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descending degeneration occurs and is very extensive near the seat of injury. This degeneration involves systems than the one immediately affected by the injury. Ascending degenerations too may follow injuries to the cord, and may become very extensive. Secondary degenerations may follow compression of the cord by tumors of the vertebra or of membranes of the cord, or from Pott's disease (tuberculous caries of both forms) or from fracture, dislocations or from hemorrhages in the neural canal fracture, or within the cord or from wounds of the cord, especially gunshot and stab wounds. The special pathology of degenerations from diseases of the cord has been exhaustively studied by Collier and Buzzard (Brain, Vol. 6, No. 104).

Occasionally certain malformations of the cord call for surgical interference and the pathology of these affections must be understood before undertaking operative measures for their relief. Spinal bifida is the one malformation which is strictly surgical in its treatment, and Dana says, "and then only in meningocele."

Syringomyelia, due to formation of gliomatous tissue in the cord becomes of surgical importance at times and its surgical pathology under such conditions is briefly, the cavity in cord tissue is filled with a fluid which is causing undue pressure symptoms, and Horseley says, "temporary improvement in simple syringomyelia may be obtained by tapping the dilated cavity in the cord." I have seen but one case of syringomyelia and no surgical interference was necessary.

Of diseases of the vertebra which involve the cord, tuberculous caries is the most common. Tuberculosis of the bone usually follows slight contusions in susceptible individuals, and the invasion of the bacilli is where the growth of the bone is greatest near the periosteum and intervertebral substance. The anterior surface just beneath the anterior longitudinal ligament, says Warren (Surgical Pathology) is a favorite seat. Here the vessels which run into the bone more or less perpendicularly to the surface, are surrounded with granulation tissue, and the absorption of the bone is therefore greatest at these points Less frequently, the center of the bone is affected. Two or more foci may exist in each body. The destruction of bone goes on until characteristic deformity occurs and compression of the cord results. Horseley speaks of caries without deformity, and says in the lumbar region that it is perfectly possible for extensive tuberculous caries non-suppurative to occur producing the severest paraplegia, without the slightest deformity of the spine. The cervical region

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too seems to be exempt from deformity. saw one such case. New growths involving the vertebra or the membranes of the cord may cause compressions of the cord. Sarcoma and carcinoma of the bodies of the vertebra and sarcomatous growths arising in the tissues adjacent may invade the neural canal. I have seen five cases (two in males) of secondary carcinoma involving the cord or its roots by compression. All cases have been secondary to carcinoma of the breast.

SURGICAL SPINAL LESIONS.

The surgical spinal lesions are compression of the cord from injuries, from tumors, from caries, from hemorrhage and irritations of the roots of the spinal nerves from new growths, etc. To make a diagnosis: first, as to the nature of the lesion; and second, as to its localization, is at times easy, while in other cases, as Cushing aptly expresses it, "There are no clinical puzzles more interesting to disentangle, none more confusing when left in a snarl, than those connected with the segmental localization of a cord lesion, the determination from disturbances of function of its transverse extent, a decision as to the recoverability of the injured tracts, and a knowledge of just where the intact arches of the spinal vertebra, must be entered in order to expose the diseased focus."

In order to solve these problems a complete neurological diagnosis is necessary, certain symptom groups being studied in routine order, viz.: First.-Motor, as shown in paralysis in some form, varying from involvement of one muscular group of muscles to complete loss of power in one or more limbs. Motor irritations or excitations, as shown, is spastic states, rigidity, contractures, spasms,

The differential study of paralysis or irritations cannot be considered here. The second group of symptoms, the sensory, require great care in their differentiation and involve consideration of tactile sense, temperature, pain and muscle sense, etc., and the varied irritations of nerve roots, and later destruction of these roots, etc., paresthesia, neuralgic pains, ataxia and later anesthesia, analgesia, thermoanesthesia, etc. In the study of sensory localization much patience and skill will be required to obtain satisfactory results, and as the symptoms are very important, it is necessary to get full notes and follow carefully a definite routine in examination. The diagrams of Sherrington, of Starr, will be of great aid in differential study. In the third important symptom group are considered the reflexes. The condition of the reflexes is an index of diseases of the cord. They are therefore to be given their true place in diagnosis.

