine or faeces, of several months' or even
weeks' duration, should be operated on if they do not immediately
improve under treatment. Whenever well-defined abscesses are
present burrowing through the canal with gradually-increasing
paralysis, they should be opened, the cavity scraped out, good
drainage established, and the spinal column examined. Operate
in cases of pressure threatening destruction of the cord. Chipault's
statistics include five cases of operation in non-paraplegic cases and
one hundred and three for Pott's paraplegia.

Lane jSi operated on a woman, 54 years of age, who had suf-
fered for only a few weeks from progressive symptoms of com-
pression of the cord.

Horsley ^^ states that although it is usually stated that the
bony deformity associated with caries of the spine is the chief
source of the pressure symptoms as shown by the paraplegia, there
is another and veiy important cause — the thickening from chronic
inflammatory changes of the tissue surrounding the theca. When



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A-64 PILCHER AND LLOYD. [^cKSf •"

signs of compression suddenly supervene, they may be due to the
rupture of an abscess into the neural canal, hemorrhage, or dis-
placement of the vertebrae. As a rule, in these cases, all the tis-
sues in the neural canal are in a state of chronic inflammation,
and the sac-wall becomes adherent to the theca. These tissues
were likely to cause much compression. In the great majority of
instances no change is noticeable in either the membmnes or the
cord inside the theca, and for this reason Horsley does not favor
opening the theca when operating. There is evidence to prove
that tubercular disease inside the dum mater of the cord does not
exist. In the majority of cases tlie pachymeningitis causes pressure
symptoms. Most of these cases do well under rest, but much de-
pends upon whether the inflammatory lesion is of the nature of
an abscess or of a chronic pachymeningitis. In the latter case
the prognosis is good, while in the former it is by no means so
favoi'able. The most-marked symptom of compression caries is
the great loss of motor power with retention of a fair degree of
sensory power. Careful examination should be made to determine
the presence and extent of the anaesthesia, as this may give a clue
to the seat of the lesion. The deep reflexes are exaggerated ac-
cording to the extent of the involvement of the cord. The vesical,
lumbar, and rectal centres may be involved early in the course of
the disease. When recovery takes place from bony ankylosis,
the process is an extremely slow one ; the age of the patient has
much to do with the result. In old patients, when the disease is
due to senile struma, the prognosis is invariably bad, much vvoi-se
than in young persons. If the case come under observation early,
the patient should be put in elastic extension. This is by far tlie
best method of treating caries of the spine, and there is none bet-
ter for obliterating the curvature. There is not much to be said
in favor of Sayre's jacket ; in some cases it may be useful, but in
all the patients upon whom Horsley had been obliged to opemte
these jackets had been employed.

If under the elastic-extension treatment no improvement took
place in the pamplegia after a fair trial, then the question of
operation would have to be considered. Experience sliowed that
tlie acme of the curvature corresponded to the point a little
below which the greatest compression existed. In the event of
an abscess having been found to cause the pressure symptoms, this



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iSdS&UlSSriU.] SURGERY OF THE SPINE. A-66

was incised and the pus let out ; afterward the abscess-cavity was
syringed out with some antiseptic solution, a tube was inserted,
and drainage secured from behind. In operating upon these cases
it was essential to recollect the contingency of general tuberculosis
following as the result of direct infection of the operation wound.
The recovery of power resulthig from the performance of lami-
nectomy for caries of the spine usually began fourteen days after
the operation. This was the average period ; but sometimes the
improvement was much slower in its appearance. There were, of
course, some failures in these cases ; they are usually due to an
incomplete operation, but in some instances the cord had under-
gone severe injury preparatory to any operative interference having
been attempted. Aft;erward it was advisable to apply a splint.

In illustrating these remarks, Horsley presented several pa-
tients upon whom laminectomy had been performed. Attention
was called to the sodden appearance of the wounds, which was
attributed to the escape of cerebro-spinal fluid always keeping the
wound surfaces moist; it did not, however, interfere with the
primary union.

Gardner, Delorme, and Pick have also reported cases of
laminectomy; the former's patient was not improved, Delorme's
case died, while the last was reported at the time of the operation,
and the final result is unknown.

Cheyne and Symonds, DJi.n« Noble Smith, ji^Chipault,^^ and
Uoyd oJj?M all advocate the opemtive treatment of spinal abscesses,
— ^laying open the pockets, incising and dilating the sinuses, and
carefully disposing of all diverticuli. Careful irrigation and scrap-
ing are essential points in the treatment.

GUNSHOT WOUNDS AND OTHER INJURIES OP SPINAL CORD.

CrutcherJ2.i*oports the case of a man who was shot with a ball
of rather small calibre, about six inches from the spinal column.
He was completely paralyzed in the lower extremities and par-
tially in the upper. Anaesthesia extended to a line below the
nipples, and the cord was found to be injured. He died of pneu-
monia three weeks later.

Eskridge,i.4 reports a case of traumatic myelitis in a patient
who was shot at the level of the ninth dorsal vertebra. She at
once became paraplegic, but there was a slight plantar reflex ; all



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A-66 PILCHEB AND LLOYD. ['iiSSSS!*

the other reflexes up to the eighth rib were completely abolished.
Anaesthesia extended up to this point. The operation was per-
formed by Boyce, and no cause of pressure either from the ball,
depressed bone, or eflFused blood was found. The laminae of the
fourth dorsal were then removed, but no further information was
gained. There was no sign of the ball or its track. The patient
died two months later, and on opening the dura a thick layer of
yellow pus was found surrounding the pia and cord from the fourth
to the eighth dorsal vertebrae, throughout the extent to which the
canal was exposed at the operation. The cord at the ninth dorsal
segment was a soft, pulpy mass, and on cutting it across at this
point the softened cord-substance ran out, showing that it had been
almost completely destroyed for the space of nearly half an inch.

