iliw»^i*^^i;\;^ ||p;rE'";r'i„^,.,_^ ••^i • 111 : •'I ,->i'S<'i ' w ;;ks f".;;i. -2U( G 3 1924 104 225 036 Date Due -PH^-fl;- tOEft ■utod ■ ^fP--4r 1 1 1 (|) PRINTED IN O. 5. A. Cornell University Library The original of tiiis bool< is in tine Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31 9241 04225036 ON CONCUSSION OF THE SPINE NERVOUS SHOCK AND OTHER OBSCURE INJURIES TO THE NERVOUS SYSTEM IN THEIR CLINICAL AND MEDICO-LEGAL ASPECTS BY JOHN ERIC ERICHSEN, F.R.S. •URGBON EXTRAORDINARY TO THE r several months, there was every reason to hope he would ultimately recover. The treatment that was adopted in India consisted of rest, plain and nourishing diet, a liberal allowance of claret or burgundy, plenty of fresh air, and shampooing. Strychnine and moderate doses of quinine and iron were administered, and the bowels regulated by suitable aperients. I saw Col. S on his arrival in England on the 36th March. He had improved greatly dur- ing the voyage, being considerably better in all respects than when he left India. There was no cerebral disturbance, no impairment of any of the senses. He ate and slept well ; he had complete control over the sphincter of the bladder, but had not regained power over the sphincter ani. The paralysis chiefly affected the left arm and the right leg : he dragged this leg very remarkably. There was a good deal of rigidity in both these limbs, more especially about the shoulder, and pain on flex- ing or moving them extensively. The paralysis in the arm chiefly affected the muscles supplied by the musculo-spiral and the circumflex nerves. There was numbness in both the lower extremities, but the right leg and thigh were less sensitive than the left. He complained of numbness in both hands. The spine was tender on pressure and pain- ful on movement in the upper dorsal region. The grasp of the hands was weakened, the pressure on the dynamometer of the right hand indi- cating 37 lbs., that of the left only 15 lbs. There was very marked hypersesthesia of the right hand, and, more or less, of the surface of the body generally. If he put the hand into cold water it felt as if it were being scalded. He could not, for the same reason, bear a cold bath, as the skin on the right side of the trunk generally was hypersesthetic, and cold produced an extremely painful impression upon him. The treat- ment consisted of rest, but not absolute ; iodide of potassium in full doses, with moderate quantities of iron and strychnine. Under this plan he gradually improved, was able to return to India at the expira- tion of his leave, and is now in the full exercise of his military duties. Case 8. Compression and Concussion of Cervical Spine, from Blow on Head — Paraplegia — Slow Recovery. — J. S., aged 4G, consulted me on December 11, 1868. He was a tall, strong, healthy-looking man. He stated that on hurriedly quitting a steamer between decks at Aspinwall he struck the top of his head violently against the under side of a deck beam, so that it appeared as if he had jammed his head down between his shoulders. He fell forwards on his face, did not lose consciousness, but was instantly aware of being completely paralysed everywhere below the neck. He lost all power except that of speech. The paralysis of motion was complete in all the four limbs. He could not move a finger or toe. He had no uneasy sensations or pain of any kind. He passed water voluntarily, could retain it, and could control the action of the bowels. The accident happened on April 18, 1867. He was car- ried across the Isthmus of Panama, went on to California, perfectly powerless all the way. He did not suffer at any time from priapism, but he continued to be impotent for more than a year. When he ' arrived at San Francisco on the 3nd May he was quite powerless, but he soon began to regain some motion in the lower limbs, and in the course of a month was able to walk a little. From this time his walk- 18 LECTURE II. — SEVERE DIRECT INJURY OF SPINE. ing power gradually increased, and he began to regain power in his hands, principally in the left. He began to be able to write again in July, but the character of his handwriting was entirely changed. Dar- ing this period he lost about 20 lbs. in weight, of which he had since regained a considerable portion. There, was little treatment adopted -except rest. On examination I found the follovFing condition : — The spine was kept straight, had lost its flexibility, and could not be moved without considerable pain. There was tenderness on pressure, and on movement over the first, second, third, and fourth dorsal vertebree. In pressing on this part of the spine he said that he felt pains shoot down the limbs into his feet. When he walked he felt the jar of the pave- ment, and suffered much if it was at all irregular. If he attempted to write for any time he was seized with much stiffness and uneasy crampy sensations in his right hand and arm. His general health was good, his pulse quiet. Ho suffered much from coldness of the extremities. He was put upon a course of the iodide of potassium, under which he rap- idly improved. Case 9. Direct Blow on Bach by Fall — Sloiv Development of Paralyt- ic Symptoms. — J. W., aged 55, consulted me July 18, 1871. Three and a half years ago he met with an accident at New York, falling five feet on his back on to a pile of rough stones. He was not stunned, and no ill effects were felt at the time or for about three months afterwards, dur- ing which period he went about his business as usual, being a minister in a Methodist Church. The first symptom he complained of was loss . of sleep. He was unable to sleep more than three hours at a time. He then suffered from extreme mental depression, became hypochondriacal and suicidal. He was extremely nervous, so that he could not with comfort be left alone. He then began to walk with difficulty, especially when attempting to go up or down stairs. He suffered some ti'ouble about the bladder, over which he partially lost control. Great tender- ness came on in the spine, in the neck and across the loins. He suffered a good deal from numbness and tingling sensations in the left thigh. His feet readily became cold, and his bowels were extremely costive. By rest he improved somewhat. He was advised to go into the country, to be in the open air, and to try gardening. This made him very materially worse. He had increased in weight, being about twelve pounds heavier than he was. When I saw him he was suffering from, extreme weakness and constant feeling of exhaustion. There was no energy left ; he could do no work, mental or bodily. He slept badly, but better than he did some time ago. He walked slowly and very feebly. He could manage about two miles in the course of the day, always using a stick. He went up or down stairs with great difficulty, and easily tripped. He suffered much from a burning, pricking sensa- tion in the left leg and thigh, but there appeared to be no difference in the strength of the two limbs. There was no affection of the sphinc- ters. His limbs were somewhat wasted. The sight was weak, but it was so before the accident. The spine was extremely tender over the seventh cervical vertebra and the lower lumbar region. There was also some tenderness over the occiput and the sacro-iliac articulation. He was ordered the phosphates of iron, quinine, and strychnine, a generous diet, and complete rest. Case 10. Direct Bloiv on Back by Fall Downstairs — Slow Development of Symptoms of Meningeal Irritation and of Paralysis. — Mrs. E., ao-ed '45, consulted me on December 31, 1869. Three and a quarter years previously she fell down eighteen stairs, having at the time her arms full of clothes. Her feet slipped, she fell on her back and bumped down the stairs. She was not stunned, but her back was severely CASE 12.— CONCUSSION— MENIN(JIT1S — DEATH. 19 struck. She got up and walked some distance. She did not keep her bed, and did not think much of the accident, except that she continued from time to time to suffer pain in the lower part of the back. This had continued ever since ; she had never been free from it. She com- plained that her memory was impaired, that she forgot dates ; she could not recollect where she placed things, and occasionally she used the wrong word or forgot a particular word she wished to emjDloy when talking. She was apt to lose the thread of her sentence so as to have to begin it again. Her sleep was greatly disturbed by dreams of a terrify- ing character. There were constant noises in the head, slight deafness of the right ear. Any sudden or loud noise, such as the crying of chil- dren or the falling of fire-irons, distressed her extremely. The sight, smell, and taste were unaffected. She suffered much from pain at the back of the neck and across the top of the head. Fatigue and excite- ment increased this pain very much. Pressure on the spine, rotation and 3,ntero-posterior movement occasioned pain over the second and seventh cervical and second and third lumbar vertebra. The right hand was numb, and she had pricking sensations in the fingers. She had a difficulty in writing and in taking up small objects. The other limbs were free from all uneasy sensations. The hands were cold, the appetite bad, and she had lost flesh considerably. She was ordered bro- mide of potassium at night, small doses of iron and strychnine in the day, and belladonna embrocation for the back. Case 11. Concussion of Spine from Direct Violence — Condition of Patient Sixteen Years after Injury. — J. "W. A. S., aged 37, from Rhode Island, U. S. A., consulted me on June 29, 1869. He stated that at a fire in June, 1853, sixteen years previously, some bricks fell from a chimney and struck him on his back. He was knocked down by the blow and was laid up for several months. He slowly improved, but continued to be extremely weak in the back, so that although he was able to walk he could not raise himself up if lying in the recumbent position. The left arm was also materially weakened. He had never recovered from the effects of this accident, although he had been able to lead an active, intellectual life, attending very closely to his business. Latterly, however, he had broken down completely in health, and had come to Europe for its recovery. On examining him I found that he complained of his head being heavy, and of a sensation of weight and l^ressure across the eyebrows, mcreased by stooping. He dreamed much at night ; he was affected by sudden loud noises ; his sight was weak ; he wore glasses, and suffered a good deal from muscse volitantes. The left eye was particularly weak, and there appeared to be some amblyopia. The spine was slightly tender in the middle of the dorsal region. His hands were both numb, but more especially the left one. He suffered a good deal from pricking sensations at the end of the fingers, especially in the left index. He also complained of darting pains in the legs, with sudden spasmodic twitchings, tingling, and uneasy sensations in the feet and toes, with occasional cramps. He suffered a good deal at any attempt at bending up the foot. Case 12. Slowly Developed Spinal Meningitis, from Direct Injury, received in a Railway Collision, terminating eventually in Death. — R. E. M., about 27 years of age, a post-office clerk, was injured in a rail- way collision on June 23, 1866. At the time of the accident he was standing up in the post-office van. He was violently struck on the right side and loin against the edge of the table in the carriage. He felt giddy, confused, and faint, but did not lose consciousness. For a day or two he was obliged to give up his work, but in the course of a few days was sufficiently recovered to be able to make a journey to Pres- 20 LECTUKE II. — SEVERE DIRECT INJURY OF SPINE. ton and back. The pain in the back at the part struck gradually in- creased. He suffered much from tenderness in tlie spine, in the lumbar region ; his health broke down, and he became so much enfeebled as to be obliged to take to his bed. Ho was seen by Dr. Waller Lewis, and afterwards by Sir James Paget. These gentlemen recognised a severe injury to the structures of the spine at the part struck. He was ordered complete rest, mercurials in small doses, and the application of two or three leeches daily to the spine. This treatment was continued until the end of October, 1866, by which time he bad had between 70 and 80 leeches applied with very great relief after each application. The pain, however, returned severely in two or three days if the leechings were discontinued. I saw the patient in consultation with Dr. Lewis on No- vember 3. He was then lying in bed, looked pale, worn, and haggard in face, and appeared to be ten or fifteen years older than he really was. On examining him we found that he was unable to stand without hold- ing to a chair or table. Whilst standing he kept his feet far apart in order to steady himself with a broader basis of support. The muscles of the back on the right side of the lumbar vertebrfe were rigid and contracted. He suffered much pain on pressure in the dorsal and lum- bar regions of the spine, but particularly about the second or third lumbar vertebra. He complained of pain shooting down the outside of the thighs. The pain in the spine was greatly increased on any exer- tion or movement, more especially if he attempted to stoop to pick up anything. In doing so he did not bend the spine, but went down upon his knees, keeping the spine straight. He suffered great pain when his shoulders were pressed downwards, and especially if there was any attempt at- rotation or at bending backwards. He slept badly, seldom more than half an hour at a time, starting up in terror. Street noises, the shaking of the house by the passage of a heavy waggon, the slam of a door, all jarred and alarmed him greatly. There was no loss of sensa- tion in the legs, but he complained of creeping feelings and of pins and needles. He was ordered the iodide of potassium and bark, absolute rest and good diet. I saw the patient again on February 6, 1867, in consultation with Dr. Lewis, Dr. Webb, and Mr. Holden. He stated that he was no better than at the last visit, and indeed he looked worse. He was wan, pallid, almost livid in the face ; his pulse was quick and intermittent about once in every forty beats. There was a good deal of twitching of both arms, but more especially of the right one. His urine had escaped involuntarily on three or four occasions, and he had more than once lost control over the sphincter ani. On examining the spine we found that it was much in the same condition as at the last visit. There was some tenderness in the upper dorsal region ; then an absence of pain along the spinous processes ; and then extreme tender- ness on pressure over the first, second, and third lumbar vertebrae. Movement of any kind or in any direction aggravated his sufferings in these situations very greatly. The muscles of the spine on the right side were very prominent and hard, those on the left soft and flattened, so that a very considerable difference presented itself in the examination of the back on the two sides. He could only walk with difficulty, and with the aid of a stick. He dragged the left foot, which was consid- erably everted ; he could not raise the toes off the ground. On examin- ing the leg we found that the extensor and peroneal muscles were those that were chiefly paralysed. There was a good deal of numbness and loss of sensation over the whole of the left side of the body, but espe- cially in the left leg. These symptoms came on about three weeks pre- viously, and had been gradually increasing. I saw him again in the fol- lowing June. He had been in the country for some length of time, but CASE 13. — CONCUSSION — PARAPLEGIA — DEATPI. 21 had not improved in health. He was extremely weak and had almost completely lost power in his limbs. The pulse was from 86 to 90, very feeble and intermittent. He eotild not sleep continuously, owing to frightful dreams. He walked with very great difficult}', leaning on a stick and with his legs widely apart ; the left leg was kept straight with the foot everted. He suffered a good deal from cramps in the legs, more especially in the left one, and complained greatly of pain if it was moved away from the side or bent. Latterly he had suffered from sick- ness and occasional vomiting, twice or thrice in the course of the week. After the conclusion of the legal proceedings connected with the case, I lost sight of the patient, who retired into the country ; but Dr. Waller Lewis informed me in 18?1 that he had eventually died from the effects of the accident. The particulars of the latter period of his illness and of his death could not be obtained. Case 13. Severe Contusion — Paraplegia — Unsuspected Laceration of Intervertebral Ligaments — Death on Ninth day.— 3. R., a clerk by occupation, was admitted under my care into University College Hos- pital, October 2, 1863. He had been knocked down half an hour pre- •viously by a Hansom cab, the horse falling partly upon him and strik- ing him on the neck with its knee. He never lost consciousness, but being quite unable to move, was carried to the hospital ; on his way he passed his urine and fseces involuntarily. On examination after admission it was found that he had an abrasion a,nd ecchymosis on the left side of the neck. There was no inequality or irregularity about the spinous processes, or any evidence of fracture of the spine, but the patient complained of severe pain at the seat of the bruise. There was complete paralysis of sensation and of motion in the lower extremities and the trunk as high as the shoulders, and inconti- nence of faeces, retention of urine. The breathing was wholly dia- phragmatic. He was quite conscious, and gave a description of the accident. He had suffered from urethral stricture for thirty-three years, so that only a No. 5 catheter could be passed. On the following day his state was much the same. He complained of great pain in the right arm and hand, which were bruised. He said he thought he was paralysed, as he could not move his legs ; but on be- ing pressed to do so, after some difficulty he succeeded in raising both legs, and in crossing them. Sensation appeared to be completely lost. His most distressing sensation was a feeling of tightness as of a cord tied tightly round the abdomen below the umbilicus. 