Extracted from The American Journal of the Medical Sciences, April, 1894. 
A CASE OF FRACTURE AND DISLOCATION OF Tip SECOND 
LUMBAR VERTEBRA, WITy OPERATION^ 
By Richard C. Newton, M.D., 
MONTCLAIR, N. iU- 
ATTENDING SURGEON MOUNTAINSIDE HOSPITAL; SURGEON TO THE NEW YORK^jD 
GREENWOOD LAKE RAILROAD. 
With a Report of the Microscopical Examination of~ a 
ISection of the Spinal Cord. 
By Henry Power, M.D., 
NEW YORK CITY ; 
PATHOLOGIST TO THE MOUNTAINSIDE HOSPITAL. 
H. P., aged twenty-four years ; single; teamster; born in New Jersey. 
Has a slight admixture of African blood, although he is very nearly 
white. Admitted to the Mountainside Hospital, January 12, 1893. 
Previous and family histories not of especial significance, except that 
the patient claimed to have come of healthy stock, and that he had 
never suffered from any serious illness in his life. He distinctly denied 
all venereal lesions. 
On admission the patient was quite helpless and was suffering acutely 
from an injury to the back, which he had sustained in the following 
manner: He was driving a team of horses attached to an excavating 
wagon, of which the driver's seat was very high. In attempting to 
drive into a barn he did not notice, until it was too late, that there was 
almost no space between the jamb of the door and the seat of the wagon. 
There was some ice upon the road and upon the approach to the barn- 
door, and the patient's horses were smooth-shod. As the latter ap- 
proached the door they began to slip, and naturally quickened their pace 
to get inside the barn. The patient tried to hold them back, and finding 
this impossible, he dropped his reins and tried to slide or roll off of his 
seat. In an instant he was caught between the door-jamb and the high 
back of the wagon-seat and pinned there until the team had pulled the 
wagon into the barn. 
He fainted away from pain and shock. After the door-jamb had been 
passed there was more room and the patient was pulled down from his 
exalted position and medical aid summoned. He thought that there 
was rather more than six inches of space between the door-jamb and the 
back of the wagon seat. 
When admitted to the hospital he was perfectly conscious, and, after 
morphine had been administered hypodermatically, passed a fairly com- 
fortable night. The next day he was not suffering any pain. His 
bladder was full of urine, of which he had passed none since his accident. 
He was completely paralyzed as to both sensation and motion in both 2 
NEWTON, POWER*. FRACTURE OF A VERTEBRA. 
lower limbs. The line of anaesthesia in front was at Poupart's ligament, 
and behind at the upper extremities of the gluteal eminences-thus 
corresponding to the seventh zone of anaesthesia in Prof. Starr's tabula- 
tion (The Amer. Journ. of the Med. Sci., July, 1892). According 
to the Professor's observation this line of anaesthesia indicates a lesion 
of the cauda equina and filum terminale at the level of the second 
lumbar vertebra, and in my case the injury was afterward proved to be 
at this point. There was complete loss of the reflexes, both deep and 
superficial, below the seat of the injury. The patient could not feel the 
passage of the catheter, although he felt relieved after the water was 
drawn. The surface temperature was apparently somewhat raised over 
the lower limbs, but of this there was no certainty at the time, inasmuch 
as it took a day or two to procure a surface thermometer. The feet 
were also warm. But the ankle clonus could not be elicited. Although 
the rigidity of the joints of which Starr speaks (ibid.) was noticed, it 
was impossible by tickling or pricking of the soles of the feet to awaken 
any sensation or provoke any movement, reflex or otherwise. There 
was no priapism. No emesis. There was at this time no deformity nor 
bulging of the spinal column. No crepitus could be detected. None 
of the vertebral spines seemed to be missing or displaced. No bruises, 
lacerations, nor ecchymoses-in a word, no evidence of external violence 
was found on the man's body, although carefully looked for, and none 
subsequently appeared. It should be stated in passing, that the man 
was a short, stocky, heavily muscled person, and his spinal column was 
well walled in with firm muscular tissue. 
For the first three days after admission the temperature in the mouth 
was 101° F. ; pulse 80 to 86. Two drachms of compound licorice 
powder produced a copious stool, of which the patient was unaware. 
On the morning of the third day some bulging backward-of the spine 
was noted in the upper lumbar region. A plaster jacket was put on the 
patient, extending from the axillae to the hips. During its application 
he complained strenuously of pain, and twice nearly or quite fainted 
away, so that he had to be let down from the apparatus in which he was 
suspended and laid flat upon his back on the floor until he revived. 
The plaster jacket seemed to make him somewhat more comfortable 
and he could pull himself about in the bed by his arras. He complained 
more or less constantly of pain in the abdomen. Some suspicious-look- 
ing round, black spots appeared on his heels, and a number of small, oval, 
red ones. His urine was drawn three times daily with a soft catheter. 
