TWO CASES OF 
SPINAL SURGERY, 
By 
F. X. DERCUM, M.D , 
AXD 
J. WILLIAM WHITE, M.D., 
OF PHILADELPHIA. 
Reprint from Annals of Surgery, June, 1889. TWO CASES OF SPINAL SURGERY. 
F. X. DERCUM, M.D., 
OF PHILADELPHIA, 
INSTRUCTOR IN NERVOUS DISEASES, UNIVERSITY OF PENNSYLVANIA, NEUROLOGIST 
TO THE PHILADELPHIA HOSPITAL 
AND 
J. WILLIAM WHITE, M.D., 
PROFESSOR OF CIINICAL SURGERY, UNIVERSITY OF PENNSYLVANIA, SURGEON TO THE 
university; Philadelphia and german hospitals. 
Neurological Memoranda by Dr. Dercum. 
CASE I.—C. K., set. 55 years, a cigar maker, a German by birth 
and a very intelligent man, gave the following history ; His 
father had died at 56, of carcinoma of the stomach, and his mother at 
39, of phthisis. He had one brother who was still living and in good 
health. He himself had, previous to his present disease, been per- 
fectly well. He had never had any illness of moment. He had never 
drunk to excess and had never had any venereal disease. There was 
no history of injury or exposure. 
On Christmas day of 1887 he was attacked with severe pains in the 
arms and shoulders. These were most marked on the insides of the 
arms and were burning and shooting in character. The parts became 
very painful on motion, but there was at no time any loss of power. 
Three or four days after the commencement of the attack he noticed 
distinct weakness of the thighs. He found that he could not raise them 
as readily as before. This weakness became more marked and rapidly 
spread down the legs to the feet and upward over the trunk as far as 
the breast. In the course of eight days he had become completely 
paralyzed. Both sphincters were involved. Hand in hand with 
this loss of power, numbness made its appearance and soon be- 
came profound. It involved both legs and the trunk up to the level of 2 
F. X. DERCUM.—J. IV. WHITE. 
the nipples. Pains had at no time been present in the legs. Anaes- 
thesia, on the.other hand, had never invaded the arms. The pain in 
the latter which had characterized the beginning of the affection grad- 
ually subsided and at the end of three weeks had disappeared. For 
three months following, no new symptoms had made their appearance. 
At the end of this time, however, he began to notice a constricting 
pain at about the level of the nipples. A little later also a small bed- 
sore formed over the lower portion of the sacrum. The girdle pain 
gradually grew more intense and caused him much suffering. His 
general health, too, became more and more impaired. He remained 
in this condition until October i, 1888, when the following notes of 
his case were made: 
Has complete paraplegia. All of the muscles, not only of the legs 
but also of the trunk as far up as the intercostals of the fourth or fifth 
interspace, if not higher, are paralyzed. This paralysis is absolute. 
The diaphragm is not involved. All of the reflexes, both deep and 
superficial, are much exaggerated. Ankle and patellar clonus, are 
not only present, but marked to an unusual degree. This also true of 
Sinkler’s great toe reflex. The plantar and cremaster reflexes are also 
elicited with great ease and are unusually active. The legs are per- 
fectly relaxed and flexible. Nothing suggestive of a spastic condition 
nor of contracture obtains, nor are there any clonic spasms. No 
marked wasting has taken place. Faradic irritability appears slightly 
increased. 
Profound anaesthesia is found to exist everywhere over the paralyzed 
parts, both to touch and temperature. It ceases abruptly at the level 
of the second rib or slightly below it. Here a sharp line of demarca- 
tion can be made out running transversely over the chest and also 
over the back. It is readily traced except in the axillary region and is 
slightly irregular in its course. It is so sharp that a variation in the 
position of the pin point of but a quarter or even an eighth of an inch 
above or below it, determines the recognition or non-recognition of 
the impression by the patient. This line was also confirmed by means 
of a pointed faradic electrode though this gave a slightly lower level, 
due, doubtless, to the diffusion of the current. There is nowhere ex- 
cept, perhaps, in the axillae, any shading from the sensitive into the an- 
aesthetic areas. 
A little below the level of this line the patient experiences an intense 
girdle pain. The position of this pain has not varied since its onset 
in the preceding April. It is slightly diffused, but appears to be most 
marked just below the third rib. It is further noted that slight blows TWO CASES OF SPINAL SURGERY. 