5th. — He had slept well, and was able to move his legs with less diffi- culty. Pulse 64 strong ; passes faeces involuntarily. Urine drawn oif, iind was ammoniacal. He was placed on a water mattress, as his back was becoming excoriated. Ordered quinine and acids. %th. — Was able to move his head and neck from side to side. Had less pain. Urine more ammoniacal : faeces passed involuntarily. Bed- sores over sacrum had much extended. lhad been irown out of a pony-chaise, which was accidentally upset. He hurt, s right knee and bruised the right arm, but sustained no blow, and lere was no evidence of injury on the head or back. He was much ■uised and shaken at the time, but did not suffer any serious ill effects ir several months after the accident, although during the whole of this jriod he felt ailing, and was in some way suffering from the injury he id sustained. About six months after the accident he began to be troubled with the llowing train of symptoms, -which had continued ever since :— Con- ision of thought ; impairment of memory ; giddiness, especially on oving the head suddenly ; failing sight ; muscre volitantes, and sparks- id flashes of light. He could not continue to read beyond a few min- ;es, partly because the letters ran into each other, partly because he^ raid not concentrate his thoughts so as to fix his attention. He now began to suffer from a feeling of numbness and a sensation : 'pins and needles ' in both hands, but more particularly in the left, id chiefly in those parts supplied by the ulnar nerve. He complained of similar sensations in the left leg and foot. He alked with difficulty, and with the legs somewhat apart, using a stick, • else supporting himself by holding on to pieces of furniture in the )om as he passed them. He could stand on the right leg, but the left le immediately gave way under him. He walked with great difficulty p and down stairs, and was obliged to put both feet on the same step. he spine was tender on pressure and percussion in the lower cervical igion and between the shoulders. The spine was stiff and he could not 3nd the back without pain, and could not stoop without falling forward. He had irritability of the bladder, passing water every second or third 3ur, and could only do so in a sitting posture. He had completely ist all sexual power and desire. The urine was slightly acid. These 'mptoms had continued with varying intensity since about six months iter the accident. He thought they were most severe about a year after ley began, and had somewhat improved since then. But he had never 3en free from them, or enjoyed a day's health, for the last seven and a a,lf years, and did not expect to do so. This case closely resembled, in all its general features, and in many : its details, those that have just been related. It only differed in the 'mptoms being less intense, as would naturally be expected, from the icident that occasioned them being less severe than those which occur om railway collisions. The persistence of the symptoms for so length- led a period as nearly eight years was significant of the tenacity and ng duration of the pernicious effects of these insidious and at first ap- irently slight injuries to the nervous system. But the prolonged duration of the most serious nervous phenoniena, om comparatively slight injuries to the spine, receives additional illus- atidn from the following case. Case 21. Injury of Spine in Infancy — Persistence of Symptoms to dult Aqe.—M.\s& "B., aged 26, was brought to my house, April 11, 44 LECTURE IV. — SLIGHT OK INDIRECT INJURY OE SPINE. When about eighteen months old, she fell out of her cot and injured her cervical spme. From that time she had suffered from a continuous and remarkable train of nervous phenomena which were aggravated about the period of puberty, and which were still further mcreased at the age of,17, m consequence of her falling over a stile baciiwards. She had never 'had hysteria in any of its ordinary forms, or paralysis, epilepsy, or convulsive attacks of any kind. On examining the spine, I found no lateral curvature and the body was well formed. There was a distinct projection backwards of the spinous processes of the fifth and sixth cervical vertebrae. She com- plained of a constant pressure and pam of a grating or grinding char- acter in this region, as if the bones were in contact with one another. . There was no evidence of abscess or of any distinct mischief m or around the tender vertebrse, and nothing was to be observed with the laryngo- scope at the anterior part of the cervical vertebraj or in the pharynx. Prom the projection of the cervical vertebrae a peculitir sense of uneasi- ness spread itself over the whole of the body and limbs, producing ner- vous sensations of the most distressing character. These sensations, which consisted of tingling and painful feelings, prevented her sitting still or lying down quietly for any length of time. She was better when in movement. She could not sleep for more than an hour or two at a time, and was conscious of her sufferings through her sleep. Her power of movement had never been impaired, the distress being confined to sensation, and not producing any disturbance of motion. She could walk well under certain circumstances, could stand, and in fact she scarcely ever sat ; but she could not turn suddenly without be- coming giddy and afraid of falling. She could walk well so long as there was anything near her. Thus she could walk along a street guided by the area railings ; but when she came to an open space, as a square or crossing, she was lost, and required to be guided or she would fall. She could not bear the sensation of having a space around her, and would fall unless supported. She had unceasing loud noises in her head, which she compared to ' gravel stones ' rolling through it. They were so loud that she fancied that other people must hear them. Her hearing was good. Her sight was strong, but she saw the circulation of the blood in her eyes, the corpuscles spinning round in convolutions, and often coloured. There was no perversion of smell or taste. The hands and feet were always cold, even in summer. She had been from first to last under the care of at least thirty medical men, and had had every variety of treatment applied — even a seton kept open in the neck and the clitoris excised ; but so far from benefiting she had slowly but steadily become worse, and her general health was, when I saw her, now beginning to give way. This lady, who was remarkably intelligent, gave a lengthened and minute history of her ailments, of which the above is a sketch. She referred all her morbid sensations to the seat of the excurvation in the cervical vertebrae. At this point there had evidently existed disease leading to organic changes to which the remarkable train of general phenomena were doubtless referrible. If I were to hazard an opinion, it would be that some thickening of the meninges of the cord had prob- ably taken place, the effect of which was to interfere with the sensory portion of the cord, rather than with the motor. Since the period referred to above this patient has married and has ' had children, but her condition of health, so far as the nervous system is concerned, continues unchanged. CASE 22. — GENERAL SHOCK — PARAPLEGIA — RECOVERY. 45 LECTUEE V. CONCUSSION OF THE SPINE FEOM GENERAL SHOOK. There is another class of cases of an extremely insidious and pro- racted character to which I wish to direct your attention, viz., those ases in which the patient has received no blow or injury upon the head r spine, but in which the whole system has received a severe shake or hock, in consequence of which an immediate lesion, probably of a aolecular character, is sustained by the spinal cord, and disease of an aflammatory character, or of a disorganising nature dependent on nodification of nutrition, is developed in it, the inflammatory action ventually creeping up to the membranes of the brain. These cases, Ithough neces;arily more frequent in railway than in other injuries, do ccasi on ally occur as a consequence of ordinary accidents. 1 will first elate a case of this kind, and then direct your attention to the details if several other instances that have fallen under my notice of similar ihenomena occurring after railway accidents. Case 22. Concussion of Spine in Hunting — No Direct Injury of 3ack — Immediate and Severe Symptoms of Meni^igeal Extravasation — ^Mebitis — Pleura- Pneumonia — Complete Recovery. — A gentleman ,bout 60 years of age, healthy, of active habits, and much given to field ports, whilst jumping a drop-fence on March 2, 1872, landed on the lommel of the saddle. He was not thrown, but felt himself violently arred. His first impression was that he had smashed the testes, and hat blood was running down his thighs. He placed his hand instinot- yely to the part, but finding no bleeding concluded that an internal iiceration had taken place. He gradually fainted away on his horse ; was aken off and carried home in a cart, a distance of about four miles. He ras found to be completely paralysed as to motion in the lower extremi- ies, and there was not the slightest power below the pelvis. When the imbs were moved he suffered intense agony in the middle of the back. :'here was a disposition on the part of the right lower extremity to be- ome abducted, to ' stray' away, and he suffered great pain when it was eplaced in the straight position. He had control over the bladder, ut not over the sphincter ani ; there was no priapism. He was placed on a water-bed, treated by dry cupping to the spine, nd had small doses of the perchloride of mercury in bark. I saw him n April 9, five weeks after the accident, in consultation with Mr. Vancis. I found that there was some improvement in his condition ; bat the pains in the limbs were less severe, and that the power over the phincter ani had been in some measure regained, though flatus still t times escaped involuntarily. The left leg and foot were weaker than tie right, and felt very cold and even numb. When out of bed he ould scarcely move, and only with great difficulty ; his legs became eeply cyanosed ; he felt faint and was obliged to lie down again. ?^hen recumbent he could move the legs somewhat. His general health 46 LECTURE V. — CONCUSSIOX EKOM GENERAL SHOCK. with gi-eat oedema of the limL. This was appropriately treated, and he made a good recovery from it. June 3 he dined downstairs, and on the ninth was able to walk to his stables, and rapidly improved in his power of locomotion. On the 29th he was seized with a severe stitch in the right side. This gradually increased until July 7, when Mr. Marriott, of Leicester, who had been called in, found effusion up to a height of four inches, attended by the most excruciating pain. The following day the left pleura became im- plicated. On July 9 I saw him in consultation with Mr. Marriott, and found him in a most precarious state. Extensive pleuritic effusion on both sides ; double pneumonia ; dusky countenance ; deep rusty-coloured sputa; pulse 130 ; temperature 101 '2° ; respiration 44. He was ordered five grains of carbonate of ammonia, and chloric ether every four hours ; two drachms of brandy every alternate four hours, and one grain of calomel with one-sixth of a grain of morphia at night. Under this, treatment he gradually improved, so that on the 14th Mr. Marriott wrote that the pleuritic effusion was subsiding ; lungs clearing up ; respiration tranquil, 18 to 20 ; pulse 100 ; temperature 99° ; sputa scarcely tinged with blood. From this time his improvement was pro- gressive. It ought to be observed that previous to his attacks of phlebitis and pleurisy he had been very sick for several days. • In September he went to Brighton in a state of much debility. He could only walk with difficulty, and with the aid of crutches or two sticks. Scarcely able to crawl, he stayed there a month ; took Turkish baths with much advantage, leaving greatly improved in motor power and general health. From this time his recovery was progressive, and the recovery so far as the paraplegia and spinal symptoms were con- cerned was complete, the patient being able to walk and ride without any sign of weakness. After much exercise he felt, however, a dull aching pain in the lumbar spine. This case is an excellent illustration of the supervention of phlebitis and pleuro-pneumonic inflammations after injury of the spine, and paraplegia, probably dependent on meningeal extravasation. There was this clinical sequence : — 1. Severe concussion of spine from below upwards. 2. Immediate paraplegia with external ecchy- mosis. 3. Thrombosis of saphena and femoral veins. 4. Acute (embolic) pleuro-pneumonia. 5. Eventual recovery. Case 23. Fall in Hunting — \o Direct Bloiu on Head or Back — Slow Development of Symptoms.- — H. B., aged 30, groom in a hunting-stable, was sent to me March 8, 1872. Always active and healthy. He stated that on Dec. 26, 1871, was thrown on soft ground whilst going fast ; had no blow on head or back, but was struck on the chest by the horse in getting up. He thought nothing of it, and went on ; felt no bad effect for two or three days ; then had ' faltering' in the legs, which felt numb and cold ; he could not walk or stand for any length of time without support, and had been obliged to use a stick ever since. On the fifth day (Dec. 31) he began to suffer in his head. Since then till the time I saw him he had had the following symptoms : viz., a con- stant ' whirl ' in liis head ; giddiness ; confusion of thought and forget- fulness of ordinary occurrences ; slight deafness in both ears, but espe- cially in the right ; feeling of numbness in both legs ; the sphincters acted normally, and there was no pain in the head or spine ; he walked with a tottering unsteady gait, and with the aid of a stick ; he moved the feet with difficulty, and there was slight impairment of sensation as well as of motion ; sight good ; pulse 72 ; bowels regular. He had been well leeched, blistered, and purged before I saw him ; hut without CASE 25. — CARRIAGE ACCIDENT^PAKALYSIS. 47 much, if any benefit. I put him on a course of the perchloride of mer- cury and quinine. March 22. — He had considerably improved in all the nervous symp- toms, but felt very weak. I ordered the perchloride of iron instead of that of mercury. April 30.— Felt stronger and better, but his head swam if he hurried lumself ; he could walk better, but was not quite safe without the stick ; he was still unable to ride, as he found his head became confused, and he complained of a loud noise like that of an engine iji it ; he had be- come very deaf, so that it was necessary to call loudly to him. This in- terfered much with his comfort and safety. Could not sleep well ; pulse 76, soft. Ordered in addition to the 'iron, the bromide of potas- sium, which he took with much benefit. Case 24. Fall in Hunting — Slow Develo^jment of Symptoms after Slight Bloiv on Bead.—W. A., aged 42, consulted m'e on Feb. 6, 1&72, by the advice of Dr. Cowan, of Glasgow. He had been a man of active habits, addicted to field sports. Stated that twelve years ago he had a heavy fall in hunting, the consequences of which he felt in the way of giddiness, confusion of thought, and general ill health for about a year. At the expiratmn of that time he recovered, and was able to resume his usual occupations at the desk and in the field. In March, 1870, nearly two years before I saw him, he had another fall, striking the head on the left side, but not materially bruising or otherwise injuring it exter- nally. He was not stunned ; he rode the whole day, went to a dinner party afterwards, next day he went to business, and to a ball in the evening; feeling no ill effects of his accident. On the fourth day he woke giddy, had double vision, pain across the forehead, confusion of thought, inability to concentrate his thoughts, &c., and was obliged to ^ive up all occupation for two months. He then returned to business, but found that he could not concentrate his thoughts or devote himself 30 closely to it as before the accident. The double vision also contin- ued for nearly a twelvemonth, when he thought he had fairly recovered. Dn resuming his former life he felt that he was not equal to it. He iiow-began to suffer from extreme nervous depression ; a sense of ex- liaustion after slight mental exertion or bodily efforts. His appetite failed him ; latterly he had been able to eat little solid food. Had be- 3ome emaciated, and lost more than a stone in weight. His pulse was feeble, and about 90. His sight was not good, but the pupils were remarkably contracted — looked like pin-hole apertures in the iris. He passed much pale urine of light specific gravity, but otherwise normal. The treatment on which he was put consisted of cod-liver oil, nux romica, &c., with carefully regulated diet and rest. This case is an instance of the slow development, after an interval of ipparent health, of a long-continued train of cerebral symptoms from a ilight but direct blow on the head. Case 25. Carriage Accident — A'o Direct Injury of Head or Spine — "ilow Development of Symptoms — Palsy and Anmsthesia in one Side — Hypermsthesia in other — Gradual Recovery. — A gentleman, aged 44, vas injured on Jan. 16, 1874, on his way to an evening party, by the )rougham in which he was driving being upset by a tram car. He was lot bruised, stunned or visibly injured. He went to the party where, hough feeling nervous and shaken, he danced till 3 a.m. He returned 48 LECTURE V. — CONOUSSIOX FROM GENERAL SHOCK. and upper dorsal spines, and the left upper extremity became suddenly hyperfesthesic. It was especially sensitive to the cold, and the applica- tion of cold water or the impact of a cold current of air caused him to feel, as he said, ' scalded by ice.' On the 20th lie lost power in the right leg, and the palsy gradually crept on, involving the left lower extremity ; the sphincters were, how- ever, not affected. He was attended by Mr. Llewellyn, Dr. Moxon, and Mr. Jabez Hogg, and was treated with large doses of iodide of potassi- um. When I saw him on Jan. 20, 1875, a year after the accident, he had in a great measure recovered. The right arm, hand, leg, and foot were, however, still partially paralysed, with some conti-action about the muscles of the shoulder and leg, so as to impair the use of the limbs. He could not write as before, could not walk up and down stairs except step by step, could not dress or undress without assistance. His busi- ness aptitude was greatly reduced. This case is remarkably interesting in several respects : 1. That the paralysis and spinal symptoms did not begin to show themselves for nearly 24 hours after the accident. 