Lane A^.„ reports the case of a woman, 35 years of age, who,
twelve years before, had on several occasions been struck violently
over the lumbar spine. About six years later she noticed that
her walk was insecure and that she rolled about, especially to
the right side. Her back also became weak, and, though she
suffered no pain there, she had difficulty in carrying heavy ob-
jects, particularly up and down stairs. This condition gradu-
ally increased, and a deformity of the lumbar spine developed.
When she was admitted to the hospital it was noted that there
was a kyphosis, the apex of which corresponded to the spinous
processes of the third and fourth lumbar vertebrae. Compres-
sion paraplegia was suspected in spite of the indefinite history,
and the spine and laminae of the fourth lumbar vertebra were
removed. The distension of the dura-matml sheath at this point
with fluid indicated that the compression was lower down. The
fifth lumbar vertebra was found to be placed in the upper part
of the sacral canal, quite in front of its normal position. I^ne
says that this case is of great interest because of its rarity, and, so
far as he knows, it is the only case of spondylolisthesis of the fifth
lumbar vertebra in which pressure on the lumbar and sacral nerves
was described. He had found that spondylolisthesis was the
normal condition in coal-heavers, and in other occupations a sim-
ilar displacement existed.

Morton]^. reports the case of a man who was struck in the
dorsal region by a mass of coal which he was mining. He had
immediate paraplegia and some irregular areas of anaesthesia of the



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5'5J£1] SURGERY OP THE SPINE. A-67

lower limbs and bed-sores. He was treated by rest on his back,
massage, faradism, and head-extension. Twice daily he was sus-
pended by his head. He made an uninterrupted recovery, being
able to walk about with slight assistance.

Barrow g^^ operated on a man with a fracture of the cervical
spine and compression of the cord. There was absolute paraplegia
of the whole body excepting the head, abdominal breathing, and
loss of all sensation up to about the nipples.

Leckie, oJ.-* in cases of destruction of a small portion of spinal
cord after fracture, suggests the feasibility of removing a sufficient
amount of the spinal column to allow of the approximation of
portions of the cord which have not been affected by the injury.
He advances no method of carrjdng out his suggestion.

Puncture of the spinal canal and evacuation of a portion of
the cerebro-spinal fluid have been recommended by Quincke ^i'^, l^
in hydrocephalus, for the purpose of reducing the pressure in the
central nervous system. He has operated twenty-two times.
Ziemssen has employed this procedure in several' cases of tuber-
culous cerebro-spinal meningitis, cerebral tumors, etc. The punct-
ure is performed under chloroform narcosis, and the spine must
be flexed so as to enlarge the interspaces between the vertebral
arches. According to the existing conditions of pressure the
cerebro-spinal fluid flows out more or less rapidly. In simple
hydrocephalus the evacuated fluid is clear; in a case of epidemic
cerebro-spinal meningitis the exudation was turbid, and contained
shreds of fibrin and diplococci. In both these diseases a decrease
of cerebral pressure always ensued after the puncture. Decided
improvement was observed in a case of tuberculous meningitis,
the puncture being repeated four times. Examination of the
evacuated fluid may throw some light upon the diagnosis.

Tumors. — Caponnotto hoSS-m operated on a patient who, when
6 years of age, had received an injury to the cervical region.
Thirteen years later symptoms of a spinal tumor developed. The
arches of the second and third dorsal vertebrae were removed, and
a whitish intra-dural tumor, the upper edge of which corresponded
to the third vertebra, was discovered. It extended down to the
lower margin of the fifth vertebra. The tumor occupied the
whole dural sheath, so that hardly a trace of the spinal cord was
found. It was a fibro-sarcoma.



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A-68 PILGHER AND LLOTD. [Nenwwtomy.

Chipault ^"^ has been able to collect more than twenty oper-
artions for medullary or retro-medullary tumors compressing the
cord. In the intra-meduUary tumors there are not sufficient data
upon which to base conclusions. Of the extra-medullary tumors,
cancer and aneurism are inoperable, and in these cases, as well as
in diffuse intra-dorsal lesions due to tuberculosis, the opemtion
can only be exploratory. But in the greater number of cases the
tumor is extra-medullary, and is easily removed.

Huber lij^ reports a case of sacro-coccygeal tumor in a child
3 weeks old. It was evidently a multilocular cyst starting from
the coccyx, but no communication with the spinal canal was dis-
covered. A small portion of the tumor, running toward the anal
region, was, in consequence of the condition of the patient, left
undisturbed. Five weeks later this portion was operated upon,
and the main body of the growth was found to be of a different
nature, of a firm consistency and apparently lipomatous in charac-
ter, without any sharply-defined capsule. One cyst was found
running posteriorly and laterally, involving the coccyx. The
tumor was removed and the wound loosely packed with iodoform
gauze. The child recovered. The tumor weighed 200 grammes
(6^ ounces).

SURGERY OP THE NERVES.

Several operators claim priority in devising operations de-
signed to reach and remove the Gasserian ganglion. One of these
controversies has arisen between Andrews, of Chicago, ,St and
Rose, of London. O0CW.-M The former has operated four times,
twice with complete relief for over two years. The third case died
of shock following the operation, and the fourth had just been
operated upon at the time of the report. It is claimed that
Andrews first performed his operation on the cadaver, while Rose,
working independently and without any knowledge of Andrews's
work, first operated upon a living subject.

Another controversy has been going on between Hartley ^ and
Krouse. a^„ The latter claims that he had performed his opem-
tion on the cadaver, even before Rose made his report to the Med-
ical Society of London. It would seem that these investigators
arrived at practically the same conclusions independently of one



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