Surgical Interference.-Of the indications for surgical interference I would say that in fractures, dislocations, etc., of the spine, the tendency of the times is to advocate early operation. Walton (Journal of Nervous and Mental Disease, Jan., 1902), of Boston, one of the most practical of our eminent American neurologists, is an earnest advocate of early interference. He says, "That we have no symptoms from which we can assert at the outset that the cord is crushed beyond the possibility of a certain degree of repair, and that early operation in all doubtful cases will not only accomplish all that late operation will do for these cases, but it will be performed to better advantage before reparative processes with adhesion and callus have appeared. Total relaxed paralysis, anesthesia of abrupt demarcation, total loss of reflexes, retention, priapism, and tympanites, if persistent, Walton believes point to complete and incurable transverse lesion: but, the onset of such symptoms does not preclude a certain degree, at least, of restoration of function. The prognosis without operation is grave, but this is hardly a sufficient argument, as it is also grave with operation. While the results of operation are not brilliant, he thinks they are sufficiently encouraging to warrant us in making the practice more general, and in most cases it will be wise to operate within a few days of injury; but a delay of some hours is advisable, partly on account of shock, and partly to eliminate the diagnosis of simple distortion. Instead of selecting the occasional case for operation, we should, he thinks, rather select the occasional case in which it is contraindicated (the patient with great displacement of the vertebrae, the patient with high and rising temperature, the patient plainly moribund, the patient still under profound shock). The dura should be opened freely; it need not be sutured; drainage is not necessary.

C. L. Dana, in discussing this paper, remarked that in his experience, operation is practically safe, and that the spinal column is not injured by the operation.

Cushing (Cleveland Medical Journal, Jan., 1905) in speaking of the indications for surgical intervention in cases of spinal traumatism said, "For the sake of having some tangible and definite rule for conduct, I have always divided these cases into three categorjes: (1) Those in which an operation is contraindicated because it can do no good and may increase the damage already done. To this group belongs the traumatic hematomyelia, a not uncommon lesion, one easily recognized from its symptoms alone and without radiographic aid, and one which, up

to a certain point, is recoverable by natural processes of repair. (2) Of these cases we had twelve. Cases of fracture-dislocation, which are relatively common, and which, so far as we know, are beyond all hope of restoration, owing to the complete transverse nature of the lesion. In these, operation can do no harm, but it is an unjustifiable ordeal for both patient and operator. (3) Cases of partial injury to the cord with symptoms which are increased and perpetuated by pressure from a foreign body, such as a fragment of bone or a bullet, form a group in which an operation undoubtedly will do gond, provided it is so conducted as not to aggravate, by further traumatism, the already existing symptoms. All of these conditions are commonly regarded as surgical, and I have mentioned them for the sake of emphasizing certain limitations which should be recognized. Only in the long standing cases, therefore, which present undoubted evidences of transverse destruction, no matter whether the lesion in its transverse extent originally was or was not complete, is an operation to be considered utterly futile.

REGENERATION OF THE CORD.

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The possible regeneration of the cord after severance by accident is one of the new features in cord surgery, brought into prominence by the remarkable case of Stewart (Phil.. adelphia Medical Journal, June 17, 1903) where by gunshot through the spinal cord, a complete transverse lesion occurred. By operation three hours after the accident, the ends of the cord, which had been separated were, with difficulty united by sutures. teen months later, functions of the cord were restored to the extent, that she was able to perform flexion of the toes, thighs, extend the toes and rotate the thighs; stand with support by a chair. The bowel and urinary functions were performed with little inconvenience; menstruation was regular; sensations of touch, temperature, pain and position were present, but temperature sense was impaired. There was no reaction of degeneration; no trophic changes of skin or nails.

This remarkable case has not been explained; it is one of the most unique and extraordinary experiences of surgery. It leaves open the question of physiological restoration of function and adds to the many unexplained experiences of neurological practice.