2. That there had been no blow or direct injury to the spine. 3. That the symptoms were clearly explica- ble by Brown-Sequard's experiments on semi-section of Ihe cord ; and, lastly, the contraction of some of the muscles and the absence of palsy of the sphincters, indicated that the lesion was probably meningeal, in great part at least. Case 26. Concussion of Spine iy Fall on Feet— Gradual Superven- tion of Paralysis— Death.— On Nov. 17, 1861, I saw, in consultation with Dr. Strong, of Croydon, Mrs. B., aged 32. She stated that in November, 1860, whilst going down-stairs, she accidentally stepped upon the side of a pail, and slipped forwards, bumping down three or four stairs forcibly on her heels. She did not lose her footing, did not fall, and did not strike any part of the body or head. Of this she was quite certain. She felt nervous, faint, and shaken at the time, and was obliged to take some brandy. At the period of the occurrence of the accident, and up to that time, she had been a strong, healthy, and active woman. She was married, and the mother of two children. She had never sufiEered from any disease of the nervous system, or from any serious complaint. Two days after the trifling accident that has just been described, she was attacked with neuralgic pains in the right side of the head — appar- ently hemicrania. For this she was treated in the usual way, and did not feel it necessary to lay up. About a fortnight after the accident, she felt numbness and tingling conjoined in the right arm, hand, and leg, and also on the right side of the head, where the neuralgia had pre- viously existed. The numbness after a time extended to the right half of the tongue. When I saw her three months after the accident the numbness and tingling existed unchanged in these parts, and the left hand and arm had also begun to be affected. She felt a numb sensation in the little and ring fingers, and slightly in the middle finger. Although there was this numb sensation in the hands, and in the right leg, she had no impairment of motion. She could pick up a pin, untie a knot, and otherwise use the right hand, which was the one most affected, in ordinary small occupations. She could stand and walk fairly well. I saw the patient again on April 13, four months after the accident. Notwithstanding the treatment that had been adopted (iron and strych- nine), she was weaker, looked anajmic, and was rather worse, so far as the paralytic symptoms were concerned. She could no longer pick CASE 27. — GENERAL SHOCK — PARTIAL PARALYSIS. 49 up SO small an object as a pin, bnt could pick up a piece of money — a shilling for instance. The right hand and leg were still the worst, but the left limbs were more affected than previously. In the left hand the numbness had now affected the little, ring, and middle fingers, with the tip of the forefinger. Prom this time there was a very slow increase in the symptoms, not- withstanding a great variety of treatment to which the patient liad been subjected by the many different medical men whom she had seen. On examining her, on April 10, 1866, about five and a half years after the accident, with Mr. Ayling, her present medical attendant, she told me that she felt that she was progressively, though very slowly, getting worse. She had an anxious ancemic look. She tottered in walking, so that in going about the room she supported herself by the chairs and tables. She could not in any way walk a quarter of a mile. She could stand unsupported on the left leg, but she immediately fell over if she attempted to do so on the right. The right hand and foot were much colder than the left. The paralysis of the hands continued much the same, but a marked change had taken place m the right hand in conse- quence of the contraction of all the fingers, but more especially of the little and ring fingers. They had become rigid, and the flexor tendons stood out strongly. She could, consequently, scarcely use this hand. On testing the irritability of the muscles in the opposite limbs by galvan- ism, the contraction was almost nil in those of the right arm and hand. Much stronger, though not normally strong, on the left side. She complained of confusion of thought and loss of memory ; the senses were unimpaired. Appetite was bad, and digestion imperfect. Urine was acid. She could hold her water well. March, 1868. — Since the last report her symptoms had slowly and gradually become aggravated. She was now almost helpless. There was partial paralysis of sensation and of motion in both lower extremi- ties, but much more marked in the right than in the left ; so that she could not at all support herself without a stick or holding on to furni- ture. The right hand and arm were almost numb, the fingers drawn up and clenched. She could not dress herself. She was much de- pressed in spirits, and enfeebled in mind. From this time she slowly became worse, gradually becoming more and more extensively paralysed, and at length died in August, 1871, from the I'cmote effects of this accident. In this case a very trifling accident occasioned a jar which was com- municated to the feet, and evidently transmitted to the nervous centres, leading to impairment of innervation, and eventually to progressive and incurable paralysis. Case 27. General Shock — Symptom of Concussion of Cord — Slow Recovery. — H. M. L., a surgeon, aged 43, naturally a stout healthy man, of active professional habits, consulted me on February 23, 1865. He stated that on October 9, 1864, he was in a railway collision, by which he was thrown forwards, but without any very great violence. He received no blow on the back, head, or other part of the body. He was much frightened and shaken, but did not lose consciousness. Beyond a general sensation of illness, he did not suffer much for the first three or four weeks after the accident, but he was not able to attend to his business ; could not collect his thoughts sufiiciently for 50 LECTURE V. — COXCrssiOX FROM GENERAL SHOCK. When I saw him four and a half months after the accident, he con- tinued much in the same state ; was quite unfit for business, and had been obliged to relinquish practice ; not owing to any mental incapacity, but entirely owing to his bodily infirmities. His mind was quite clear, and his senses perfect, though over-sensitive ; loud and sudden noises and bright light being particularly distressing to him. He complained chiefly of the spine. He suffered constant pain in the lower part of it, in the lower dorsal, and the lumbar regions. He com- pared the sensation there experienced to that of a wedge or plug of wood driven into the spinal canal. It was a mixed sensation of pain and dis- tension. The spine generally was tender, and the pain in it was greatly increased by manipulation, pressure, and percussion. It had lost its normal flexibility, moved as a whole, so that he could not bend for- wards or stoop. There was no pain in the cervical region, or on mov- ing the head. He complained of painful numbness and formications in the right, and occasionally down the left leg. The legs were stiff and weak, espe- cially the right one. He could not stand unsupported on this for a moment. He walked in a slow and awkward manner, straddled, and was not able to place the feet together. If told to stand on his toes, he immediately fell forwards. He had lost coatrol over the limbs, and did not know exactly where to place the feet. He had a frequent desire to pass water, suffered greatly from flatus, and had completely lost all sex- ual desire and power. The pulse was at 98 ; appetite bad ; digestion impaired. I saw this patient again, at Brighton, towards the end of April, seven months after the accident, in consultation with Mr. Curtis, and found that his condition had in no way improved. I saw him again in 1878 with Mr. Bellamy. He had tried to follow his profession, but was un- able to do so. He had partial paralysis of the musculo-spiral nerve of the right arm with atrophy of the muscles supplied by it. He had partial paraplegia. I believe this mischief to have been of a chronic iiiflammatory nature ; the tenderness of the spine, the feeling of disten- sion, the pain on movement, and the habitually high pulse, pointed in this direction. Case 28. General Shock — Symj^toms of Spinal Concussion and Meningitis — Very Slow and Imperfect Recovery. — Mr. C. W. E., aged about 50, naturally a stout, very healthy man, weighing nearly seven- teen stone, a widower, of very active habits, mentally and bodily, was in a railway collision on February 3, 1865. He was violently shaken to and fro, but received no bruise or any sign whatever of external injury. He was necessarily much alarmed at the time, but was able to proceed on his journey to London, a distance of seventy or eighty miles. On his arrival in town he felt shaken and confused, but went about some business, and did not lay up until a day or two afterwards. He was then obliged to seek medical advice, and felt himself unable to attend to his business. He slowly got worse, and more out of health. Was obliged to have change of air and scene, and gradually, but not uninter- ruptedly, continued to get worse, until I saw him on March 26, 1866, nearly fourteen months after the accident. During this long period he had been under the care of various medical men in different parts of the country, and had been most attentively and assiduously treated by Dr. Elkmgton, of Birmingham, and by several others, as Dr. Bell Fletcher, Dr. Gilchrist, Mr. Clamgee, Mr. Martin, &c. He had been most anx- ious to resume his business, which was of an important oflScial character, and had made many attempts to do so, but invariably found himself quite unfit for it, and was most reluctantly compelled to relinquish it. CASE 28. — GENERAL SHOCK— l^ARTIAL PAliALYSIS. 51 I When I saw him at this time he was in the following state : — He had lost about twenty pounds in weight, was weak, unable to ■walk a quarter of a mile, or to attend to any business. His friends and family stated iiiat he was, in all respects, ' an altered man.' His diges- tion was impaired, and his pulse was never below 96. He complained of loss of memory, so that he was often obliged to break off in the midst of a sentence, not being ^-ble to complete it, or to recollect what he had commenced saying. His thoughts were confused, and he could not concentrate his attention beyond a few minutes upon any one subject. If he attempted to read, he was obliged to lay aside the paper or book in a few minutes, as the letters became blurred and confused. If he tried to write, he often mis-spelt the commonest words ; but he had no difficulty about figures. He was troubled with horrible dreams, and waked up frightened and confused. His head was habitually hot, and often flushed. He complained of a dull confused sensation within it, and of loud noises which were constant. The hearing of the right ear was very dull. He could not hear the tick of an ordinary watch at a distance of six inches from it. The hearing of the left ear was normal ; he could hear the tick at a distance of about twenty inches. Noises, especially of a loud, sudden, of clat- tering character, distressed him greatly. He could not bear the noise of his own children at play. The vision of the left eye had been weak from childhood. That of the right, which had always been good, had become seriously impaired since the accident. He suffered from muscae volitantes, and saw a fixed line or bar, vertical in direction, across the field of vision. He com- plained also of flashes, stars, and coloured rings. Light, even of ordinary day, was especially distressing to him. In fact, the eye was so irritable that he had an abhorrence of light. He habitually sat in a darkened room, and could not bear to look at artifi- cial light — as of gas, candles, or fire. This intolerance of light gave a peculiarly frowning expression to his countenance. He knitted and de- pressed his brows in order to shade his eyes. The senses of smell and taste seemed to be somewhat perverted. He often thought that he smelled fetid odours which were not appreciable to others, and he had lost his sense of taste to a great degree. He com- plained of a degree of numbness, and of ' pins and needles 'in the left arm and leg, also of pains m the left leg, and a feeling of tightness or constriction. All these symptoms were worst on first rising in the morning. He walked with great difficulty, and seldom without the aid of a stick ; whilst going about a room he supported himself by taking hold of the articles of furniture that came in his way. He did not bring his feet together— straddled in his gait— drew the left leg slowly behind the right— moved it stiffly and kept the foot flat in walking, so that the heel caught the ground and the limb appeared to drag. He had much difficulty in going up and down stairs, could not do so without support. He could stand on the right leg, but if he attempted to do so on the left it immediately bent and gave way under him, so that he fell. The spine was tender on pressure and on percussion at these points— Tiz., at lower cervical, in middle dorsal, and in lumbar regions. The Tiain in these situations was increased on moving the body in any direc- 52 LECTURE V. — CONCUSSION FROM GENERAL SHOCK. The genito-urinary organs were not affected. The urine was acid, and the bladder neither atonic nor unduly irritable. The opinion that I gave in this case was to the effect that the pationi had suffered from concussion of the spine — that secondary inflammatory action of a chronic character had been set up in the meninges of the cord — that there was partial paralysis of the left leg, probably depend- ent on structural disease of the cord itself — and that the presence of cerebral symptoms indicated the existence of an irritability of the brain and its membranes. I saw the patient again on April 18, 1867, two and a half years after the accident. He then suffered much from pain in the head, and in the cervical spine. He was subject to fits of continual depression, was gen- erally nervous and little fitted for his ordinary business, memory was defective, and ideas unconnected. The head felt hot, face had a some- what heavy expressionless look, pulse 96 to 98, digestion bad, urine phosphatic, left leg numb, with occasional darts of pain and sensation of ' pins and needles.' It was colder than right leg. Case 29. General Shock — Concussion of Spitie — Clironic Metiingif.is — Severe Symj^tonis — Slow and Incomplete Recovery. — The following case presents some very remarkable and unusual nervous phenomena, resulting from railway shock, which I will briefly relate to you. 'March 1, 1865. — Mr. D. a man of healthy constitution and active habits, aged 33, was travelling in an "express" (third class, with divided compartment), and was seated with his back to the engine. When near Doncaster, the train going at about thirty miles an hour, ran into an engine standing on the line. He was thrown violently against the opposite side of the carriage, and then fell on the floor. 'Immediate Effects. — There was a swelling the size of an egg over the sacrum, severe pain in the lower part of the spine, which, on arriv- ing at Edinburgh the same day, had extended up the whole back and into the head, producing giddiness and dimness of sight. These, with tingling feelings in the limbs • (particularly the left), great pain in the back, and tenderness to the touch, sickness in the mornings, and lame- ness, continued for the first fortnight. ' The treatment adopted consisted of blisters and hot fomentations to the spine. ' The patient seemed to improve, and the pain between the shoulders to lessen after these applications. ' 28#A. — He was seen by an eminent surgeon, who ordered him to go about as much as possible, but to avoid cold. The result of this advice was that he found the whole of the symptoms much increased, with prostration and lameness. 'April 20th. — Left for London, breaking journey for a week in Lan- cashire, greatly fatigued by journey. A discharge came on from the urethra, the lameness was much increased, he could not advance the left leg in front of the right, and there was great prostration.' I saw him, in consultation with Mr. Hewer, May 1, 1865, when I re- ceived the above account from the patient. He was then suffering from many of the ' subjective ' phenomena which are common to persons who have incurred a serious shock to the system. But in addition to these, he presented the following somewhat peculiar and exceptional symptoms :— 1. An extreme difficulty in articulation, of the nature of a stammer or stutter of the most intense kind, so that it was extremely difficult to hold a continuous conversation with him. Although he had previously to the accident some impediment in his speech, this had been aggra- vated to the degree just mentioned, so as to constitute the most marked stutter that I have ever heard in an adult. CASE 30. — CONCUSSION — PAKTIAL PARALYSIS. 