3 
upon the head in the direction of the spinal axis are accompanied by a 
frightful exaccerbation of this pain. On turning the patient on his 
face and gently percussing the spine, pain is elicited over the third 
and fourth vertebrae, and to a less extent over the fifth. Firm press- 
ure also evokes the same symptoms. Flexion and torsion of the 
trunk also give rise to pain in this region. 
In addition, both sphincters are paralyzed; faecal evacuations take 
place without the patient’s knowledge, and the urinal is worn con- 
stantly. A bed sore, some two by three inches in size, deep, sharply 
outlined and doubtless trophic, exists at the end of the sacrum. 
No anaesthesia or paresis exists in the arms. A slight inequality of 
the pupilsis noted, the left being slightly larger than its fellow. 
The case as it now presented itself did not admit of an absolute di- 
agnosis. The history of pain and paralysis suggested a myelitis, al- 
though the gradual diffusion of the paralysis from the thighs downward 
to the feet and upward over the trunk suggested an aberrant form of 
Landry’s palsy. However, the symptoms elicited by transmitted and 
by direct blows upon the spinal column, as well as by flexion and tor- 
sion, pointed unmistakably to some localized affection of the spine or 
of its contents. Further, these symptoms received additional signifi- 
cance from the presence of the fixed girdle pain and the sharply de- 
marcated anaesthesia. 
The propriety of an exploratory operation at once suggested 
itself. Here we had a man who had been already some ten months 
in bed, who was suffering acutely and whose general condition 
had steadily grown worse. For him there was no hope of amelior- 
ation, much less of cure. The iodides and mercurials, had been thor- 
oughly tried and had availed nothing. Accordingly, on October 8, I 
called a consultation of my colleagues, Drs. Mills, Sinkler and Lloyd. 
The propriety of an operation was freely discussed and unanimously 
concurred in. Our views were communicated to the patient, the 
uncertainty and danger being vividly placed before him. With little 
or no hesitation he consented, and at once, with philosophic equa- 
nimity, made all the necessary preparations for his demise. 
Dr. J. William White was now requested to see the patient, advised 
the operation, and finally gave the sufferer the benefit of his skill on 
October 17. At my suggestion, Dr. White commenced by removing 
the spine and laminae of the fifth dorsal vertebra. This, I am now 
convinced, was too low. The fragments of bone and the underlying 
tissue, including the external aspect of the dura, revealed nothing ab- 
normal. Next, the corresponding parts of the fourth, third, second 4 
F. X. DERCUM.—J. W. WHITE. 
and first dorsal vertebrae were removed. Nothing abnormal was any- 
where detected except beneath the arches of the third dorsal vertebra, 
where the dura appeared hard and resistant. The cord, too, seemed 
to swell and rise up out of its bed. The significance of these features, 
however, was doubtful to us. Finally, it was decided to open the dura. 
This was done by a median incision some four inches in length. On 
everting the inner surface, to our great satisfaction, the dura was found 
to be intimately adherent to the subjacent pia by means of numerous 
fine bands of inflammatory tissue. Dr. White carefully separated these 
bands as far as accessible. The cord itself seemed normal. The 
wound was then closed. 
The operation had occupied about an hour and a half. The patient 
reacted promptly. Five hours later, while still suffering from the after 
effects of the ether, he complained of great pain in his knees. This 
was a new symptom, and, as he expressed it, a reminder that he was 
really the possessor of a pair of knees. The pain was somewhat re- 
lieved by flexing the limbs. He also stated that the girdle pain of 
which he had so long and so persistently complained, had entirely dis- 
appeared. 
On the following morning, October 18, he complained much of the 
pain in the knees and also of pain in the back and limbs. The re- 
markable fact was now demonstrated that there was a distinct return 
of sensation in the feet. He was not able, however, accurately to lo- 
cate impressions, invariably fixing them much too high. Further, he 
presented the symptom of allocheiria, persistently referring every im- 
pression to the opposite limb. 
On the following day, October 19, it was thought best not to dis- 
turb the patient by an examination. 
On October 20 the following note was made: Up to this time 
the limbs have been perfectly relaxed. Now, however, the thighs are 
markedly adducted, and there is considerable resistance to passive 
movement. This, of course, is involuntary. When tested for sensa- 
tion he now readily recognizes the touch of the hand, and accurately 
locates the impression when in the neighborhood of the right knee. 
There is no perceptible delay in the response in some areas and de- 
cided delay in others. The cutaneous sensibility is not, as yet, evenly 
distributed, and seems to have returned in patches. Further, the pa- 
tient is very apt to locate the impression far too high; for instance, he 
describes a touch upon the ankle as having been made upon the knee, 
and a touch upon the toes to the middle of the foot. Sensation is 
best along the edges of the tibiae, and quite poor or absent on the TWO CASES OF SPINAL SURGERY. 