For three days careful observations of the surface temperature were 
made with a Seguin's surface thermometer, about six minutes being 
consumed in an observation. They were as follows : Temperature on 
front of abdomen near umbilicus, 99°. Front of left thigh between hip 
and knee, 97° ; right, 94f°. Front of left arm between shoulder and 
elbow, 97° ; right, 98°. Front of left thigh between hip and knee, 99° ; 
right, 97°. Front of right thigh between hip and knee, 96 ; left, 98f °. 
Front of right arm between shoulder and elbow, 97f°; left, 95°. As 
these results seemed inconclusive the observations were discontinued. 
After a period of eight days without a movement from the bowels, 
the patient experienced great distress from tympanites of the abdomen, 
which became so excessive as to embarrass the respirations. Accordingly 
two drops of croton oil were given, and were followed in an hour and a 
half by an exceedingly copious action of indescribable fetor. This gave NEWTON, POWER: FRACTURE OF A VERTEBRA. 
3 
temporary relief, but was the beginning of fecal incontinence. About 
this time several small blebs were noted about the feet and ankles. 
On the 27th of January, after a consultation of the entire hospital 
staff, an operation was determined upon in the hope that something 
might be accomplished for the relief of this man's pitiable condition. 
The uncertainty and danger of the proposed operation had been ex- 
plained to the patient and his friends and their full consent to it 
obtained. 
It seemed better not to wait any longer, because the patient was daily 
losing ground, and we feared that he would not be in a condition for 
operation if a period of six weeks was allowed to elapse, as suggested by 
Dr. White and others, before undertaking an operation. Accordingly, 
I proceeded to operate with the assistance of my colleague, Dr. Love, 
and Drs. Ward, Whitehorne, and Francis, of the hospital staff. The 
plaster jacket was cut up the back and removed. There was a moderate 
posterior bulging of the upper lumbar vertebrae, and the most prominent 
of these seemed to be the second. We had agreed to do an Abbe's 
operation. A longitudinal incision, six inches long and one-half inch 
to the right of the vertebral spines, was made, beginning at the tenth 
dorsal vertebra and extending to the sacrum. The tissues were divided 
down to the laminae of the vertebrae. It was then observed that the 
second lumbar vertebra was displaced by having been rotated to the left, 
so that the hollow between the spinous and right transverse processes 
of this bone was nearly or quite in the median line of the back. The 
spinous processes of the remaining vertebrae were in their proper align- 
ment. A strong hook was employed, and several attempts were made 
to rotate this bone into its proper place, but without success, although 
an extraordinary amount of force was used. 
The arches of the first and second lumbar and the right transverse 
process of the latter were then cut away with a long pair of bone- 
forceps, exposing the medullary canal. The spinal dura mater had been 
torn by the original injury, so that only a small portion of the segments 
of the spinal cord that we had exposed was covered by its membranes. 
In fact, only a triangular-shaped piece of the dura mater, with its 
hypothenuse running from above downward and from right to left, was 
found. This covered probably a fifth of the two segments ; the remain- 
ing four-fifths of the dura mater we could not find. Of the cord itself 
a fusiform enlargement was observed, which probably increased the 
diameter of the cord by 50 per cent. This was purplish in color. No 
spiculm of bone and no blood-clots were observed in the medullary 
canal; nor so far as could be ascertained was there any pressure being 
exercised upon the substance of the cord. The patient now began to 
exhibit unmistakable signs of collapse. The operation had been long 
and bloody, and inasmuch as it seemed that little good and much harm 
might follow further manipulation, it was decided to close the wound 
and do nothing further. Considerable difficulty was experienced in 
stopping the hemorrhage, which was venous in character and welled up 
between the cut surfaces of bone. Affusions of hot water and pressure 
from sponges wrung out of boilkhg water finally stanched the flow of 
blood, and the wound was closed. A strip of iodoform gauze was used 
for a drain. The deep sutures were of catgut, specially prepared and 
kept in closed glass tubes. The muscular tissues wrere brought together 
With sutures of silkworm-gut. Every approved antiseptic precaution 4 
NEWTON, POWER: FRACTURE OF A VERTEBRA. 
had been observed. Abbe's operation had, of course, proved impracti- 
cable owing to the displacement of the second lumbar vertebra. 
The patient was profoundly shocked by the operation. The next day 
his pulse was 132 and thready; temperature, 102° F.; and respiration, 
28. In forty-eight hours the temperature fell to 97-1°, and then rose 
again to 102|°, at which point it remained until death. On January 
31, 1893, five days after the operation, the patient had rallied somewhat 
and we felt some encouragement about his chances of recovery, albeit 
there had been no improvement whatever in the symptoms caused by the 
accident. On February 1st, however, his condition again became alarm- 
ing, and he died very quietly shortly after midnight, five and one-half 
days after the operation, and twenty-one and one-half days after the injury. 