53 2. A very peculiar condition of the spine and the muscles of the back. The spine was rigid— had lost its natural flexibility to antero-posterior as well as to lateral movement. There was an extreme degree of sensibility of the skin of the back, from the nape of the neck down to the loins. This sensibility extended for about four inches on either side of the spine. It was most intense between the shoulders. This sensibility was both superficial and deep. The superficial or cutaneous sensibility was so marked, that on touching the skiu lightly or on drawing the finger down it, the patient started forwards as if he had been touched with a red-hot iron. There was also deep pain on pressure along the whole length of the spine, and on twisting or bend- ing it in any direction. Whenever the back was touched at these sensitive parts, the muscles were thrown into violent contraction so as to become rigid, and to be raised in strong relief, their outlines becoming clearly defined. 3. The patient's gait was most peculiar. He did not carry one leg before the other alternately in the ordinary manner of walking, but shuffled sideways, carrying the right leg in advance, and bringing up the left one after it by a series of short steps. He could alternate the action of the legs, but he could not bring one leg in front of the other without twisting the whole body and turning, as on a pivot, on the leg that supported him. He could not bend the thigh on the abdomen. I saw this patient several times during the summer and autumn. In the early part of December, his condition was as nearly as possible the same as that which has been described in May, no change whatever in pain or in gait having taken place. There was not at this time, nor had there ever been, any signs of paralysis, but he complained of the sensation of a tight cord round the waist. In addition to Mr. Hewer and myself, this patient was seen at differ- ent times by Sir W. Fergusson, Drs. Eeynolds and Walslie. We all agreed that the patient was suffering from ' concussion of the spine,' and that his ultimate recovery was uncertain. After the trial he was continuously under my care, and I saw him at intervals of about a month. He was treated by perfect rest, lying on a prone couch ; by warm salt-water douches to the spine, for which pur- pose he resided at Brighton, and by full doses of the bromide of potas- sium. Under this treatment he considerably improved (May, 186G). The extreme sensibility of the back was materially lessened, and he could walk much better than he did. He also stammered less vehe- mently, but he still had considerable rigidity about the spine, could only walk with the aid of a stick, and retained that peculiar careworn, anx- ious, and aged look that is so very characteristic of those who have suffered from these injuries. March 5, 1870, five years after the accident, this patient called on me. He looked pale, haggard, more than his real age. Had done no business since the trial. Still felt nervous, when put to anything how- 3ver trivial. Still felt a want of power in left leg and hand, as if asleep )r dead. Still had tenderness in lower dorsal and lumbar regions. His dealth was very variable, often he was unfit for any work. Case 30. Railway Concussion — Sloiu Development of Symptoms — Partial Paralysis — Incomplete Recovery. — E. C, aged 47, a gentleman M LECTUKE V. — CONCUSSION FROM GENERAL SHOCK. tination. At night, however, he coald not sleep, and this was the first symptom that attracted his attention. The next morning he felt stiff, and complained of creeping sensations up and down the back, and of unpleasant sensations, almost amounting to pain, in the head. By the middle of the day he was forced to recline on a couch, as he could scarcely sit up. He felt very unwell for several days. During this period he had sensations as if electric shocks were passing through the body and limbs. He returned home, continued to feel unpleasant sen- sations in his head, back, &c., being often giddy, but was still able to take a certain amount of exercise, and even to ride on horseback. He continued in this unsatisfactory state until August 12, when he became suddenly extremely giddy and scarcely able to stand. His head became very confused, he could not attend to the business on which he was engaged, and seemed to have lost all energy and power. He continued to feel the electric shocks through the body. In November he began to suffer from an increasing difficulty about the lower extremities. He was obliged to leave off riding, as he had entirely lost both his grip and the power of balancing himself. He also found that he walked with difficulty, and occasionally seemed to lose control over his legs. On November 29, when getting up in the morning, he suddenly fell, and probably momentarily lost consciousness. He lost all power in his legs and suffered intense pain in the head. As he was gradually getting worse, he came up to Loudon, when I saw him on January 6, in con- sultation with Mr. Oalthrop. At this time he was complaining of vari- ous sj'mptoms referable to the head, such as loss of memory, inability to attend to business, difficulty in grasping a subject. There was general debility, incapacity for exertion ; he was unable to ride, could scarcely walk, looked haggard and ill, and felt himself a perfect wreck. On examining the body I found the following objective signs. There was flabbiness and wasting of the muscles of both the lower extremities and of the buttocks, the skin hanging loose. The left lower extremity was more shrunken than the right. The thigh at its middle was one inch smaller in circumference ; the leg at the calf was three fourths of an inch smaller than the right. There was a considerable diminution in the temperature of the limbs, especially of the left, which was very con- siderably colder than the right and the rest of the body. The electric irritability of the muscles was very materially diminished in both lower extremities ; it was nearly lost in the left leg below the knee. In the upper extremities it was extremely active, the difference being very striking. The pulse was quick, varying from 100 to 110, and weak, the beats intermittent twice in the minute. On January 26 there was no improvement ; in fact he was in more suffering, and had lost all power in the left, leg. There was also a good deal of pain in the spine in the upper dorsal and lumbar regions, more especially on the left side. It gave him pain both to lie and to sit on the left side. He could not rise from a recumbent position without assistance from one or two persons, and could not dress without help. During this period he suffered much from pains in the head and singing in the left ear. On April 27 I again saw him in consultation with Mr. Calthrop and ISh. Buller, when these symptoms were noted as continuing without any change. This state of thmgs continued throughout the summer— the legs being cold and almost powerless, the pain in the head, the electric shocks, and inability to move remaining unaltered. On July 6 the symptoms continued without material change. He went to Yarmouth for change of air, but suffered intensely from the head, and derived no benefit. He continued uiider my observation for more than a twelvemonth, and after the ter- mination of the legal proceedings, on February 18, 1867, he went into CASE 31. — CONCUSSION — MENINGITIS — PARALYSIS.,. 55 the conntrjr. No material improvement took place in his condition for a very considerable length of time, and up to the present time there has been no recovery from the more serious symptoms. Case 31. Railioay Concussion—Injury to Cervical Spine — Meningitis — Permanejit Injiiry— Paralysis and Irritation of Spinal Accessory, Musculo- Spiral, and Circumflex Nerves. — J. M. was injured in a rail- way accident on October 29, 186G. He suffered from the usual symp- toms of spinal concussion, for which he was treated by Dr. Woodford, of Bow, with whom I saw the patient in consultation on November 30, 1867. At that time he presented three sets of symptoms of a very marked character, referable to the head, to the spine, and to the right arm. The head symptoms consisted of an inability to concentrate his thoughts, and of loss of memory on many points. In the course of con- versation he ' dropped,' to use his own word, the thread of the discus- sion. There was a complete inaptitude for business. The spine was evidently the seat of very considerable mischief. It was rigid, moved as a whole when he was told to stoop, and was extremely painful on pressure and on movement in any direction, namely, in the lower cervi- cal and in the middle and lower dorsal regions. The pain in this situa^ tion was described by the patient as being of a hot, burning character. From the seat of pain in the neck he suffered constant spasmodic pain shooting down the right arm and right side of the chest, with frequent cramps in the muscles of the arm. From the seat of pain in the dorsal region be complained of the sensation as of a cord being tightly bound round his body and pressing on his ribs. The right arm and hand had suffered considerably. There was great loss of muscular power in the limb, so that the patient was unable to hold it up in a horizontal position, or to support it extended for more than a few seconds. The grasp of this hand was much weakened, and considerably feebler than that of the left. The limb was wasted, more particularly below the elbow, where it was smaller than the left arm. The hand also was wasted, more especially about the muscles of the thumb. The patient complained of severe twitchings and spasmodic pains shooting down the fore-finger and the thumb. The attitude of the patient was very remarkable ; he stooped forwards, and the right shoulder was raised about two inches higher than the left. This position was never changed. He suffered from severe spasmodic pains through the side of the neck and shoulder, and on examining the parts, the trapezius and sterno-mastoid muscles were found extremely tense. The muscles that were chiefly wasted in the right arm were those which are supplied by the musculo-spiral nerve. These muscles had lost their electric irrita- bility. The raising of the right shoulder was evidently due to irritation of the spinal accessorv nerve, in consequence of which the trapezius was kept contracted, and 'the spasms that passed through it were due to this irritation. The conclusions arrived at in connection with this case were that at the time of the accident there had been some concussion of the brain and of the spinal cord ; that the brain Was still suffering from the consequences of that concussion, but only to a slight degree ; that the spinal cord had been severely injured ; that there was evidence of chronic inflammation and irritation of it, these changes being seated m the meninges of the cord ; that partial paralysis of the musculo-spiral nerve had already taken place ; that the wasting of the limb and arm 56 LEc;ruKE \'. — cu)Ncussion from genekal hiiock. 12, 1868. In, many respects he was then worse than when I had seen him in the previous December. He looked verj- ill ; he suffered more than previously from twitchings in the neck and right arm. I found the paralysis of the right arm was more complete than it had been. He could not move the arm from the side, and the paralysis extended to the muscles about the shoulder, to those, in fact, that were supplied by the circumflex nerve. There was an utter absence of all electric irrita- bility of the muscles supplied by the musculo-spiral and circumflex nerves. I saw him again on January 18, 1869, with Dr. "Woodford. We found that he still suffered from irritation of the brain and spinal cord, the spine continuing to be rigid and painful ; that the right shoulder was drawn up and displaced forwards ; that the right arm and hand were paralysed so as to b<^ absolutely useless for all practical pur- poses, an-i that the right leg h'.d gradually become to a great extent powerless. By order of the Court of Queen's Bench, he was seen on May 38, 1809, by Mr., now Sir James, Paget, who found that J. M. complained of constant pain in his back, extending across the shoulder and to the back of his head ; of pains passing through his chest, and of pain round the chest as if he were being compressed ; of aching down the right thigh as far as the heel. The right shoulder was always slightly raised, and he had occasionally involuntary twitchings of its muscles. The muscular power of the right shoulder and forearm was much decreased, and he was subject to frequent twitchings of the right lower limbs, which prevented his walking more than very short dis- tances, or taking any active exercise. The manner of walking was slow and feeble. During the last two years he had wasted very much, and his skin and muscles felt soft and weak. The pulse varied from 40 to 50. His bowels and lower limbs felt unnaturally cold. He said that his appetite and digestion were always bad, that he never slept well, and that his memory was impaired. On reference to these symptoms of injury which Mr. M had suffered since October 1866, it was the opinion of Sir James Paget, in which Dr. Woodford and I fully con- curred, that there was no reason to think that his sufferings on the whole were materially decreasing, and there was no doubt that they were the consequence of severe injury to the spinal cord. We were further of opinion that he would never recover health as he had had it before the injury, or be again fit for the active business in which he had been engaged. On February 15, 1871, four and a half years after the accident, J. M. wrote to say that he still suffered greatly. His arm was partially paralysed ; the thumb useless ; his spine tender, and ached on movement or after exertion of any kind ; his nights sleepless, and he was quite unfit for the ordinary business of life. There are several points worthy of observation in railway accidents. Thus it often happens that all the persons injured in any given collision present very much the same class of symptoms. In some cases all will be but shghtly shaken, and in others they are all severely concussed. This may be accounted for, to some extent at least, and in some cases, though certainly not in all, by the severity of the collision and the resulting intensity of the shock, varying in different accidents according to the rapiditv with which the train is travelling at the moment of the collision, or the force with which it is run into from behind. But par- ticular and special symptoms, not dependent on the mere severity of the shock, are sometimes observable in all who suffer in any one particular accident. Thus in some cases I have seen the head, in others the spine, in others again the general nervous system appear in all the sufferers to have sustained the greatest amount of injury. I have seen after some accidents that almost all the injured persons vomited ; in other cases MECHANISM OF KAILWAY INJUIUES. 57 this symptom has been entirely absent. In some accidents they suffer most from concussion of the brain, or general nervous shock ; in others from concussion of the spine. Those who are asleep at the time of the accident very commonly escape concussion of the nervous system. They may, of course, suffer from. direct and possibly from fatal injury to the head or trunk ; but the shock or jar, that peculiar A'ibratory thrill of the nervous system arising from the concussion of the accident, is fre- quently not observed in them, vi^hilst their more wakeful and less for- tunate fellow-travellers may have suffered severely in this respect. I have often remarked that in railway accidents those passengers suffer most seriously from concussion of the nervous system who sit with their backs turned towards the end of the train which is struck. Thus when a train runs into an obstruction on the line, those who are sitting with their backs to the engine will probably suffer most ; whilst if a train is run into from behind, those who are facing the engine will most freqviently be the greatest sufferers. The explanation of this fact ap- ■ pears to me to be as follows. When a train runs into a stationary impediment, its momentum is suddenly arrested, whilst that of the pas- sengers still continues. Those who are facing the engine are in the first instance thrown suddenly and violently forwards off their seats against the opposite side of the compartment ; hence they will frequently be found to be cut about the head and face, and more especially across the knees and legs, by coming in contact with the edge of the opposite seats. They then rebound, and in the rebound may sustain that con- cussion of the spine which they escaped in the first shock. Those, on the other hand, who are sitting with their backs to the engine, being carried backwards when the momentum of the carriage is suddenly arrested are struck at once ; and if travelling rapidly, are jerked vio- lently against the backs of their seats, and thus suffer in the first instance and by the first shock from concussion of the spine. The force with which they strike the partition between the compartments with their shoulders or loins is greatly augmented by their opposite fellow- travellers being thrown upon them. In the oscillation and to-and-fro movement to which the carriage is subjected they are apt to be thrown forwards, and, rebounding, to be struck again about the posterior part of the body. They are more helpless than those who are facing the engine, who frequently have time to stretch out their hands in order to save themselves, or to clutch hold of the sides of the carriage when in the act of being thrown forwards. When a carriage is run into from behind, the reverse of this takes place, and the carriage is driven, as it were, against those passengers who have got their backs turned towards the hind part of the train. In the violent oscillations that take place a passenger is thrown backwards and forwards by a kind of shuttlecock action, and frequently coming in contact with others on the opposite side, may become seriously injured, especially by contusions about the head. The oscillations to which the body is subjected in these accidents are chiefly felt in those parts of the vertebral column that admit of most movement, viz., at the junction of the head and neck, of the neck and shoulders, and of the trunk and pelvis. Hence it is that the spine so frequently becomes strained and injured in these regions by railway injuries. 