5 
outer and posterior aspects of the legs. The symptom of allocheiria 
is much less marked than at the previous examination, though it is 
still occasionally elicited. Out of four trials, for instance, he answers 
correctly three times, and at the fourth refers the impression to the op- 
posite foot. 
The reflexes appear to have undergone no change. On testing him 
with closed eyes, regarding his knowledge of the position of the limbs, 
he answers quite accurately, a condition not previously present. The 
girdle pain is still absent. The pain in the knees continues. 
On October 23, on testing his sensation again, he remarked that the 
hand touching his feet was cold, which was true. The remark was un- 
solicited and entirely spontaneous. The responses of the various tests 
were still delayed here and there, and there was still considerable 
confusion in locating the impression. For instance, when a pencil 
point was placed on the inner aspect of the right leg he referred it to 
the outer aspect, and when it was placed over the middle third of the 
tibia he referred it to the foot. At other places, over the back of the 
feet, for example, the impressions were accurately located. Allo- 
cheiria was elicited now and then, but less readily than at previous ex- 
aminations ; thus, a touch upon the middle third of the inner aspect of 
the right leg was once referred to the corresponding region on the 
outer aspect of the left leg, and at another time a prick upon the inner 
aspect of the left leg was referred to the anterior tibial region of the 
right leg. Again when the great toe of the left foot was passively 
flexed, the patient claimed that it was the great toe of the right 
foot which had been moved At another time when the great toe of 
the right foot was passively flexed the patient responded correctly. 
He was now asked to concentrate his attention upon the toes of his 
left foot, and to make a strong effort to move them. The result was 
negative. He was then asked to do the same for his right foot, and it 
was thought by myself and the resident that an almost imperceptible 
movement in the toes resulted. However we were not certain. 
On examining the reflexes, we discovered that upon the left side 
they were no longer as excessive as formerly. They had evidently un- 
dergone a diminution. Upon the right side they were unchanged. 
On October 25, he distinctly moved the right great toe. In other 
respects there had been no marked change. 
On November 1, the toes of both feet were repeatedly 
moved. There was also some slight improvement in sensation. The 
patient’s general condition was also much better. On searching for 
the bed-sore, it was found to have completely healed, nothing but a 
small scar remaining. 6 
E. X. DERCUM.—J. W. WHITE. 
Observations were now made from time to time, a general improve- 
ment, both as regards sensation and motion, being noted. By Decem- 
ber he could distinctly move the feet and began to manifest some con- 
trol over the muscles of the thighs, and finally became able to flex 
and extend both the legs and thighs to a considerable degree. Sensa- 
tion also continued to increase in accuracy of location. Fewer errors 
were constantly being made. His improvement continued slowly but 
steadily throughout January of 1889. In February, hand in hand 
with this improvement, he had some return of pain in the chest. It 
was not the old girdle pain, but a new pain confined to the left side 
and more diffuse than the preceding, but attended by distinct tight 
or drawing sensations. It was less severe than before, and, he assures 
me, has at the present time, April 13, largely disappeared. 
On being questioned regarding the sphincters he says that he is now 
conscious of every movement of the bowels, that he can always in- 
form the nurse in time to keep himself from being soiled, and at times 
he thinks he can slightly control them. Regarding the bladder, his 
statements are more positive. He says that the urine no longer con- 
stantly dribbles from him, but that it accumulates in the bladder and 
is voided in bulk and at tolerably regular intervals ; further, that he is 
always conscious of what is taking place, and that he always knows it 
beforehand and is positive that he has a number of times controlled 
the act. He is steadily increasing in strength. The movements of the 
legs, though leaving much to be desired, are evidently gaining in 
power, while the muscles of the trunk seem almost completely re- 
stored. He now sits up daily in a chair for three or four hours. His 
sensation is almost up to normal. He accurately separates the points 
of the aesthesiometer in all but a few areas. His responses are imme- 
diate and for the most part given with assurance. 
It should also be related that the original girdle pain which disap- 
peared so promptly after the operation never recurred, nor was it pos- 
sible at any time to produce pain by transmitted shock nor by forced 
movements of the column. 
In looking back over the case, it is undeniable that the improve- 
ment is directly due to the operative interference, whatever the lesion 
of the cord may have been. It is extremely probable that the evi- 
dences of internal pachymeningitis observed at the time of the opera- 
tion were but secondary to some other process, and it is further proba- 
ble that the operation did not extend sufficiently high. It certainly 
would have been well to have included the 6th and 7th cervical verte- 
brae, though the unanimous opinions of those present was that the TWO CASES OF SPINAL SURGERY. 