PERIPHERAL NERVE SURGERY.

The recent studies of nerve anastomosis have opened up a most promising field in neurological surgery. It is in this department of special surgery that extended experimental work is meeting with such favorable

results. The work of Cushing, of Johns Hopkins Hospital; of Spiller and Frazier, of the University of Pennsylvania in this country; of Kilvington of the University of Melbourne; of Manasse of Munk's laboratory in Berlin; of Kennedy in Glasgow, and other workers in France and Italy, has proven the practicability and possibility of nerve anastomosis so that grafting of a paralyzed nerve upon an intact nerve will result in the return of function of the paralyzed nerve.

In order to better understand the principles underlying this practice, let me briefly state that according to the present stage of our knowledge, the various nerve fibres which run in a nerve trunk are grouped as follows, according to Kilvington: (1) Motor nerves proceeding direct from the central nervous system as skeletal muscles. (2) Preganglionic fibres arising in the central nervous system and ending in nerve cells placed peripherally. (sympathetic ganglion cells, mesenteric ganglion cells and those of the heart and salivary glands, etc.). (3) Postganglionic fibers arising in these peripheral ganglia and ending in smooth muscle and glandular tissue. (4) Afferent fibres arising in the peripheral sensory apparatus and pro-, ceeding to the central nervous system; with these must be classified for the present, the vasodilator nerves.

Now, it is a fact that in nerve crossing that all of these groups may be embodied in one nerve, but it is the motor fibres which are most in evidence in the experimental work. The experiments have been complete, and it would be an interesting and profitable twenty minutes to devote one paper before this society on this subject alone. I can only mention the latest publication along this line, the conclusions of the experiments of Kilvington (British Medical Journal, April 25, 1905) which are:

1. It is possible to functionate two oppoɛ. ing groups of muscles by a single nerve, which previously supplied one group only; or, to put in another way, it is possible to innervate fairly completely muscles with a much smaller number of motor horn cells than usually bring about this effect.

2. When the central end of one nerve is joined to the peripheral ends of two nerves there are many more fibres in the peripheral nerves than in the central nerves, so that the nerve fibres in the proximal trunk divide on going to the distal trunks.

3. In some cases at least some of the branches from one nerve fibre go to supply one set, and others the opposing set of muscles. This may prevent very delicate movement being restored.

4. After this form of suturing the arrange

ment of the nerve fasciculi in the peripheral
nerves is considerably altered. Though
these experiments are incomplete, as they
have not been performed on the human
subject, I think sufficient has been done to
justify the clinical trial of the method.
It seems it would be likely to improve some
of those distressing cases of infantile para-
lysis for which so little can at present be
done. It may be applicable, too, in some
injuries with loss of some of the length of the
nerves, tumors of nerves, etc. (I would say
that Spiller and Frazier have anticiated Kil-
vington nearly two years in applying these
facts in
facts in a successful case reported before
the Philadelphia Neurological Society, and
of which I will speak later).

Cushing (Annals of Surgery, May, 1903) has reported favorable results in nerve anastomosis in facial paralysis, and in his report in comenting upon nerve anastomosis he says "In this form a given nerve with normal central connections is completely divided and its peripheral distribution abandoned as being of comparative unimportance. The central end of this nerve is then brought in its entirety into connection with the peripheral end of the nerve considered of greater importance, but whose central connections have been destroyed. (The accessorius was abandoned and its central end joined to the peripheral end of the facial nerve.) "On purely anatomical grounds, this operation is suited to those cases in which a lesion of the facial nerve has occurred proximal to the stylomastoid foramen; and fortunately, for operative repair, it is in this interosseous portion of its course that the nerve is most susceptible to injury whether from disease or traumatism."

Cushing further says: "The length of time which may elapse after the reception of an injury to a motor nerve and still allow of restoration of function through nerve anastomosis is necessarily uncertain and dependent entirely upon the condition in which the muscles have been kept by massage and electrical exercises. In case there has been complete atrophy of the muscles, so they no longer respond to galvanic stimulation, probably no hope can be entertained of their recovery. Consequently, should there be any doubt of the completeness and permancy of the lesion, as in the frequent paralyses following otitis. media in children, or the severe types of Bell's palsy in the adult, the muscles should be kept in tone by daily galvanism for the number of months during which it may seem advisable to await a possible regeneration without operative intervention.