58 LECTUKE VI. — SPRAINS, ETC., OF THE SPINE. LECTUKB VI. ON SPRAINS, TWISTS, AND WEENCHES OF THE SPINE. Speains, strains, wrenches and twists, of the spine are of very fre- quent occurrence. They may be followed by every possible kind of mischief to the vertebral column, its bones or ligaments, the cord or its membrane. The symptoms indicative of lesion of the cord or its membrane may be immediate, or they may, as in many of the cases I have already related, come on slowly and progressively. I will give you abundant illustration of both of these methods of development of symptoms. It is important to bear in mind that the vertebral column is more apt to suffer in these strains of the spine than in the other forms of inj"ury that we are discussing, and that in serious cases, as in the following, the full force of the mischief appears to be expended on the spine itself independently of its contents, which escape uninjured. Case 33. Crush of the Spinal Column from Forcible DouHing For- ward—No Permanent Injury to the Cord or its Membrane. — E. B., 26 years of age, was admitted under my care at the University College Hospital on February 8th, 1875. He stated that thirteen weeks ago, whilst working under a turn-table at a railway station, the table was accidentally turned upon him so that he was doubled forward under- neath it. He suffered intense pain in the back, and was taken to a hos- pital, where he remained for a few weeks and was then discharged. When I saw him he presented the following symptoms. He could not stand upright, but bent forwards. He walked with diflBculty and was unable to do so for more than half an hour at a time, on account of the pain that he suffered in the back, round the sides, and underneath the ribs. On examining his spine it was found that the spinous processes of the 10th and 12th dorsal vertebra projected, whilst between them there was a distinct depression. The spinous process of the 11th dorsal vertebra was broken off and twisted out of the perpendicular so as to lie directly across towards the left side. On the right of this depression the muscular and tendinous structures could be felt under the skin loose. When lying on his back in bed the patient was unable to get up without using his hands to support himself. Both the lower extremi- ties were wasted, but equally so. The sensibility of both legs was equal and appeared to be normal. The reflex irritability was also equal and normal. There had been no tinglings or other uneasy sensations in the limbs. On applying the secondary interrupted current, the muscular irritability appeared to be the same in the different groups of muscles, the extensors, the peroneals and the flexors in both legs. If there was any difference, which was doubtful, it appeared to be rather less in the extensors of the right leg, and the patient appeared not to be able to support himself quite so easily on the toes of the right foot as he could on those of the left. There was no paralysis of the sphincters, and no sen- sation as of a cord being tied round the body. This case illustrates in a remarkable manner the possibility of the existence of a fractured spine attended by displacement of bone, without any sign not only of paraly- sis, but even of meningeal irritation, and shows that the electric sensi- CASE 32. — MODE OF OCCURREIfCE OF SPKAIlSrS. 59 bility and irritability of the lower limbs may continue perfect after such a severe injury. Boyer relates a fatal case of wrench of the spine received in practising gymnastics, and Sir Astley Cooper gives an instance, to which I shall refer, of a fatal wrench of the spine from a rope catching a boy round the neck whilst swinging. In two cases which I shall relate, the injury also arose from violence applied to the cervical spine ; in one from a railway accident, in the other from a fall from a horse. These wrenches of the spine are, from obvious reasons, most liable to- occur in the more mobile parts of the vertebral column, as the neck and loins ; less frequently in the dorsal region. In railway collisions, when a person is violently and suddenly Jolted from one side of the carriage to the othei', the head is frequently forci- , bly thrown forwards and backwards, moving as it were by its own weight, the patient having momentarily lost control over the muscular structures of the neck. In such cases the patient complains of a severe straining, aching pain in the articulations between the head and the spine, and in the cervical spine itself. This pain closely resembles that felt in any joint after a severe wrench of its ligamentous structures, but is peculiarly distressing in the spine, owing to the extent to which fibrous tissue and ligament enter into the composition of the column. It is greatly increased by movement of any kind, however slight, but esiiecially by rotation. The pains are greatly increased on pressing- upon and on lifting up the head, so as to put the tissues on the stretch. In consequence of this, the patient keeps the neck and head immovable, rigid, looking straight forwards — neither turning to the right nor to- the left. He cannot raise his head ofE a pillow without the assistance- of his hand, or of that of another person. The lumbar spine is often strained in railway collisions, with or with- out similar injury to the cervical portion of the column, in consequence of the trunk being forcibly swayed backwards and forwards on the pelvis, during the oscillation of the carriage on the receipt of a powerful shock. In such cases the same kind of pain is complained of. There is the same rigidly inflexible condition of the spine, with tenderness on exter- nal pressure, and great aggravation of suffering on any movement, more particularly if the patient bends backwards. The patient is unable to stoop ; in attempting to do so, he always goes down on one of his knees. These strains of the ligamentous structures of the spinal column are not unfrequently associated with some of the most serious affections of the spinal cord that are met with in surgical practice as a remote conse- quence of its injury. They may of themselves prove most serious, or even fatal. Thus, in- Case 34, we have an instance of loosening of the cervical portion of the- spinal column to such an extent that the patient could not hold the head upright without artificial support. In Case 35 we have an example of inflammatory swelling developing around the sprained part to such an extent as to compress the cord and spinal nerves, and thus lead to paralysis. And lastly, in Sir A. Cooper's case, we have an instance of a sprain of the spine terminating in death, and a description of the post-mortem appearances presented by this accident. The prognosis will depend partly on the extent of the stretching of the muscular and ligamentous structures, partly on whether there is any inflammatory action excited in them which may extend to the interior of the spinal canal. As a general rule, where muscular, tendinous, and ligamentous struc- 60 LECTURE YI.— SPKAINS, ETC., OF THE SPINE. tures have been violently stretched, as in an ordinary sprain, however severe, they recover themselves in the course of a few weeks, or at most within three or six months. If a joint, as the shoulder or ankle, con- tinues to be weak and preternaturally mobile, in consequence of elonga- tion of the ligaments, or weakness or atrophy of the muscles, beyond this period, it will, in all probability, never again be so strong as it was before the accident. The same holds good with the spine ; and a vertebral column, which, as in Case 34, has been so weakened as to require artificial support, after a lapse of eleven months, in order to enable it to maintain the weight of the head, will not, in all probability, ever regain its normal strength and power of support. In strumous or delicate constitutions sprains or wrenches of the spine will frequently lay the foundation of serious organic disease of the bones and articular structures, leading to angular curvature of the spine, with abscess, paraplegia, and possibly ultimately a fatal result. The follow- ing case is one of many that I have seen illustrative of these facts. Case 33. Wrench of Spine in Hunting — Gradual Supervention of Angular Curvature — Paraplegia — Partial Recovery — Second Accident — Large Abscesses and Death. — C. D., aged 21, was seen by me in con- sultation with Mr. Hey, of Leeds, in April 1869. He was a slender active young man, much given to athletic exercises. One year pre- viously, in April 1868, whilst hunting, his horse suddenly went into a hole. The patient was looking round at the time, and, in order to pre- vent being thrown, made a violent effort. He felt at the time that he had given himself a severe wrench in the left side, close to the middle of the back ; but no sign of paralysis or of any injury to the nervous system was manifested. He was obliged, however, to lay up for some months, and was kept quiet by order of his medical attendants. In the course of the summer he lost the pain at the seat of injury, and grad- ually recovered his health. In the autumn he went to Whitby, where he rode, played at cricket, ran races, danced ; in fact, indulged in all those exercises and sports that were natural to his age and consonant with his disposition. He continued much in this state until Christmas 1868, when he became rather suddenly paraplegic, without pain, cramps, or any sign of meningeal or spinal irritation. He was obliged to lie by, the paraplegia of the lower limbs being complete. When I saw him at Ilkley, in consultation with Mr. Hey and Dr. Call, I found that there was complete loss of motive power in the lower extremities ; sensation also was greatly diminished, if not entirely abolished. The sphincters were not affected ; he passed his urine voluntarily ; it was acid. He could not restrain, although he could feel, the passage of his motions. There was considerable excurvation of the sixth, seventh, and eighth dorsal vertebrae, the seventh being very prominent. There was no ten- derness, however, or sign of abscess anywhere. The conclusion that we came to was, that in consequence of the wrench of the spine there was dry caries of the body of the seventh dorsal vertebra, and the cord was compressed at this situation. He was ordered small doses of the per- chloride of mercury, caustic issues or the actual cautery to the side of the spine, the prone position, and to take cod-liver oil and good diet. Un- der this treatment he gradually recovered. In May 1871 he was able to come up to London. He walked well, and was quite free from all paralytic symptoms. He was able to walk three or four miles, could stand and hop on one leg. He complained of occasional spasmodic and involuntary twitches in the legs, and of some stiffness in one knee. There was no trouble with the bladder or rectum, but the bowels were constipated, and he had loss of sexual desire and power. The excurva- CASE 34. — STRAIN — PARAI.YSIS — WKAKNESS OF NECK. 61 tion of the spine continued, but there was no tenderness on pressure or pain on moving the vertebral column. Unfortunately, he was some time afterwards thrown out of a dog-cart, in consequence of which he sustained a fresh injury to his spine ; an abscess, which I opened in April 1873, developed, and he eventually died in May of the same year, from exhaustive and irritative fever, consequent upon extensive suppu- ration. One great prospective danger in sprains of the spine is the possibility of the inflammation developed in the fibrous structures of the column extending to the meninges of the cord. This I have several times seen occur, and I believe that this happened in some of the cases I have recorded. We see that this is particularly apt to take place when the sprain or twist occurs between the occiput and the atlas or axis. In these cases a rigid tenderness is gradually developed, which is most dis- tressing and persisting and evidently of an inflammatory charactei'. Or, as in Case 31, the paralysis may remain incomplete, being confined to the nerves that are connected with that part of the spine which is the seat of the wrench, one or other of their roots either having suffered lesion, or the nerves themselves having been injured in their passage through the intervertebral foramina. Lastly, as in Sir A. Cooper's case, a twist of the spine may slowly and insidiously be followed by symptoms of complete paraplegia, and event- ually by death from extravasation of blood into the vertebral canal. Case 34. Severe Strain of C'errical Spine — Paralysis of Left Arm — Long-continued Weakness of Neck. — Miss , a lady, 28 years of age, was involved in a terrible catastrophe that occurred on June 9, 1865, when, in consequence of a bridge giving way, a portion of a train was precipitated into a shallow stream. This lady lay for two hours and a half under a mass of broken carriages and debris of the bridge, an- other lady, a fellow-passenger, who had been killed, being stretched across her. Miss was lying in such a position that she could not move. Her head was forcibly twisted to the right side, and the neck bent forwards. When extricated she was found to be a good deal cut about the head and face, and the left arm was extensively bruised, ecchymosed, and perfectly powerless. Her neck had been so violently twisted or wrenched that for a long time Miss lost completely all power of supporting the head, which she said felt loose. It used to fall on any side, as if the neck was bro- ken, usually hanging with the chin resting on the breast. Without going unnecessarily into the minute details of all the dis- tressing symptoms with which this young lady was affected, it will sufiBce to say that she gradually recovered from all her general bodily sufferings, except these conditions, viz., a weakened state of the neck, a loss of power in the left arm, and pain in the lower part of the back. The neck had been so severely twisted and sprained that the liga- mentous and muscular structures seemed to be loosened, so that in order to keep the head in position she was obliged to wear a stiff collar lest the head should fall loosely from side to side. At first it had a special tendency to fall forwards ; but after a time the tendency was in a back- ward direction. When lying on her back she had no power whatever to raise her head, and to do so was obliged to put her right hand under it so as to support it. If she wished to get up when in bed, for instance, she assumed a most distressing action, being compelled to roll over on to her face, and then, pressing the forehead against the pillow, to get upon her knees. There was no pain in the cervical spme, nor could any irregularity of 62 LECTUKE VI. — SPRAINS, ETC., OF THE SPINE. "the vertebrae be detected. There was no pain in forcibly moving the head on the atlas, or rotating this bone on the axis. The looseness ap- peared to be in the lower part of the cervical spine. The left arm at first and for many weeks afterwards was completely powerless, all sensation as well as power of motion in it having been lost. Sensation gradually and slowly returned. But the whole of the nerves of the brachial plexus appeared to be i^artially paralysed, so far .as motor influence was concerned. The circumflex, the musculo-spiral, the median and the ulnar nerves were all affected to such a degree as to ■occasion great loss of power to the muscles they respectively supplied. Thus she could not use the deltoid so as to raise the arm to the top of the head. She could not pick up a pin or even a quill between the thumb and forefinger. She could not hold a book. The power of .grasping with the left hand and fingers was infinitely less than that with the right, and there was some rigid contraction of the little and ring fingers. The muscles of the left hand and of the ball of the thumb were wasted. This crippled and partially paralysed state of the left arm was a most serious and distressing inconvenience to the patient. Before the acci- dent she had been an intrepid rider, a skilful driver, and an accom- plished musician, playing much on the harp and piano. All these pur- suits were necessarily completely put a stop to, and from being remark- able for her courage she had become so nervous that she scarcely dared to ride in a carriage. Mr. Tapson had most skilfully and assiduously attended this very dis- tressing case almost from the time of the accident, and the patient had occasionally had the advantage of Mr. Holmes Coote's advice. When I saw Miss in consultation with these gentlemen on April 20, 1866, ten and a half months after the accident, they told me that the condi- tion of the neck had certainly, though very slowly, improved, but that the state of the left arm, which was such as has just been described, had undergone no change for several months. The pain in the lower part of the back had increased during the last two months. There was no disturbance of the mind, and no sign of cerebral irritation. The bodily health generally was fairly good— as much so as could be expected under the altered circumstances of life that this accident had in so melancholy a manner entailed on this young lady. The state of the cervical spine in this case was most remarkable. It was movable at its lower part in all directions as if it were attached to a universal joint, or had a ball-and-socket articulation, the weight of the head carrying it in all directions. It was almost impossible to conceive so great a degree of mobility existing without dislocation — but there was certainly neither luxation nor fracture, the vertebrse being apparently loosened from one another in their ligamentous connections and their muscular supports, so that the weight of the head was too great for the weakened spine to carry. This loosening was niost marked in the lower cervical region, and did not exist between the atlas and the occiput. It was clearly the direct result of the violent and long-continued wrench to which this part of the spine had been subjected. The paralysis was confined to the left arm, no other part of the body haying been affected by it. At first the paralysis was complete, the arm being perfectly powerless and sensation being quite lost. After a time sensation returned, but motion was still very imperfect, and no improve^ ment had taken place in this respect for several months. As the nerves of the whole of the brachial plexus were implicated, and apparently to CASE 35. — TWIST — GENERAL PAUALYSIS — KECOVJOItY. 