7 
operation had been as extensive and as thorough as the strength of 
the patient would permit. 
As it is, the return of function, especially the almost immediate re- 
turn of sensation, and the immediate relief of girdle pain, point to 
the relief of pressure. Further, it should be stated, no attempt was 
made with instruments to explore the anterior aspect of the cord. 
Surgical Memoranda, by Dr, White. 
In the case of C. K. the patient was prepared for operation by the 
administration of a saline purgative on the previous day, followed by an 
enema on the morning of operation. Five or six hours before my arriv- 
al at the hospital the skin of the upper dorsal region was washed with 
soap and hot water, then with alcohol, and finally with a solution of 
1:20 carbolic in 1:500 bichloride, after which it was covered with cloths 
wet in the same solution. At the time of operation the patient was 
etherized in an adjoining room and was then placed upon the operat- 
ing table in a semi-prone position, a small flat pillow under the ster- 
num serving to throw out and make prominent the dorsal spinous pro- 
cesses. An incision beginning a short distance above the spine of 
the vertebra prominens was carried down for about seven inches in the 
median line, going directly to the bones and extending below the level 
of the sixth dorsal spine. The ligamentous attachments and the mus- 
cular masses occupying the vertebral gutter on the right side were then 
rapidly separated with the edge of the knife and the bones cleared 
with a curved periosteal elevator. A few large muscular branches were 
caught with haemostatic forceps, and the wound was packed with 
sponges wrung out of hot bichloride solution. The opposite side of 
the spine was then treated in a similar manner. Small flat rectangular 
retractors with blunt serrated edges were then used to separate widely 
the sides of the wound, no transverse division of the deep fascia being 
found necessary. The spinous processes of the 4th and sth dorsal 
vertebrae were then divided at their bases with powerful bone forceps, 
set at an obtuse angle and were removed, greatly enlarging the field 
of operation. With similar forceps set at a still larger angle—nearly 
straight—the lamellae of the sth dorsal were then cut through by small 
“ bites ” first on one side, then on the other, and as near as possible to 
the transverse processes, after which the attachments of the vertebra to 
the 4th and 6th were divided by the same forceps cutting transversely 
to the axis of the spinal column. The loose portion of bone was then 
seized with lion forceps and separated from its attachment on the 8 
K X. DERCUM.—J. IV. WHITE. 
under surface first by a few touches of the knife and then by the use 
•of scissors curved on the flat. This exposed the posterior surface ot 
the dura which was quite intact, and even gave room for the gentle 
exploration of the lateral and antero-lateral aspects of the cord with 
the tip of the little finger. The spines and lamellae of the 4th, 3d, 2nd, 
and Ist dorsal vertebrae were successively and easily removed in the 
same manner. At Dr. Dercum’s request, I then picked up the dura 
with a pair of fine-toothed forceps, nicked it, and with scissors divided 
it in the median line to the full length of the incision. It was found 
at places, and particularly toward the upper angle of the wound, to be 
very adherent by new fibrous tissue to the subjacent membranes and 
cord and was separated with some little difficulty. Exploration with 
the finger, which could be passed well toward the anterior surface of 
the cord, revealed nothing abnormal. As enough of the cord had been 
exposed, in the opinion of Dr. Dercum, Dr. Mills, Dr. Lloyd, Dr. 
Sinkler and the other neurologists, present to cover the area supposed 
to be implicated, I then proceeded to close the wound. The dura was 
stitched by interrupted catgut sutures introduced at intervals of about 
one third to one quarter of an inch by means of long handled staphyl- 
loraphy needles. A medium sized rubber drainage tube was then laid 
in the wound, its ends projecting at each extremity. The muscles, in- 
cluding the deep fascia, were then brought together by chromicized. 
catgut stitches and the skin and subcutaneous structures by silver wire. 
The wound was dusted with iodoform, covered with protective and 
then with bichloride dressings held in place by an antiseptic roller 
appled as a circular of the chest and a posterior figure-of-eight. There 
was a moderate amount of shock, but the patient soon rallied. 
Surgically the subsequent course of the case was uneventful. Free 
oozing with escape of cerebro-spinal fluid necessitated a daily change 
of the dressings for several days, after which it was dressed at much 
longer intervals. The tube was shortend by drawing it out at the 
lower angle of the wound on the sth day, and was withdrawn com- 
pletely on the 10th day. There was great pain on the second day 
after the operation and considerable discomfort for three or four days 
later, referred to the back and legs. 