In cases of undoubted destructive lesions, as in a case reported by Faure, and the

writer's, the operation, of course, should be done at the earliest possible moment. The failure in the former case was undoubtedly largely due to the long interval, namely, eighteen months, which elapsed between the injury and the operation. An operation such as Bloodgood successfully performed in one instance by exposure and suture in the Fallopian canal of a nerve previously injured in a mastoid operation would, except under most favorable circumstances, be difficult in the extreme, and the procedure would hardly be applicable for the cases in which anastomosis is proposed.

"As far as the nerve itself is concerned, a reasonable delay in the operation need alter in no respect, the prognostic favorability of the case. Clinical experience as well as the researches of Howell, Bethe, Ballance and others, shows that there is some change, whether a true regeneration or not, which takes place in the peripheral portion of a divided nerve and puts it in a state of readiness most favorable for an early return of function after reunion by suture. It must be remembered, also that cases of suture of individual nerves have resulted in return of function, though the operation has been done some years after the original injury.

"It is naturally of sonie interest to consider in what way restoration of cortical control is brought about in transplantations of this kind. That undiminished strength and power co-ordination will return to a group of muscles after section and suture of their controlling nerve is a common observation. It is inconceivable, however, that the divided ends of each individual nerve fibre should once more unite in the process of regeneration by perfect coaptation. Supposedly each fibre is represented by a motor cell in the central nervous system so that it is presumable, under the readjustment of healing, that the individual cell make connection with new groups of muscle fibres. Under these circumstances there is on the part of the individual, during the slow period of motor return, an unconscious effort to co-ordinate the early movements, which by training leads to a perfect result. In case the nerve is grafted into an entirely different motor territory, the problem of functional restoration becomes much more complex, and the training of coordination would supposedly be correspondingly difficult. Return of well co-ordinated movement nevertheless seems experimentally to have been as rapid in cases of nerve anastomosis as in those of simple nerve division. Probably the age of the individual is a most important factor, and without doubt the younger the subject the more favorable is the prognosis after anastomosis, especially in case

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Other peripheral nerves have been successfully crossed in surgical practice and one of the most interesting and instructive cases is that reported by Spiller and Young before the Philadephia Neurological Society in February of 1903 (Journal of Nervous and Mental Disease, June, 1903). "The case was one of anterior poliomyelitis of two years standing, in which the anterior tibial muscle alone was paralyzed.

The operation having been decided upon, the most important feature was the route to be selected. From a careful dissection personally made, Dr. Young decided that the lateral route was the better one, and accordingly, an incision 10 cm. in length was made downward from the head of the tibia in the long axis of the leg. The incision included the skin and superficial fascia. The deep fascia was divided upon a groove director, exposing the peroneal nerve. The nerve was followed down, and by separating the peroneous longus muscle three divisions were found: (1) The fasciculus of the nerves supplying the upper part of the anterior tibial muscle; (2) the anterior tibial nerve; (3) the musculo-cutaneous nerve, these divisions corresponding to those found in the cadaver. It was decided to take the upper division, of which there were four or five fasciculi, and perforating the external division, the musculo-cutaneous, the former were united to the outer side of the latter by fine catgut sutures.

Great care was taken not to injure the mus culo-cutaneous nerve any more than necessary, and the fasciculi of the nerves which supply the anterior tibial muscle at its upper part were pushed through the incision in the external musculo-cutaneous nerve without any attempt being made to separate the nerve fibre from the sheath instruments were used, and the nerves were handled as little as possible.