63 the same degree, it was difficult to account for this in any other way than by an injury inflicted upon them at their origin from the cord, or in their exit through the vertebral column. I think it most probable tliat this latter injury was the real cause of nervous weakness to the left arm, for the spine had been wrenched in the lower cervical region, in that part, in fact, which corresponds to the origin of the brachial plexus, and there was not at the time of my visit, nor did there appear to have been at any previous period, any disturbance in the functions of the spinal cord as a whole ; the paralysis being entirely and absolutely localised to the parts supplied by the left brachial plexus, implicating these only so far as motor power was concerned, and affecting no other portion of the nervous system. Case 35. Fall on Head — Twist of Cervical Hpine — Gradual Paralysis €f Whole of Body — Slmv Recovery. — The following case, which I have seen several times in consultation with Dr. Russell Reynolds, under whose immediate care the patient was, and to whom I am indebted for its early history, affords an excellent illustration of some of the effects that may result from a severe twist or wrench of the spine. Mr. G., about 23 years of age, a strong, well-formed, healthy young man, was thrown from his horse on December 12th, 1865. He fell on the back of his head, on soft ground, and rolled over. He got up im- mediately after the fall and walked to his house, a distance of about one hundred yards. He had no' cerebral disturbance whatever, being nei- ther insensible, delirious, concussed, nor sick. The head was twisted to the left side, and he felt pain in the neck. He kept his bed in conse- quence of this pain in the neck till January 1st, 1866, and his room for a week longer. At this time he tried to write, but found great diffi- culty in controlling his right arm. He managed, however, to do so, and did write a letter. He was under surgical treatment in the coun- try, and was not considered to have paralysis, as he could use his arms well for all ordinary purposes, and could walk without difBculty. Towards the end of January, nearly six weeks after the accident, symptoms of paralysis very gradually and slowly began to develop them- selves. The right arm became cold, numb, and was affected by creep- ing sensations. His right leg became weak, unequal to the support of the body, and he dragged his right foot. He came to town on February 21st, when he was seen for the first time by Dr. Reynolds, who reports that at this period the paralysis of the right arm had become complete, while that of the right foot was partial, the patient walking with a drag of the foot. His limbs gave way under him, so that he had occasionally fallen. He had no pain in any part of the body ; his mind was clear, but he was very restless. On the 27th February, whilst stooping he fell in his bedroom, strug- gled much, and was unable to rise. He was found, after a time, Ijing partly under his bed. On the following day, it was found that the 'eft side was partially paralysed, the right side continuing in the condition alreadv described. There was now considerable swelling and tenderness on the'lefb side of the neck and about the third and fourth cervical ver- tebrae. He was seen shortly after this by Sir \¥illiam Jenner, in con- sultation with Dr. Reynolds, and was ordered complete rest, with large doses of the iodide of potassium. I saw him on March 3rd, in consultation with Dr. Reynolds. I found him lying on his back in bed. The mind quite clear ; spirits good. No appearance of anxiety or distress in the countenance ; in fact I was much struck by the happy, cheerful expression of his countenance under the melancholy circumstances in which he was placed. I found his condition much as has been described. There was com- 64 LECTURE VI. — SIM^AINS, ETC., OF THE SPINE. plete paralysis of the right arm and partial. paralysis of the right leg. The left arm was also partially paralysed, and the left leg slightly so. He was unable to stand. There was no affection of the bladder or of the sphincter ani. The skin was hot and perspiring ; the pulse qnicii ; the urine acid. He could not raise his head off the pillow, and lay quite flat on his back. On being raised up in the sitting posture, it was necessary to support his head with the hands ; and when he was seated upright, he held the head firmly fixed, the spine being kept perfectly rigid. He was quite unable to turn or move the head. The back part of the neck was swollen, especially on the left side, and was tender on pressure. The swelling was less than it had been. The cervical vertebrse felt as if they were somewhat twisted, so that the head inclined towards the right side. It was doubtful whether this was really so. The patient continued the iodide of potassium, and a gutta percha case, extending from the top of his head to the pelvis, and em bracing the shoulders and back of the chest, was moulded on him, so as to keep the head and spine motionless. He was ordered to lie on his back, and not to move. I saw the patient several times with Dr. Reynolds, and we were grati- fied to find that a steady improvement was taking place. On March 37th, he had completely lost all symptoms of paralysis on the left side of the body ; the right leg had recovered its power, and the paralytic symptoms had almost entirely disappeared from the right arm. He could raise it, gi-asp with his hand, and in fact use it for the ordinary purposes of life. He could stand, though in a somewhat unsteady way. This seemed owing rather to his having kept the recumbent position for so long a time than to any loss of nervous power in the legs. The swelling of the neck had entirely subsided, and the cervical spine was straight, but it was rigid, and he could not turn the head. The support was habitually worn, and gave him great comfort. This case is remarkable in several particulars. In the first place, the fact that the paralysis did not begin to show itself until many weeks — nearly six — had elapsed from the time of the accident is a mat- ter of the greatest consequence in reference to these injuries. Then again, the fact that although the brain was throughout unaffected, and the injury purely spinal, the paralysis was of a hemiplegic and not a paraplegic character, is also not without import. And lastly, the grad- ual subsidence of the very threatening symptoms with which the patient was affected, and the disappearance of the paralysis of the limbs in the inverse order to that in which it developed itself in them, should be observed. That wrenches or twists of the spine may slowly develop paralytic symptoms, and may be attended eventually by a fatal result, is well illu3trated by a case recorded by Sir Astley Cooper as occurring in tlie practice of Mr. Heaviside. It is briefly as follows : — A lad, 13 years old, whilst swinging in a heavy wooden swing, was caught under the chin by a rope, so that his head and the whole of the cervical vertebrte were violently strained. As the rope immediately slipt off, he thought no more of it. For some months after the occurrence he felt no pain or inconvenience, but it was observed that he was less active than usual, and did not join in the games of his schoolfellows. At that time it was found that he was really weaker than before the accident. He suffered froin pains in the head and in the back of the neck, the muscles of wliich part were stiff, indurated, and very tender to external pressure. Movement of the head in any direction gave rise to pain, and there was diminution in voluntary power of motion in his limbs. CASK 36. — TWIST OF SPINE — PAKAPLEGIA, 65 Eleven months after the accident the paralytic affection of the limbs was gradually getting much worse, in addition to which he felt a most Yehement and burning pain in the small of his back. His symptoms gradually became worse, difficulty of breathing set in, and he died exactly twelve months after the accident. On examination after death the whole contents of the head were found to be perfectly healthy. There was no fracture or other sign of injury to the spine, but ' the theca vertebralis was found oveiflowing with blood which was effused between the theca and the inclosing canals of bone. The effusion extended from the first vertebra of the neck to the second vertebra of the back, both included. ' ' This case is a most valuable one. It illustrates one of the important points in that last described, viz., the very slow, gradual, and progres- sive development of paralysis in these injuries of the spine. And as it was attended by a fatal issue and the opportunity of a post-mortem examination, it also proves that this slow and progressive development of paralysis after an interval of ' some months ' may be associated with extensive and serious lesion within the spinal canal, with the effusion,, in fact, of a large quantity of blood upon the membranes of the cord, — the very condition that has already been shown (p. 69) to be the com- mon accompaniment of many fatal cases of so-called ' Concussion of the Spine.' Each of these cases of twist of the spine is typical of a special group of these injuries. In the first we have sudden and immediate paralysis of one arm produced by the wrench to which that portion of the spine that gives exit to the nerves supplying that limb had been subjected. In the second we have paralysis, resulting after an interval of some weeks, as a consequence of the pressure of the secondary inflammatory effusions that had been slowly produced by the injury to the spine and its contents, — that paralysis disappearing as these effusions were absorbed. In the third case we have an instance of death resulting in twelve months after a wrench of the spine by the effects of haemorrhage into the spinal canal. The following cases will illustrate many of the points to which I have drawn special attention in this Lecture. I saw the following case in November 1866, in the London Hospital. It illustrates well the rapid supervention of paraplegia from a twist or wrench. Case 36. Sudden Twist of Spine— Paraplegia. — J. H., aged 44, an iron founder, six weeks before, whilst standing in a constrained attitude inside the mould of a casting, and engaged in throwing out some heavy shovelfuls of sand in a way that required much twisting of the body, suddenly experienced a sensation in his back which he likened to a snap of the fingers. He did not fall down, but was able to continue his work till the evening without difficulty, although he said that about an hour after the event he was walking home, and felt a ' swimminess ' in his legs for a moment, and as if he would fall. He went to bed early in the evening, and when he tried to get up the following morning, he found he had lost all power over his legs and all sensation in them, be- ing unable to rise out of bed or to stand, which he had not been able to do since. Efeces and urine passed involuntarily and without his know- ing it. There was noAv no power of motion in either foot, reflex move- ments were also absent ; sensation was absent in both legs and in the trunk to about the level of the umbilicus. On the inner side of the sole ' Sir A. Cooper, Fractures aiul Dislocations, 8vo ed., p. 530. 66 IjECTURe \i. — sPKAiisrs, etc., of the spine. of the left foot, however, he could still feel. The left arm, he said, be- came numb if he let it remain still for any length of time. Its temper- ature was about half a degree lower than that of the right. The urine was alkaline, had a very ammoniacal odour, effervesced strongly on the addition of nitric acid, had a deposit which disappeared partly on the addition of nitric acid (phosphates) ; the part which did not dissolve having the appearance of mucus. There was no pain on pressing the hand down the vertebral column. He left the Hospital at the end of the following March. Mr. Adams kindly informed me that there was not much improvement in his paral- ysis. He was, however, just able to move his toes and feet very slightly, but was utterly nnable to stand. His water dribbled away, and his fsBces passed involuntarily, though with some irritation. The next case is a very similar one of rapid supervention of paraple- gia, after a strain of the spine in a railway accident. Case 37. Wrench of Spine from Raihoay Accident — Symptoms not immediate — Paraplegia — Phlebitis — Eventual Recovery. — Miss A. B., aged 22, a young lady of remarkable personal beauty, tall, strong, and well formed, in excellent health, who, to use her own expression, could ' ride all day and dance all night,' without feeling fatigued, met with the following accident. Whilst travelling on the London and North Western Eailway, on De- cember 26, 1865, the carriage in which she was seated came into col- lision with some obstruction on the line and was turned over. Miss was violently shaken, bruised about the knees and legs, but received no blow upon the body. She felt a sudden wrench or twist in the lower part of the spine, and according to the statement of her fellow-passen- gers, called out, ' Oh ! my back is broken ! ' She was, however, uncon- scious of the exclamation. After being extricated from the overturned carriage, she was able to walk, and sat down upon the embankment, feeling no pain, but rather stifE. In the evening she found a difficulty in moving the legs. The next morning she was unable to stand, and from that time she was j)aralysed in both lower extremities. The paralysis was almost complete so far as motion was concerned. The only motor power left consisted in moving the toes to a limited extent, and the foot or the ankle very slightly. She could not raise either limb, nor had she the slightest power of supporting herself or standing. Sensation was little if at all impaired, but there was rigidity of the mus- cles of the legs. The pelvic organs were not affected. There was severe pain on pressure and on movement, opposite tlie second and third lumbar vertebrae, especially if the body was bent back- wards. The pain extended towards the left side of the pelvis, but ex- isted nowhere else. About six weeks after the accident, the veins of the left thigh became obstructed by thrombosis, the limb swelled and became cedematous, and the general health suffered very seriously. This young lady was seen by several surgeons. The treatment that was adopted was chiefly complete rest on a couch, and alterative and tonic medicines. She continued in much the same state, with litth^ if any change in the symptoms, until October 1866, when she came nunc completely under my care than she had previously been. I now ordered her repeated blistering to the tender part of the spine, and put her on ;i course of small doses of the perchloride of mercury in bark. Undpr this plan of treatment she began to improve, so much so that she could bend the knees, draw up the legs, and move the feet more freely. In the early part of 1867, a spinal support was fitted on, so as to remove pressure from the spine and uphold the trunk. The blistering CASK 38. — WRENCH — PARALYSIS — EEC()^•EKY, 67 was continued, and iron and strychnine substituted for the other remedies. She was sent to Brighton, where for months she was confined to the recumbent position, but was taken as much as possible into the open air on a wheel couch. This treatment was continued till February 1867, when she was able to sit up, and a few months later to stand upright by leaning on to the back of a chair. From this time she slowly but pro- gressively recovered. By July 1868 she was quite well, and has remained so ever since. I give the next two cases in extenso, as taken from the Hospital Case Books. Case 38. Severe Wrench of Cervical Spine — Paralysis — Recovery. — W. H., aged 23, London, admitted into University College Hospital November 21, 1868. The patient had the same day fallen out of the front of a van, and was ' rolled up by the axle,' though the wheel did not pass over him. He did not feel much pain, but experienced a strain or twinge at the lower part of the neck behind. He was carried away quite sensible to the Hospital, not feeling pain, but numbness, extending downwards from the lower hinder part of the neck to the feet. On admission the patient was perfectly conscious. He had lost all sensation in his arms, legs, and in the trunk below the third rib. His limbs were powerless. When the patient was put in bed and his neck examined, there was great tenderness on pressure over the (?) fourth cervical vertebra ; in this situation there was unusual prominence. There was retention of the urine, and paralysis of the sphincters. Pa- tient was put on a mattress, his head on same level as his body. A catheter was passed. Wov. 22nd. — Patient can move his right leg about, also his left arm, but the right arm only slightly. Cannot clench his fist. Deficient sen- sibility in his limbs and trunk. Ordered a simple enema, which was retained. The deltoid and biceps of the right arm act, but the triceps and muscles of the forearm and hand do not. The flexors and extensors of .the arm, and the extensors of the forearm of the left side act, but the other muscles are useless. 23rd. — Sensation not yet natural, his chief pain is in his right shoul- der. When he moves his head he has pains shooting down the legs and right arm. Complains of tingling in the thumb and two outer fingers of both hands, extending towards the wrist. In the other fingers there is numbness. 2ith. — Great pain is caused if the right arm is brought forwards over the chest, and there is semi-priapism. Back of patient beginning to feel sore. A large splint was applied to the back to support his head. 25th. — Patient feels better. Total loss of voluntary power in lower extremities. Some slight reflex action on tickling the soles of his feet. Complains of hot sensations running down his right arm. The back is getting worse, and a bed-sore is forming. 