There was almost no fever; with the exception of one day—the nth— 
when it suddenly rose to 103°. It never went above xoo°. On that 
occasion it was found to be due to obstinate constipation and fell per- 
manently after the use of purgatives and quinine. The deep portions 
of the wound healed in about two weeks, but the skin edges were 
separated by the bad practice of some of the attendants who raised the TWO CASTS OF SPINAL SURGERY. 
9 
patient in bed, when it became necessary to wash and change him, by 
drawing on the arms, thus forcibly separating the scapulae, and with 
them the wound. This, however, granulated promptly and nicely, and 
union was complete in a little more than three weeks. 
There were no complications of any sort whatever and at no time, 
so far as the operation was concerned, was the patient’s condition one 
that could justify anxiety. 
Neurological Memoranda, by Dr. Dercum. 
Case II.—J. G., set. 23 years, a laborer, an Irishman by birth, gave 
the following history: His mother had died at middle age; cause of 
death unknown. His father was living, as were also his brothers and 
sisters. As far as he knew, they were in good health. He himself 
had never had any other disease than measles in childhood. 
One year and four months ago he commenced to have pain across 
the small of the back. It was a dull ache and seemed to spread from 
the spine along the region of the false ribs on either side, being worse 
on the left. Little by little he noticed that he could not run or walk as 
well as before, and also when he rested his foot against a chair, as in 
the act of lacing his shoes, that his leg commenced to shake to and 
fro. If he stood for any length of time the pain in his back would grow 
worse and his legs would get stiff. Did not notice that they grew cold. 
In March, 1888, he was admitted to the Philadelphia hospital with 
pneumonia of the right lung. His convalescence was very prolonged. 
He was in bed two months, during which time he noticed frequent 
trembling of the limbs and on attempting to stand the vibration be- 
came excessive. These symptoms became more and more pronounced 
during the convalescence from the pneumonia. For about two weeks 
after leaving his bed he walked about the ward with the aid of a cane. 
At the end of this time walking was impossible. The loss of power 
had, however, been gradual. Finally, it became absolute and he could 
no longer move the legs even in bed. His last successful effort con- 
sisted in moving the toes, but this he had not accomplished for some 
two or three months. 
At the time of the examination complete paralysis of all the muscles 
of the lower extremities existed. The abdominal muscles were possibly 
paretic but not decidedly so. 
The myotatic condition was now studied, a, Body prone. Percus- 
sion over the trapezius, the rhomboid, the latissimus, the scapular 
and the quadrate muscles yielded no response. Slight responses 10 
F. X. DERCUM.—J. W. WHITE. 
were elicited in the gluteus maximus and gastrocnemius of either side. 
Percussion of the ham strings tendons provoked faint contraction of the 
corresponding muscles. Percussion of the tendo achillis provoked 
marked contraction of gastrocnemius. Percussion of the plantar fas- 
cia elicited flexion of all the toes, more marked in the right foot. The 
responses, as a rule, were more marked on the right side. 
At the level of the twelfth dorsal vertebra and below it, superficial 
reflexes could readily be evoked; not, however, in the lumbar muscles. 
In all of the muscles, too, of the buttocks, back of thighs and back of 
legs most extensive reflexes could be evoked by stroking the overlying 
or neighboring skin. 
On attempting gradual flexion of the leg upon the thigh a slight re- 
sistance was experienced. Rapid flexion elicited a faint clonus of the 
gluteal and ham-string muscles. In the right leg these features were 
more marked. 
The following curious reflex was also developed. The patient, it 
should be remembered, was still lying prone. If now the foot was 
rapidly extended and then released, the leg would at once be flexed 
upon the thigh. This phenomenon resembled Sinkler’s toe reflex in 
character, but the movement was altogether different. The toes 
were not grasped by the hand, simply the metatarsus and tarsus, and, 
moreover, the quadriceps extensor took no part in the response. It 
was more marked on the right side. 
b. Body supine. Percussion of the pectorals elicited a slight, normal 
response. The recti responded very vigorously, especially the middle 
and lower portions. The quadriceps yielded vigorous responses on both 
sides. The adductors of the thighs yielded a slight response, while the 
extensor group of either leg yielded a very decided response. 
Knee jerk and ankle clonus both very excessive. Sinkler’s toe re- 
flex very marked. 
No response to stroking the skin over the pectorals. Very vigor- 
ous response on stroking the skin over the abdominal muscles and the 
extensors of the thighs. Cremaster reflex also elicited, but not exces- 
sive. 
