SECTIONAL MEETING.

DISCUSSION.

DR. H. F. BIGGAR: Gentlemen, we will now commence the business of this bureau. I will state to the members present that we have deviated a little from the regular order in regard to the subjects which will be discussed. It was thought that the Institute would grant us permission to do this. In arranging the subjects for discussion it was thought best at Milwaukee to devote our attention to spinal diseases, and in view of that fact we appointed Dr. Franklin to report in regard to certain conditions with reference to angular curvature, and Dr. McClelland, of Pittsburgh, to report in regard to lateral curvature. Dr. Franklin has not yet reported in regard to his part of the subject, but Dr. McClelland is here to report; and with reference to his report I would say that I am glad that we have deviated, because it gives us a variety of subjects to listen to and to discuss. I think it would be proper now if we would commence the business of the afternoon by calling upon Dr. McClelland to read his paper upon lateral curvature of the spine, which was the subject selected for discussion.

DR. MCCLELLAND: Previous to that, and in deference to the other members who have prepared papers upon subjects different from the subject selected by the bureau, I would first make a motion that each paper in turn as it comes up before the bureau shall be the subject for discussion. Agreed to.

Dr. McClelland then read his paper upon Lateral Curvatures of the Spine.

DR. TALBOT: In regard to the plaster jacket, I think that if you put the plaster on dry you can fit the bandage into its place more easily; then you can saturate it in place without any motion of the parts, and it hardens more quickly and makes, I think, a firmer cast than it does when it is put on wet. It is very easy to saturate two or three thicknesses of the bandage.

DR. HELMUTH: As Dr. McClelland has quoted from my work on surgery, I would say that it is a hard thing to remember all I have written in that book. But with reference to the cause being purely mechanical, I would say that since I have written that work in some instances I

have had reason to change my mind in reference to the causes of lateral curvature of the spine. I will say that in my opinion a good many cases are owing to the very pernicious habits of children in the school, from the manner in which they sit at the desk when writing. I am also of the opinion that in very many cases there is a reflex cause somewhere in the body. To show you how nearly Dr. McClelland and myself agree, I would say that in many cases of lateral curvature the cause is a reflex one. I would like also to say that there is a great deal to be done after the apparatus is applied in the way of treatment of this variety of curvature. Great care should be taken where the jacket is applied, to see that the patients stand correctly and erect, or these muscles will become weakened in their condition.

Now, with reference to this jacket, I have seen a good deal of the application of the plaster of paris jacket, and have applied it a good deal myself, not only in Pott's disease but in lateral curvature. The great defect in the jacket is its inability, as it was formerly applied, to maintain the proper position. The fact of the matter is, that when you suspend the patient, some of the muscles are put on the stretch no matter how you suspend them. The question is, does the curvature lessen from the actual action of the pressure on the curved part, or does it lessen from the extension and resistance of the healthy integral cartilage, and if so, does the curvature only lessen from the side of the healthy portion? And then, when the bandage is applied we keep the healthy parts in a state of extension which is not always good for the patient. Another objection to this jacket is that it should be taken off-removed frequently. Any one who has had any experience in removing the jacket knows the difficulty of taking it off. After the jacket is applied it should be divided and removed, taken to the instrument maker and bound and the eyelets put in and then re-applied, and then it can be removed with great facility. I generally apply it not in a complete state of extension, but in a state of partial extension. It is better not to make too much tension on the muscles. When it is placed on a child there can be no doubt that this mechanical support relieves the child immediately, but the question is whether the relief is always permanent. Sometimes the relief is deceptive, but at the same time very encouraging. Take a patient unable to walk, put on the plaster jacket and they are able to walk off at once. This is very encouraging, but the fact is, in very many instances this is only temporary relief. What I want to urge upon the members is this, that in these cases of disease of the spine, it does require the internal administration of the proper homoeopathic remedies as well as the application of the mechanical support. Correct mechanical support is necessary.

DR. S. R. BECKWITH: Mr. Chairman: We are all of us liable to get into ruts because it is more easy traveling than over an unknown road, so that it is easy to fall into the plan of applying Sayre's plaster of paris jacket. I grant you that I fell into it, but I have since dropped it. I made careful observations as to what portion of the spinal column was curved. That has been of the greatest advantage to me, so far as my own experience is concerned. I have found that where the curve occurs in the upper portion of the spine, in the cervical or the dorsal portion of the spine, it is of but little use, and when it occurs in the very low portion of the dorsal, it is of but little use. It is only when it is met with in the small of the back, as it is called, that I have found it to be of any advantage. As to the other curves of the spine or as to curvature in the other portions of the spine, I have abandoned its use entirely as not being of any advantage, and ever since I have confined its use to the treatment of that one form of curve. I have not considered its merit at all, or what merit it has at all, but I have simply come to this conclusion, that very much depends upon the skill of the operator in applying it—very much indeed. I have seen physicians apply it all about our country and they have kept it on from four to six weeks, and in some instances for twelve months, without any great benefit. We have a neighboring surgeon of ours in Ohio who may be considered an expert, perhaps. I mean with Dr. Sayre's jacket. Some patients to whom he applies it seem to improve to a certain extent. Now, my own opinion is that it is mostly overrated—that it is the most overrated thing that has been generally used that I have been acquainted with. I form this conclusion from two reasons, the first, which is the most valuable, from practical observation, and second, from viewing it as a mechanical contrivance. It is very evident indeed that it is nothing more and nothing less than another contrivance for accomplishing the same purpose that the old apparatus accomplished; having fixed points at the hips and a fixed point at the axilla, with left and right hand screws, you would raise up the spine and in that way accomplish all that is accomplished by suspension. Now, you may take the old plan, and if it is properly applied you can make the same extension and I think as a whole you would get about the same benefit as in the plaster jacket. So my experience has been that the invention is not so very valuable as is claimed.