26th. — Last night patient had an enema. This was retained. This morning had one ounce of castor oil. His bowels were freely opened and he felt better. No return of voluntary motion in the legs. 28fh. — Patient is able to move his legs very slightly, raises his knees a little off the bed ; right more than left. If he moves his head, the same shooting pains are still felt in the right arm. He complains most of his back. Was put on an air-bed to-day. 2dth. — Patient moves his right arm more easily. Extension is grad- ually gettiug easier. Voluntary motion has increased in left arm. 68 LECTURE VI. — SPRAINS, ETC., OF THE SPINE. SOth. — Voluntary motion has improved in the legs. He can raise the knees better ; right more than left. Sensibility has improved. Dec. 2nd. — Yesterday an enema was ordered, and not retained. Patient can now flex the hip and knees to a considerable extent. Can also move the left leg, but not to the same extent. ' Cannot pass his urine yet. The priapism is subsiding. There is pain in the lower part of th& abdomen. 4^^. — Patient has gradually regained the power of moving his legs. To-day, for the first time, his urine contained blood. 6th. — Haemorrhage from the bladder still continues, though to a less extent. Incontinence of urine is now present. 10th. — Mobility of lower extremities and arms, more especially the left, improving. Incontinence of urine still continues. Haemorrhage less. 11th. — Patient quite conscious of his water passing away from him. Other symptoms the same. 12th. — On account of the great spasm caused by the- passage of the catheter, morphia had to be injected hypodermically to relieve it, and this it did effectually. This also relieves the pain at the lower part of the abdomen. 13th. — Morphia injection still used before washing out the bladder. 17th. — Up to to-day the bladder has been washed out every other day. The urine has gradually improved ; it is of its natural colour to-day. The haemorrhage has ceased. Patient can now retain his water for a short time, a quarter to half an hour, and is beginning to regain the power of passing his mine to a slight extent. Still some incontinence. 18th. — Bladder washed out after a previous hypodermic injection of morphia. Partial control over the sphincters of the bladder and anus. No pain anywhere. 19th. — Patient can now move right leg freely. Less movement of left, for although he can adduct the thigh he cannot flex the hip. His urine has always been very fetid, alkaline, and full of mucus. 23rd. — Patient has some pain at the lower part of the abdomen. Urine the same. 24:th. — Pain in abdomen has increased. Bowels confined. Tongue furred. 26th. — Pain somewhat better in abdomen. Bowels open last night ; very constipated. This morning the urine is not so fetid. His general condition to-day is : — Partial paralysis of the right arm. The movements of this limb being slight attempt at supination ; the arm being always kept pronated on his chest, he can just raise the hand off the chest and then twist it round till it attains the perpendicular ; he cannot supinate it more than that. Any attempt to extend the arm passively or to supinate it forcibly gives him pain. The left leg is in a similar condition to the arm ; he can draw his leg and thigh up, but he cannot raise his heel off the bed. The constant irritation of the urine about the scrotum has made this red and excori- ated. The bed-sore on the back is getting better. 9 P.M. Patient has been very merry, and felt free from pain all day, but now he is in a low, depressed, semi-hysterical state, his pulse beat- ing quickly and jerking. On enquiring into the cause of this, he said that he had just been dreaming how he was placed on a board very nicely balanced on the parapet of Waterloo Bridge, and he was making CASE 39. — WRENOII — MENINGO-MYELITIS. 69 most violent efEorts to sare himself when he woke up. He says that since the accident he is very subject to these horrid dreams, which gen- erally leave him in the state he was then found. The pain at the lower part of the abdomen is worse. Bowels confined. Skin hot. Tongue dry, furred ; great thirst. Temperature 100° ; pulse 100. Slst. — Urine decidedly improving ; not so thick or fetid as it has been. Patient can hold his water better. The paralysis has not materially improved ; bed-sore nearly well. Temperature 9 p.m. 98.5 (between thigh and scrotum). Appetite very good. Jan. 7tk. — Patient has materially improved since last report ; so far as the urine is concerned, this is not fetid, or very little so. No mucus in it except when drawn ofE with a catheter, then the last drops contain a few shreds of mucus ; no blood. He can hold his water for two hours at a time. The bladder only requires to be washed out every other day, and sometimes only every fourth day. He still has the spasms when the catheter is introduced. He can raise his left heel a little (1 in.) ofE the bed. Sensation almost «qual in both legs. On the inner side of the left tibia is a small neu- roma about the size of a cherry-stone. It came on some years ago, after a cut on the leg. The tumour is just about half an inch above the cicatrix of the wound. It is somewhat tender on pressure, not painful otherwise. He can move his head about without pain. There is no tenderness over the seat of injury in the neck. His general appearance has undergone a change for the better, he looks more cheerful, and is getting stronger and stouter. Feb. 13ih. — Patient can now move his legs about quite freely, and when he extends the knees forcibly I cannot bend them ; the same with the ankle. There is therefore very marked improvement so far. He uses his arms quite freely, the right is still weaker than the left. Sensibility restored over whole body. Reflex action perfect in both legs. The bladder has very much improved, although not so much as the legs. He can now hold his water for several hours. Catheterism is no longer required, and the urine is perfectly normal. He can sit up in bed without support, but does not get out of bed yet. His bed-sore is quite well. Appetite good ; bowels regular ; tongue clean. •March 3rd. — Patient allowed to get up for the first time to-day, still wearing the apparatus. He can now walk with assistance ; can move his head and neck freely. Sensation is complete. Motion and power in the arms perfect. No pain or other abnormal sensations. Urine normal. Micturition still somewhat frequent. Some phosphatic deposits having formed in the bladder, these were removed by the dissolvents, to the great comfort and advantage of the patient. From this time he gradually but slowly improved. He was made an out-patient, and continued to attend the Hospital for the next three or four years, very slowly mending. When suffering from a relapse, he always came to ask for a bottle of the perchloride of mercury. When I last saw him, about a year ago and five years from the time of the acci- dent, he was fairly well ; able to do light work, and walk moderately ; hut he suffered from headaches and weakness of the limbs. Case 39. Wrench of Spine— Belief— Relapse — Incuralle Meningo- Myelitis.—J. H., aged 28, shipwright at Sheerness, admitted into Uni- versity College Hospital May 4, 1867. Patient was a tall, well-built 70 LECTURE VI. — SPRAINS, ETC., OF THE SPINE. man, somewhat worn-looking and emaciated, but not greatly so. He stated that he was stout and very well before the accident. On April 15, patient, with three other men, was carrying a beam (30 ft. long by 9 in. square). The two men at the farther end let it fall suddenly, so that H. and his mate had to support most of its weight, and received a violent Jar, but no blow. Being the taller of the two men, he received most of the shock. He felt faint at the time but did not fall. He walked home at once (about a quarter of a mile). Soon after he got home he felt severe pain in the lower dorsal region and all round the upper part of the abdomen. It hurt him to breathe. At the back of his head he had a severe stabbing pain. For four days he had retention of urine (which was very thick), and he passed, for a few days, occasional clots of blood in his stools. Two days after the accident he had a numb feeling in his legs below the knees, and a feeling of coldness in the calves, but he had always been able to move his legs. States that his urine and motions used to escape involuntarily. The treatment had been expectant. Liniments and rest, no cup- ping or blisters. On admission patient stated that he suffered from giddiness, and had shooting pains up the back to the occiput. He could not see so well as previously; on reading, the letters 'jumped about,' and specks, black and white, always floated before his eyes. Hearing and speech un- affected. On examination the spine was found to be exceedingly tender on pressure, from the ninth dorsal vertebra to the end of the sacrum. Pressing the spine occasioned a spasmodic movement of the abdominal muscles and legs. There was also some tenderness at the fourth dorsal vertebra, and pain round the thorax at that level. Sensation in the legs below the knees was greatly impaired. Lying in bed, he was able to raise the right foot slightly, but had no power over the left. Could just manage to walk, but in a hobbling manner. He had now slightly defective power over the sphincters. Urine was now healthy. Bowels acted very irregularly. Slept badly, but did not dream much. May 1th. — Patient complains to-day of cramps in the calves of his legs, which he has not had before. Can stand on one leg, but for a few minutes only. Bowels now open. Sleeps fairly. Appetite tolerable. ^th. — I saw him and ordered one grain of calomel with half a grain of opium every six hours, dry cupping to the spine, to be followed by fomentations. 9th. — He has been greatly relieved by the dry cupping. Bowels open. He still complains of great tenderness down the spine on pressure. 15th. — Patient continues to improve. The dry cupping has been repeated. Power over bladder, and sensation and motion in the legs improves. 11th. — Mouth rather sore. Pills to be taken less frequently. Blis- ters to be applied every four or five days down the sjiine. IWi. — Much better. Sensation and motion in the legs much in- creased. 37(!A. — Much improved. Sensation in the legs now normal. Can raise them both from the bed with case. Pain in the back nearly gone. Blistering continued. 30<7i. — Seems almost well. Has no pain whatever in the back, and touching the back causes no spasm. H:is complete power over the blad- der and the rectvxm, and can walk steadily, and stand on one leg, though rather shakily on the left. He only complains of ' fluttering sensations in the inside.' EFFECTS OF STRAINS. 71 June 4th. — Continues to improve. Gets up every day. He now com- plains of the light, and says he has a headache, and a tender spot in the loins. To keep in bed. 8ih. — States that he feels all right again. Headache gone, and also the tender place. To get up again. 17fJi. — Going on perfectly well. No change since last report. Discharged convalescent. March 23, 1868. — Patient presented himself again -to-day. Since leaving the Hospital he thinks he has been getting gradually worse. In October last he tried to work, but was so much worse in consequence that he had to go into St. Bartholomew's Hospital, Chatham, where he remained for three weeks. Since then he has been getting worse. Complains of numbness in his legs. Sensation perfect in both legs above the knee, defective below ; firm pressure being felt, but not slight pressure. Cannot recognise which toe is pinched, but thinks that when the great tpe is pressed it is the second one. He can walk about half a mile ; then his legs tremble and he can walk no further. He complains of constant pains in the head (occipital region), and also severe occasional pains in the groins, the pain shooting round from the spine. His urine is ' muddy ' when it passes. He cannot hold it longer than two hours. Bowels obstinately confined. Sight worse of late. There is a constant dimness before him, and when he reads the ' lines run into one another.' His hearing, he says, is gradually getting worse. He describes his mind as in a state of ' constant confusion. ' Memory very bad. Sleeps badly at night, and is always dreaming. Pulse 96, feeble. Appetite bad. Tongue coated with a white fur. Ordered to take small doses of perchloride of mercury in decoction of bark, and to have complete rest. The patient continued for some length of time in the Hospital, but deriving no material benefit was discharged as incurable. Case 40. Strain of Back — Slowly Progressive Symptoms — Gradual Development of Oerelral Symptoms. — D. S., aged 54, consulted me No- vember 7, 1871. He stated that three years before, whilst lifting a heavy box, he felt that he had strained his back across the loins. He was seized with pain in this region and a sense of weakness, so that he was obliged to put down the box at once. Prom that time he was never well ; he had become weak, unable to walk as he did before, and without being able to define any precise ailment, stated that he had not felt as he did before the injury. He had become thinner, especially in the legs, and always felt a weakness and a pain across the back. About four months before I saw him he first began to complain of head symptoms. The following are the notes taken of his condition when he came to me : — He is generally weak. He complains of pain across the forehead, sleeps badly, dreams much. He cannot employ his mind in business matters or reading, as he did before the accident. His sight has become impaired, and he has a benumbed and tingling feel in the legs. The head is hot ; appetite bad ; pulse quick and feeble. On examining the spine, considerable tenderness on pressure was found over the second lumbar vertebra, with pain in moving the body to and fro, or laterally. This case presents an instance of the gradual development of cere- bral symptoms, two and a half years after an indirect injury to the lumbar spine. Doubtless owing to the extension upwards of meningeal irritation. Case 41. Strain of Bach in Wrestling— Slowhi Progressive Symptom.s ^Spinal Anmmia.—A. B., aged 27, January 14, 1875. In May 1870, 72 LECTURE VII. — MODE OF OCCURRENCE OF SHOCK. whilst wrestling, strained his back ; did not suffer much at the time, but on following night had much twitching in the legs and arms. Was incapacitated for any work for almost a year ; during the greater part of this time was unable to walk any distance round the garden, or half a mile at most. Scarcely got better, but to a certain extent was able to enter upon practice as a medical man, but not to do any very hard work. But latterly had been getting weaker and suffered more from fatigue. He now complained of dulness of head, at times confusion of thought. Pains at back of head on reading. Sleeps heavily ; dreams much. Sensation affected. Feels extreme weakness in the spine and legs ; not a sense of pain, but one of exhaustion down spine. No pain except feeling of uneasiness over seventh cervical vertebra. Sexually weak, no desire or power. No affection of sphincters ; cold extremi- ties ; looks old and worn. Treatment consisted of iron and quinine, with the continuous current to the spine and cold douches to the back. Case 43. Strain of Lumbar Spine in a man previously injured iy fall from horse — Long Persistence of Symptoms. — T. T., aged 38, was sent to me by Mr. Hooker, of Tunbridge, on May T, 1869. Two and a half years previously he had been thrown from his horse and dragged some distance, the lower part of the back being much bruised by the acci- dent. He was laid up for about a fortnight, and lost power in the right leg. There was at no time any affection of the sphincters. He gradually improved up to a certain point, where he remained stationary. He complained of weakness in the back, of numbness and darting pains in the right leg, and especially of cold. He also experienced a clutching sensation in his back, in consequence of which he had not been able to ride since the accident. Last December, whilst lifting a heavy weight, he felt that he had strained his back, suddenly dropped and fell to the ground, owing to his legs giving way under him. Both the lower extremities became numb, and he suffered very severe pains, * fearful pains,' through them. He was obliged to lie on the floor of the dining room for five days, not being able to move, owing to the excessive pain which was induced on any attempt to raise him. He gradually but very slowly improved until he was able to get about on crutches. There still remains considerable tenderness in the lumbar region, from the third to the fifth lumbar vertebras inclusive, and pain in the right gluteal region. This series of cases will illustrate more forcibly than any description of mine the ill effects and manifold evils that may result to the spine, the membranes, and the cord from sprains, wrenches, or twists of the vertebral column. LECTURE YIL ON THE MODE OF OCCURRENCE OF SHOCK, AND ON THE P.4.TH0- LOGT OF CONCUSSION OF THE SPINE. PAllT I. ON THE MODE OF OCCUKRENCE OP SHOCK. One of the most remarkable circumstances connected with inju- ries of the spine is, the disproportion that exists between the ap- parently trifling accident that the patient has sustained, and the PlilMAKY CHANGES UNKNOWN. 