There was never any paralysis of the sphincters. Bladder and 
rectum were under perfect control. 
Cutaneous sensibility was comparatively well preserved. The re- 
sponses were prompt in all portions of the trunk. Over the inner as- 
pects of the thighs and of both the inner and outer aspects of the legs 
the responses were slightly delayed. Separation of the points a little 
below normal in the legs and feet, more marked toward the feet. On TWO CASES OF SPINAL SURGERY. 
the feet, too, the patient makes frequent errors of location. How- 
ever, nowhere can actual anaesthesia be demonstrated. 
It remains further to state that a slight prominence existed over the 
region of the 10th and nth dorsal vertebrae. Tubercular disease 
was suspected. Dr. John Musser, under whose care the patient had 
been, informed me that no elevation of temperature had occurred for 
several weeks past. Syphilis was denied. Dr. J. Wm. White 
likewise saw this patient and concurred in the propriety of an opera- 
tion. To this the patient submitted on December 12, 1888. The 
9th, 10th and nth dorsal spines and arches were removed. The dura 
was not touched. 
Though the surgical interference was much less extensive than in 
the preceding case the patient died thirty hours after the operation. 
Autopsy.—Eighteen hours after death general appearance, that of 
a man of fine physical development. Muscles large, chest well shaped. 
Not much superficial fat. 
Thorax.—Visceral and parietal pleura united by numerous bands of 
old adhesions, most extensive on right side. Patch of softened tissue, 
size of egg, in posterior portion of lower lobe of right lung. Pleura 
especially adherent at this point. Minute tubercles scattered through 
both lungs. Bronchial glands caseous. 
Pericardium normal. Heart muscle pale and soft; valves normal. 
Abdomen.—Nothing worthy of note, except amyloid changes in both 
kidneys. 
Spinal Column.—Both thoracic and abdominal viscera having been 
removed, extensive tubercular disease of both dorsal and lumbar ver- 
tebrae was noted. On the right side in the thoracic region was ob- 
served a tuberculous mass which had evidently been adherent to the 
patch of softened lung tissue noted above. 
Cadaver prone: Surgical wound reopened; aspect of wound 
healthy. No effusion of serum or blood. Dura unchanged. Spinal 
canal now opened to full extent. Dura and peri-dural tissues every- 
where normal. Dura opened entire length. Cerebro-spinal fluid nor- 
mal in color and quantity. Appearance of cord, normal, except at 
level of nth dorsal vertebra. Here it is undoubtedly soft. Above and 
below the consistence of the cord does not appear to have changed. 
Immediately above the site of operation a minute extravasation of 
blood is noted. Cauda equina healthy. 
A section of cord one inch in depth was now removed, the upper 
portion of the section corresponding to the area of softening. 
Cranium unopened. 12 
F. X. DERCUM.—J. IV. WHITE. 
Microscopical Examination of Cord.—This proved to be exceed- 
ingly interesting, especially in view of the conclusions of many sur- 
geons and neurologists recently formulated by Elliott, who argues 
against the occurrence, at least the frequent occurrence of inflamma- 
tion of the cord as a result of compression in Pott’s disease.1 In the 
first place the cord shows no alteration in shape, nor does there ap- 
pear to be any change in the pia mater. A very striking change, how- 
ever, exists in the gray matter. Here extensive haemorrhagic infiltra- 
tion has taken place. It is marked on both sides, but especially so on 
the left; nor is it absolutely confined to the gray matter ; here and 
there the white matter has been invaded. It is of interest to note that 
Fig. i.—Transection of Lumbar Cord, Showing Hemorrhagic Infarct 
(Drawn by Allen J. Smith). 
this condition is relatively recent. The stage is still that of red soft- 
ening, and little, if any, change has taken place in the blood-corpus- 
cles. If we seek for indications of long standing and chronic inflam- 
matory changes we fail to find them. In the cornua of the gray mat- 
ter, the nerve cells are quite well preserved; the nerve 
tubules of the white matter likewise present a normal ap- 
pearance, and we do not find any noticeable increase in the neuroglia. 
Further it is most marked in sections made from the upper portion of 
the fragment, namely, that which had undergone most compression. 
It is not at all improbable that the long continued and un- 
avoidable administration of the anaesthetic played a part 
ISee New York Med. Journal, June 2, 1888, p. 589. The Pressure Paralysis of 
Pott’s Disease, by Geo. R. Elliott. TWO CASES OF SPINAL SURGERY. 