An autopsy was forbidden. A hurried and surreptitious examination 
of the wound, however, revealed the following condition of things: 
There was no odor and almost no pus about the cut surfaces. A thin 
coating of lymph was noted over the exposed muscles, and indicated a 
healthy healing process. There was considerable laceration of the 
deeper layers of muscles from the original injury and from the use of 
the cutting forceps. The intervertebral substance between the first and 
second lumbar vertebrae was fractured nearly through. The body of 
the second lumbar was broken-the line of fracture beginning near the 
middle and running downward and forward to near the junction of the 
anterior and lower surfaces. A fracture of the intervertebral substance 
between the second and third lumbar, and of probably at least two of 
the articular processes of these vertebrte, must have existed, although 
from lack of time all the lesions could not be accurately made out. The 
swollen and discolored portion of the cord noted at the operation was 
removed and turned over to Dr. Henry Power, the pathologist of the 
Mountainside Hospital, for examination. His report is as follows: 
" The portion submitted for examination consisted of many of the 
roots forming the cauda equina, and also some more compact material 
among the fibres. The relations of the tissue to surrounding parts were 
in no way indicated. The tissue was hardened in bichromate solution 
of 2? per cent., and then in alcohol. Sections examined by Weigert 
stain and picro-acid fuchsin. The compact material above referred to 
was not part of the cord, as had been hoped, but consisted of blood-clot 
and some adhesions binding together the nerve roots. All the nerve 
fibres showed with the Weigert method the various stages of degenera- 
tion. No evidence, however, of the exact location of the injury causing 
the same was obtainable from the specimen." 
The explanation of the displacement and rotation to the left of the 
single vertebra (the second lumbar) seems to me to be that the patient 
was struck when leaning forward and to the right side, as he endeavored, 
when too late, to throw himself from his seat to the ground. (He would 
naturally sit on the right end of the wagon seat to drive, and would 
also naturally get on and off his wagon on the right side.) The habit 
of the colored race of ducking the head when danger threatens is well 
known; he therefore ducked his head and was struck by the door-jamb 
upon the right shoulder. His spine was already bent forward as much 
as possible as he was endeavoring to slide off of the seat and avoid the 
door-jamb at the same time. The blow broke his back at the point of NEWTON, POWER: FRACTURE OF A VERTEBRA. 
5 
the greatest curvature, the second lumbar, and also, since the legs were 
now held fast by having passed under the door-jamb, the same force 
displaced the entire spinal column above the fracture to the left. As, 
however, the wagon passed on, the man's body was drawn between the 
high back of the wagon-seat and the door-jamb, and since it could not 
pass with its transverse diameter perpendicular to the opposing surfaces, 
the body was forced on to the back, and the lateral dislocation was by 
t'his means reduced while the body was passing under the door-jamb. 
The second lumbar vertebra, however, was prevented from resuming 
its place with its fellows, because it was held fast by the high seat-back, 
a board about an inch wide. Thus the intervertebral substance between 
the second and third lumbar must have been fractured and the articular 
processes broken, if they had not been broken before. A lateral dis- 
placement with rotation would also account for the peculiar diagonal 
tear to the theca, and the partial reduction of the dislocation would 
account for the disappearance of the missing portion of the membrane, 
which was probably folded away against the side of the bony canal 
under the injured cord. Whether the above explanation be the true 
one or not, it is plausible. 
It is true that the best authorities seem united in the belief that 
a total abolition of the reflexes signifies a complete transverse destruc- 
tion of the cord, and also many of them hold that in cases exhibiting 
these symptoms an operation is contra-indicated. But considering the 
low seat of the lesion in my case, there is good authority for opera- 
ting, as, e. g., Prof. White, in the able summary of the " Surgery 
of the Spine," already referred to (Ther. Gazette, October, 1891), says 
(p. 680): "As to the region involved, both theoretical and statistical 
considerations show that the lower dorsal and lumbar vertebrae are 
those which can be operated on with the greatest hope of success." 
And again (p. 682) : " That it is unsafe to say in any given case that 
the cord is hopelessly damaged would seem to be fairly well established 
by the results of such cases as Horsley's, Macewen's, and Lowenstein's, 
so that operation should scarcely be refused on that score alone." And 
again (p. 683) he quotes Chipault as saying " Trephining is absolutely 
indicated . . . when there is compression of the filum terminale from 
any cause." And finally Dr. White lays down amongst the conclusions 
to his paper the following: "Resection of the posterior arches and 
laminae should be resorted to in all cases in which there is compression 
of the cauda equina from any cause." Having then so good authority 
for operative interference in this case, I cannot think that any injustice 
was done our patient by submitting him to an operation which, while it 
was by no means successful, has taught some valuable lessons, and at 
the worst only abridged by a comparatively short period a life already 
doomed, and thereby doubtless eliminated much suffering. 6 
NEWTON, POWER: FRACTURE OF A VERTEBRA. 
The increasing number of reported operations undertaken for the 
relief of spinal injuries is, in my opinion (as Prof. White also holds), 
rather encouraging than otherwise to those surgeons who favor surgical 
interference in these cases; and who shall say that Sir Astley Cooper 
overstated the truth when he asserted that if one patient out of one 
hundred could be saved (by operation), it would be better than could 
be hoped for from Nature alone?