I have had some good results from suspension, having a suspension apparatus in use. The custom has been in the hospital to let them use the apparatus a few moments at a time in the morning or during the day, as the case might be. But I think as a rule that the plaster of paris jacket had better be used simply by the surgeons who have a large experience, and

who are read up as to mechanics, and as for the general surgeon I think he had better go back to the old splints for his cure, and that he will be better satisfied with his results. So far as Pott's disease being the result of an injury, well, really, gentlemen, Prof. Helmuth has already spoken and said that it is not always due to an injury, but when arising from an injury it is like all other diseases; if there is some unfortunate diathesis existing in the system the injury will be developed in Pott's disease; unless there is a diseased condition of the system arising; unless you trace it to the injury-to the cause whatever it is-it may be Pott's disease, or it may be an injury, or it may be from some unfortunate diathesis. There can be no doubt that these may all be the cause, but in view of the main cause in the case I say I think that your theory in reference to the plaster of paris jacket is to be taken with considerable caution, and it is to be carefully observed before we give it as a rule, so plainly as Dr. Sayre says, that Pott's disease is always the result of injury. Like Dr. Helmuth, I have had really good success by the use of proper homoeopathic remedies.

DR. PEER: I have had some little experience in the treatment of curvatures. I could not help, while listening to Professor Helmuth, thinking of a case that I had to treat with a peculiar diathesis, of course favorable to it. I recollect one case in particular that I had within the last three years; this was a child about a year and a half old. It was rather a premature birth and the nurse held it a great deal in her lap, and before I was aware of it, it had a curvature, direct, and it was a bad one, at the upper portion of the dorsal region. It was an angular curvature. I ordered the aunt to fix pieces of whalebone one on each side and to lace it up like a corset and to keep the child in a straight position. The remedies I gave it were, Kali carbonicum, Hepar sulphur, and Phosphorus. In the course of three months the child was as straight as an arrow; now he is a little boy three or four years old and is perfectly straight. I think the curvature was overcome by keeping the child in a proper position as much as any other one thing.

DR. J. E. JAMES: I like the idea of Dr. McClelland's splint because it comes nearer to the cheapness of the plaster paris jacket of Sayre, than anything else. Probably the only recommendation that the Sayre jacket has above other means is its cheapness. In children, where they are changing and growing rapidly and where you have a disease conditioned such as you have in lateral curvature, I think that your treatment will result in strengthening the part, and you will find that it has got to be frequently changed. That is one of the advantages of Dr. McClelland's splint and of the application of the elastic air cushion. That

can be used to great advantage in connection with the splint. It occurs to me that it will occupy a good place in the treatment of this class of cases that has formerly been occupied by Sayre's jacket. There is another advantage, it permits of the movement of the abdominal walls. This, I take it, is a good idea also. This splint acts as a mechanical brace, and in cases where the Sayre plaster jacket would be recommended this could also be adopted. Of course we find a great many cases where it is not adapted to the case, and then the old way should be used. This apparatus is a mechanical brace, and on account of its cheapness and its being so easy to make will be a great recommendation.

DR. MCCLELLAND: It is not easily made, and it is not cheap unless labor is cheap, it is really a very troublesome thing to make, and if it were not that I had a most competent assistant in this matter I could not have devoted the time necessary to apply it, because it takes several hours to make the mould in the first place, and then to make the cast and then to apply the cloth on the cast in order to make the jacket; but it is, I say, most admirable and satisfactory, and has advantages over many other forms of jacket in respect to its capability of being removed and otherwise. DR. HELMUTH : You have to take a cast of the body?

DR. JAMES: The material is not expensive, there is no iron work about it; no dressing about it, so that it takes the place in point of cheapness between the plaster jacket of Sayre and the mechanical apparatus, a thing which will be of very great advantage to the surgeon, because very many of these cases of spinal disease, curvature either angular or lateral, are among our poorer patients, where their diet and mode of life and everything else is such as to induce or conduce to this diseased condition. I believe that this disease is not so much due to mechanical injury or to deformity from injury as it is to a constitutional defect underlying it all, a defect caused by the very mode of life, by the diet, the amount of food, or lack of food, and where improper nourishment has weakened the part so as to induce this paralyzed condition of the muscles and ligaments of certain portions of the body. Conditions which do not attain in perfectly well nourished, healthy children with good surroundings.

DR. MORGAN: I have nothing to add to the excellent remarks of the other gentlemen, but I would simply announce, however, that my friend Dr. Korndorfer, has a unique and very interesting case to report. He has not been particularly associated with the surgical bureau, but I would ask to have him called upon to communicate that case.

DR. KORNDORFER: I mention this case because Dr. Morgan said "you must tell of it here." The case was from the effects of the mechan