13 
in bringing about a fatal termination of the case. The 
pathological findings in the case point to an earlier opera- 
tion. Had the operation in the present case been undertaken 
but a few weeks earlier it is doubtful whether the cord would 
have presented any pathological changes whatever. These 
considerations, it seems to us, are very important, affecting as 
they do the possibility of recovery from the paraplegia. 
Had it been possible to determine in advance the extensive 
tubercular degeneration of the vertebrae, it would no doubt 
have weighed against the advisability of the operation. How- 
ever, the absence of changes in temperature, the well-nourished 
and apparently good condition of the man decided the question 
in the affirmative. Further, though the vertebral disease was 
extensive, the amount of deformity was very slight. 
Sjtrgical Memoranda, hy Dr. White.—lt is not necessary to 
repeat in this case the details of the operative procedure which 
were precisely the same as in the previous one. The result 
was a surprise and great disappointment to me. So much less 
interference with both bony and nervous structures had oc- 
curred ; the patient was so much younger ; his general appear- 
ance was so good and his nutrition so excellent that my 
prognosis, based also on the reports of the attending physi- 
cians and neurologists, was very favorable, as regarded the im- 
mediate effects of the operation. The autopsy, of course, dis- 
closed a hopeless condition, or rather series of conditions, that 
went far both to explain the fatal result, and to render it less 
distressing, as the case was evidently a hopeless one. Either 
the spinal abscess or the pulmonary tubercle would have strong- 
ly contraindicated operation had their existence been re- 
vealed by persistent fever or sweats, by cough or emaciation, 
or by physical signs. In the absence, however, of these, and 
of all other significant symptoms, and in the presence of a spi- 
nal deformity which seemed to point strongly to a pressure 
paraplegia, the operation seemed justifiable. 
The immediate cause of death, I am disposed to believe, was 
a combination of shock with the free use of ether in a patient 
with crippled lung power, a degenerated heart muscle and 
amyloid kidneys. There was no haemorrhage of any moment, 
and indeed, the quantity of ether administered was not exces- F. X. DEKCUM.—J. W. WHI7 
sive as compared with that used in every-day operations on or- 
dinary patients. 
The chief lessons of the case are : 1. The apparently un- 
avoidable risk due to insidious and unrecognizable complica- 
tions, a risk which is probably greatly increased in tuberculous 
patients. 2. The existence of red softening in a case of Pott’s 
paralysis, a condition which, if we can judge by recorded au- 
topsies and by the expressed opinion of many competent ob- 
servers is more or less exceptional. 3. The necessity for ex- 
treme caution in the use of anaesthetics in all cases in which 
the existing and recognized disease makes coincident visceral 
changes probable, or even possible. 
I append the notes of my resident, Dr. Dailey, and desire to 
call especial attention to the remarkable difference in temper- 
ature between the mouth, the surface and the rectum. 
Clinical Notes. 
I P.M. Patient complained of being cold; ordered blankets, hot cans and whisky 
gss, ammon. carb. gr. v., hot water every half hour. 
1:15. Temperature, 97.10 (rectum;) pulse, —; respiration, 32; vomited matter of 
a dark brown color; whisky tr. digitalis hypodermically. 
1:30. Whisky §ss, ammon. carb. gr. v, given hot. Patient covered with cold 
perspiration ; dressing slightly soiled with blood; complains of pain in heel. 
2:00. Whisky §ss and ammon. carb. gr. v., hot. Complains of great pain in 
heel. 
2:15. Temperature, 97.i°; pulse, 138; respiration, 36. Soiled dressings show 
some oozing from wound. Feet quite waim and are losing their blue color. 
2:30. Whisky §ss, ammon. catb. gr. v, hot. The pain has extended to the calf 
of leg. Also complains of slinging pain on inside of legs. 
3:00, Whisky §ss, ammon. carb. gr. v, 
3:15. Temperature, 97.20; pulse, 136; respiration, 34. Pain in knee is com- 
plained of. 
4:30. Whisky gss, ammon. carb. gr. v. Patient vomiting. 
4:45. Whisky 3ij, ammon, carb. gr. ijss, every fifteen minutes. Vomited. 
15:00. Whisky nbxxv> tr, digitalis Tt\v, hypodermically. 
5:30. Temperature—rectum, 102°; mouth, 95.30; axilla, 98°. Whisky and 
ammon. carb. 
5:45. Whisky and ammon. carb. Patient still vomiting. 
6:00. Temperature—rectum, 102.8°; mouth, 940; axilla, 990. 
7:00. Temperature (rectum), 99.40. Still vomiting. 