The nerves which were anastomosed were divided as high up as possible, so that there would be no tension upon them. The deep fascia was not closed with sutures. The skin was united by interrupted sutures. Over the antiseptic dressing a plaster of Paris cast. was applied to insure fixation of the limb." It was my pleasure to see this case in Dr. Spiller's clinio last May, at which time improvement was decided, the child could walk almost in a normal manner and muscular power was good. This case suggests the pos

sibility of other anastomoses being performed, and especially should we emphasize it as a promising operation in these unfortunate cases of anterior poliomyelitis where one muscle or group of muscles alone is involved. Nerve anastomosis and transplantation is being advocated by Spiller and Frazier in cases of cerebral palsy. In an address (before the New York Neurological Society, and reported in the Journal of Nervous and Mental Disease, May, 1905) Spiller said: "The views here expressed are original with the authors, and if experience proves they are fallacious, they may nevertheless afford some suggestions for further investigation." The question he propounded was, Is it possible by surgical means to benefit- in any way the patient afflicted with an incomplete hemiplegia?

It is beyond the most sanguine hope to give relief by surgical means in complete or almost complete hemiplegia, but Spiller's hope is based on the cases where partial return of power is in evidence. It is the experience of observers that usually the restoration of motion in hemiplegia is greater in the flexors in the upper limb and greater in the extensors in the lower limb, except those of the toes. An operation on the upper limb is not advised because the flexors of the fingers are more useful than the extensors. In some

cases, however, this feature is of little value unless there is at least partial return of power in the antagonistic muscles, although this return need not be so great in the extensors as in the flexors. Spiller is inclined to believe that in a cases where the flexors alone regain power we might anastomose the central ends of some of the least important of the flexor nerves with peripheral ends of the extensor nerves, and in this way restore more nearly the normal relation between the flexor and extensor muscle.

We know from the experiments extending as far back to the work of Fleurens in 1824, that nerve crossing is both feasible and possible, and that even though the disused nerve may have been out of service for years, that regeneration of the united ends will occur when these nerves have not lost their connection with the spinal cells.

Another question propounded by Spiller is, Would impulses pass from the brain over the central motor tracts to the anastomosed fibres in such a way that useful return of function might be expected His answer is, that such a restoration in part would at least occur. He says: "It is true that movements and not muscles are represented in the brain cortex, but it has been demonstrated that when the lesion is in the peripheral nerves and anastomosis of nerves has been performed, a new form of associated movements

may be learned by the brain. In this association there must be some equilibrium established between extensor and flexor muscles, in order to have return of power.

This work of Spiller and Frazier seeks to give aid in certain selected cases of cerebral hemiplegia, and it is in the field of the cere bral palsies of childhood where the most good is expected, also, some possible relief in athetosis. This new possibility of neurological surely commends itself in the cerebral palsies, but the selection of cases will demand careful oversight.

It was my pleasure to study under Osler and Wilmarth some years ago a series of cases (thirty-six) of cerebral palsies, all of which are reported in Osler's Monograph on this subject, and judging from the pathological findings in those cases, the number of children amenable to surgical treatment will necessarily be limited because of the unequal destruction of motor power, and thereby lessened possibility of establishing balance between flexion and extension of muscles.

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1. The composition of the vaginal tampon consists of a roll of medicated cotton (hen egg size) tied to a 12-inch string, placed in a solution of sixteen ounces of glycerine and two ounces of boracic acid.

2. The duration of preparation of vaginal tampon should be to lie in the boroglyceride solution forty-eight hours before using.

3. The utility of the vaginal tampon is: (a) it is hygroscopic; (b) it serves as a mechanical support; (c) it contracts tissue (muscle, elastic, connective); (d) it contracts vessels. (lymphatic, vein and artery); (e) it hastens absorption of exudates; (f) it checks secretions; (g) it stimulates; (h) it curtails inflammation; (i) it drains the pelvic organs; (j) it cleanses; (k) it dissolves mucus, pus and leucocytes. The utility of a vaginal tampon depends on its composition, the quantity employed, the duration of its application, and on systematic method of use.

4. The methods of introduction consists in placing three to five vaginal tampons (with or better without the aid of a speculum) in the vaginal fornices in the direction of least resistance.

5. Disinfectants in a vaginal tampon is secondary to its other qualities, especially that of hygroscopy.

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