8;oo. Temperature—rectum, 100.3°; axilla, 99.i°; surface (calf), 95.20 ; chest, 
97-3°- 
9:00. Temperature—rectum, 101.30; axilla, 98.2°; surface (chest), 970; pulse, 82, 
feeble; respiration, 36. Repeated vomiting. TWO CASES OF SPINAL SURGERY. 
15 
io;oo. Temperature—rectum, ici°; axilla, 99-4°; mouth, 950; surface, 97-3°; 
pulse, 100; respiration, 34. Still vomiting and complains of great thirst. Hypo- 
dermic injection of whisky and digitalis. Catheterized at 10:30, and about §3 urine 
drawn off. 
11:00. Temperature—rectum, 101.40; axilla, ioo°; mouth, 950: surface, 97.30 ; 
respiration, 36. Still vomiting. Slept twenty minutes. 
12:00. Temperature—rectum, 104° j axilla, 99.20; mouth, 940; surface, 95.3; res- 
piration, 34. Whisky and ammon. carb. by mouth, followed by vomiting. Hypo- 
dermically, whisky and digitalis. Complained of pain in leg. 
1A M. Temperature—rectum, 103.40 ; axilla, ioo.i0; mouth, 940 ; surface, 96.3° ; 
pulse, 98; respiration, 33. Vomitimg brown fluid. Cocaine gr. J, followed by wine 
3ij, which was immediately vomited. Patient perspiring. Slept fifteen minutes. 
2:00. Temperature—rectum, 103.20; axilla, 99.20 ; mouth, 940; surface, 96°; res- 
piration, 38. Still vomiting. Cocaine gr. J, followed by ammon. carb. gr. v, which 
was retained. Slept fifteen minutes. 
3:00 Temperature—rectum, 101.40; axilla, ioo.i0, mouth, 940; surface, 95.40; 
pulse, 116; respiration, 37. Cocaine gr. J, followed by ammon. carb. gr. v. Slept 
fifteen minutes. Warm milk §ss vomited. 
4:00. Temperature—rectum, 103.40; axilla, 98.3°: mouth, 940; surtace, 95.40; 
respiration, 40. Cocaine, gr. i, followed by ammon. ®arb. gr. v, which was re- 
tained. 
5:00. Tempetature—rectum. 103.40; axilla, 101.20 ; mouth, 940; surface, 950; 
pulse, 80; respiration, 37. Ears cold. Slept thirty minutes. Vomited. 
6:25. Temperature—rectum, 101.10; axilla, 98.2°; mouth, 940; surface, 946°; 
respiration, 34. Ammon, carb. gr. v, vomited. Color of vomited matter dark 
brown. 
7:25. Temperature—rectum, 101.40; axilla, ioo°; mouth, 64°; surface (chest), 
95-2°; (thigh), 96°. Still vomiting. 
8:45. Temperature—rectum, 102° ; axilla, ioo.i0-, mouth, 95.10; surface, chest, 
95-I°> thigh» 95-4°- 
10.00. Temperature—rectum, 103.40; axilla, ico°; mouth, 95°; surface, 97.10; 
pulse, 80; respiration, 38. Vomiting frequently. 
11:00. Temperature—rectum, 104°; axilla, 100.20; mouth, 94.40; surface, leg, 940, 
abdomen, 97.3. Hypodermic injection, whisky and digitalis. 
12:40 p.m. Enema. Whisky §ss, peptonized milk §ij. 
12:50. Hypodermic injection, whisky fibxxv, digitalis rtpv. 
1:35. Hypodermically, whisky and digitalis. 
1:45. Temperature—rectum, 104°; axilla, 101.40; mouth, 940; surface, leg, 99.I0, 
abdomen, 99.i°. 
1:55. Mustard plaster to epigastrium. 
2:30. Hypodermic injection of whisky and digitalis. 
2:45. Plaster removed. Vomiting relieved. Enema. Peptonized milk and 
whisky. 
2.50. Slept ten minutes. No nausea. Respiration 40 while asleep. 
3:15. Vomited. 
3.45. Temperature—rectum, 104.30; axilla, 102.10; mouth, 950. 
4:25. Hypodermic injection of whisky fi\xxv, digitalis nqy, atropia gr. '/too- 
-5:45. Face dry; forehead and neck warm, cheeks and chin still cold; tongue 
moist; very restless; severe dyspnoea ; pupils moderately dilated. Hypodermic- 
ally, whisky, digitalis and atropia gr. */ioo. While under observation dyspnoea be- 
came more intense and patient died at 6 p.m.