73 real and serious mischief that has in reality occurred, and which will eventually lead to the gravest consequence. Not only do symp- toms of concussion of the sjoine of the most serious, progressive, and persistent character, often develop themselves after what are iipparently slight injuries, but frequently when there is no sign whatever of external injury. This is well exemplified in Case 26, the patient having been partially paralysed simply by slipping down a few stairs on her heels. The shake or jar that is inflicted on the spine wlien a person jumping from a height of a few feet comes to the ground suddenly and heavily on his heels, or in a sitting posture, has been well known to surgeons as not an uncommon cause of spinal weakness and debility. It is the same in railway accidents ; the shock to which the patient is subjected being followed by a train of slowly-progressive symptoms indicative of concussion and subsequent irritation and inflam- mation of the cord and its membranes. It is not only true that the spinal cord may be indirectly injured in this way, and that sudden shocks applied to the body are liable to be followed by the train of evil consequences that we are now discussing, but I may even go farther, and say that these symptoms of spinal con- cussion seldom occur when a serious injury has been inflicted on one of the limbs, unless the spine itself has at the same time been severely and directly struck. A person who by any of the accidents of civil life meets with an injury by which one of the limbs is fractured or is dislocated, necessarily sustains a very severe shock, but it is a very rare thing indeed to find that the spinal cord or the brain has been in- juriously influenced by this shock that has been impressed on the body. It would appear as if the violence of the shock expended itself in the production of the fracture or the dislocation, and that a jar of the more delicate nervous structures is thus avoided. I may give a familiar illustration of this from a,n injury to a watch by falling on the ground. A watchmaker once told me that if the glass was broken, the works were rarely damaged ; if the glass escapes unbroken, the jar of the fall will usually be found to have stopped the movement. How these jars, shakes, shocks, or concussions of the spinal cord directly influence its action I cannot say with certainty. We do not know how it is that when a magnet is struck a heavy blow with a hammer, the magnetic force is jarred, shaken, or concussed out of the horse-shoe. But we know that it is so, and that the iron has lost its magnetic power. So, if the spine is badly jarred, shaken, or con- cussed by a blow or shock of any kind communicated to the body, we find that the nervous force is to a certain extent shaken out of the man, and that he has in some way lost nerve-power. What immediate change, if any, has taken place in the nervous structure to occasion this effect, we no more know than what change happens to a magnet when struck. But we know that a change has taken place in the ac- tion of the nervous system just as we know that a change has taken place in the action of the iron by the loss of its magnetic force. But whatever may be the nature of the primary change that is pro- duced in the spinal cord by a concussion, the secondary effects are clearly of an inflammatory character, and are indentical with those phenomena that have been described by Ollivier, Abercrombie, and others, as dependent on chronic meningitis of the cord, and sub- acute myelitis. One of the most remarkable phenomena attendant upon this class of cases is, that at the time of the occurrence of the injury the suffer- er is usually quite unconscious that any serious accident has happened to him. B.e feels that he has been Violently jolted and shaken, he 74 LECTURE VII. — JIODE OF OCCURRENCE OF SHOCK. is perhaps somewhat giddy and confused, but he finds no bones broken, merely some superficial bruises or cuts on the head or legs, perhaps even no evidence whatever of external injury. He congrat- ulates himself upon his escape from the imminent peril to which he has been exposed. He becomes unusually calm and self-possessed ; assists his less-fortunate fellow-sufferers, occupies himself perhaps actively in this way for several hours, and then proceeds on his Journey. When he reaches his home, the effects of the injury that he has sustained begin to manifest themselves. A revulsion of feeling takes place. He bursts into tears, becomes unusually talkative, and is excited. He cannot sleep, or, if he does, he wakes up suddenly with a vague sense of alarm. The next day he complains of feel- ing shaken or bruised all over, as if he had been beaten, or had violently strained himself by exertion of an unusual kind. This stiff and strained feeling chiefly affects the muscles of the neck and loins, sometimes extending to those of the shoulders and thighs. After a time, which varies much in different cases, from a day or two to a week or more, he finds that he is unfit for exertion and unable to attend to business. He now lays up, and perhaps for the first time seeks surgical assistance. This is a general sketch of the early history of most of these cases of ' Concussion of the Spine' from railway accidents. The details neces- sarily vary much in different cases. There is great variation in the period at which the more serious, per- sistent, and positive symptoms of spinal lesion begin to develop them- selves. In some cases they do so immediately after the occurrence of the injury, in others not until several weeks, I might perhaps even say months, had elapsed. But during the whole of this interval, whether it be of short or of long duration, it will be observed that the sufferer's condition, mentally and bodily, has undergone a change. This is a point on which I would particularly insist. He never completely gets over the effects of the accident. There may be improvement ; there is not recovery. There is a continuous chain of broken or ill health, be- tween the time of the occurrence of the accident and the development of the more serious symptoms. It is this that enables the surgeon to connect the two in the relation of cause and effect. This is not pecul- iar to railway injuries, but it occurs in all cases of progressive paralysis after spinal concussion, and may be noted in the histories of many that have been given in these lectures. The friends remark, and the patient feels, that ' he is not the man he was.' He has lost bodily energy, men- tal capacity, business aptitude. He looks ill and worn ; often becomes irritable and easily fatigued. He still believes that he has sustained no serious or permanent hurt, tries to return to his business, finds that he cannot apply himself to it, takes rest, seeks change of air and scene, un- dergoes medical treatment of various kinds, but finds all of no avail. His symptoms become progressively more and more confirmed, and at last he resigns himself to the conviction that he has sustained a more serious bodily injury than he had at first believed, and one that has, in some way or other, broken down his nervous power, and has wrought the change of converting a man of mental energy and of active business habits into a valetudinarian, a hypochondriac or a hysterical paralytic, utterly unable to attend to the ordinary duties of life. The condition in which a patient will be at this or a later period of his sufferings, will be found detailed in several of the cases that have been related. It may, however, throw additional light on this subject, if we analyse STATE OF THE VISION. 75' the symptoms, and arrange them in the order in which they will present themselves on making a surgical examination of such a patient ; bearing this important fact in mind, however, that although all and everyone of these symptoms may present themselves in any given case, yet that they are by no means all necessarily present in any one case. Indeed this usually happens, and we generally find that whilst some symptoms assume great prominence, others are proportionally dwarfed, or, indeed, completely absent. In these as in so many other cases, whether surgical or medical, it is well not to lay too much stress on the presence or absence of any one particular symptom, hni, we should take all the symptoms that present themselves in one group. The countenance is usually pallid, lined, and has a peculiarly care- worn, anxious expression ; the patient generally looking much older than he really is or than he did before the accident. Occasionally there is flushing of the cheek and ear or of the forehead, accompanied by a sensation of great heat. The memory is defective. This defect of memory shows itself in various ways ; thus, Case 2 said that he coiild not recollect a message- unless he wrote it down ; Case 10 forgot some common words and mis- spelt others ; Case 18 lost command over figures, he could not add up a few figui-es, and had also lost, in a great degree, the faculty of Judging of weight, and of distance in a lateral direction ; he forgot dates, the ages of his children, &c. The thoitqhts are confused. The patient will sometimes, as in Case 28, break off in the middle of a sentence, unable to finish it ; he cannot concentrate his ideas so as to carry on a connected line of argument ; he attempts to read, but is obliged to lay aside the book or paper after a few minutes, not from weakness of sight, but from confusion of thought and inability to maintain a continuous mental strain. All business aptitude is lost, partly as a consequence of impairment of memory, partly of confusion of thought and inability to concentrate ideas for a sufficient length of time. The will becomes enfeebled ; the- power of decision is lost; the mind becomes vacillating, and impotent of will. The temper is often changed for the worse, the patient becoming fretful, irritable, and in some way— difficult perhaps to define, but easily appreciated by those around him— altered in character. The sleep is disturbed, restless, and broken. He wakes up m sudden, alarm ; dreams much ; the dreams are distressing and horrible. The head is usually of its natural temperature, but sometimes hot. The patient complains of various uneasy sensations in it; of pam, tension, weight, or throbbing; of giddiness ; or of a confused or con- strained feelino-. Frequently loud and incessant noises, described as roaring, rushing, ringing, singing, sawing, rumbling, or thundering are experienced. These noises vary in intensity at different periods of the day, but if once they occur, are never entirely absent, and are a source of great distress and disquietude to the patient. The organs of sj^ecial sense usually become more or less seriously affected They' may be over sensitive and irritable, blunted m their perceptions, or perverted in their sensations In many cases we find a combination of all these conditions in the same organ. Vision The impairment of vision is so important in concussion o± the spine that I shall devote a special lecture to it to which I must refer vou for details. It suffices now to give a brief sketch of the troubles connected with it in these cases of railway shock In some cases, though rarely, there is double vision and perhaps slight strabis- mus In others an alteration in the focal length, so that the patient 76 LECTURE VII. — MODE OF OCCUREENCE OF SHOCK. has to begin the use of glasses, or to change those he has previously worn. The patient suffers from asthenopia, he cannot read for more than a few minutes, the letters running into one another. More com- monly, muscae volitantes and spectra, rings, stars, flashes, sparks — white, coloured, or flame-like are complained of. The eyes often become over sensitive to light, so that the patient habitually sits in a shaded or darkened room, turns his back to the window, and cannot bear unshaded gas or lamplight. This intolerance of light may amount to positive photophobia. It gives rise to a habitually contracted state of the brows, so as to exclude light as much as possible from the eyes. One or both eyes may be thus affected. Sometimes one eye only is intolerant of light. This intolerance of light may be associated with dimness and imperfection of sight. Perhaps vision is normal in one eye, but impaired seriously in the other. The circulation at the back of the eye is visible to some patients, when they look uj) at a clear sky or on a white paper. Irregularity of the pupils is sometimes noticed, one being dilated, the other normal or contracted. The hearing may be variously affected. Not only does the patient commonly complain of the noises in the head and ears that hare already been described, but the ears, like the eyes, may be over sensitive or too dull. One ear is frequently over sensitive whilst the other is less acute than it was before the accident. The relative sensibility of the ears may readily be measured by the distance at which the tick of a watch may be heard. Loud and sudden noises are particularly distressing to these patients. The fall of a tray, the rattle of a carriage, the noise of children at play, are all sources of pain and of irritation. Deafness occasionally comes on in the course of the case ; but it is not an early symptom. If the deafness is owing to injury inflicted on the auditory nerve or on the brain, the patient will not be able to hear on the affected side the vibrations of a tuning fork when the instrument is applied to the forehead. But if the defect be dependent on obstructive disease or of injury of the external or middle ear, the nervous apparatus being perfect, the vibrations transmitted throughout the bones of the skull will not only be audible in'the affected ear, but being retained there, and prevented passing outwards, are actually heard more loudly in it than in the sound one. Taste and smell are much less frequently affected than sight or hearing ; but they may be perverted or lost. The sense of smell is more frequently affected than that of taste. It may be perverted so that the patient thinks he is always smelling a fetid odour. It is always disagreeably, never pleasantly perverted. When once lost, it is never recovered. I have never known the sense of taste to be lost ; that is to say, I have never known a patient who could not distinguish between salt and sugar ; but owing to the frequent impairment or loss of the sense of smell, the perception or taste of flavours is often lost, in the perception of which the sense of smell plays as important a part as that of taste. The sense of touch is impaired. ThcRpatient cannot pick up a pin, cannot button his dress, cannot feel the difference between different textures, as cloth and velvet. He loses the sense of tueight, cannot tell whether a sovereign or a shilling is balanced on his finger. Speech is rarely affected. Case 29 stammered somewhat before the accident, but after it his speech became a most painful and indescriba- bly confused stutter that it was almost impossible to comprehend. The same phenomenon was observed in the Count de Lordat's case, p. 5. But it is certainly rare. The attitude of these patients is usually peculiar. It is stiff and un- CONDITION OF THE SPINE. 77 bending. They hold themselves yery erect, usually walk straight for- wards, a;s if afraid or unable to turn to either side. The movements of the head or trunk, or both, do not possess their natural freedom. There may be pain or difficulty in moving the head in the antero-posterior direction, or in rotating it, or all movements may be attended by so much pam and difficulty that the patient is afraid to attempt them, and hence he keeps the head in its attitude of immobility. The movements of the trunk are often equally restrained, especially in the lumbar region. Bending forwards, backwards, or sideways, is painful, difficult, and may be impossible ; bending backwards is usually most complained of. ' If the patient is asked to stoop and pick up anything off the ground, he will not be able to do so in the usual way, but goes down on the knee and so reaches the ground. If he is laid horizontally and told to raise himself up without the use of his hands, he will be unable to do so. The state of the spine will be found to be the real cause of all these symptoms. On examining it by pressure, by percussion, or by the application of the hot sponge, it will be found that it is painful, and that its sensibility is exalted at one, two, or three points. These are usually in the upper or lower cervical, the middle dorsal, and the lumbar regions. The vertebrae that are affected vary necessarily in different cases, but the exalted sensibility always includes two, and usually three, at each of these points. It is on account of the pain occasioned by any move- ment of the trunk by way of flexion or rotation, that the spine loses its natural suppleness, and that the vertebral column moves as a whole, as if cut out of one solid piece, instead of with the flexibility that its various component parts naturally gives to all its movements. The movements of the head upon the upper cervical vertebrae are variously affected. In some cases the head moves freely in all directions, without pain or stiffness, these conditions existing in the lower and middle, rather than in the upper cervical vertebrae. In other cases, again, the greatest agony is induced if the surgeon takes the head between his hands and bends it forwards or rotates it, the articulations between the occipital bone, the atlas, and the axis being evidently in a state of inflammatory irritation. This happened in a very marked manner in Cases 18 and 19 ; and in both these it is interesting to observe that distinct evidences of cerebral irritation had been super- added to those of the more ordinary spinal mischief. The pain is usually confined to the vertebral column, and does not extend beyond the transverse processes. But in some instances, as in Case 2, tlie pain extended widely over the back on both sides, more on the left than on the right, and seemed to correspond with the distribution of the posterior branches of the dorsal nerves. In these cases, owing to the musculo-cutaneous distribution of these nerves, the pain is superficial and cutaneous as well as deeply-seated in the spine. The muscles of the back are usually unaffected, but in some cases where the muscular branches of the dorsal nerves are affected, as in Case 19, they may be found to be very irritable and spasmodically con- tracted, so that their outlines are very distinct and marked. The gait of the patient is remarkable and characteristic. He walks more or less unsteadily, very like a person who is partially inebriated, or like one suffering from locomotor ataxy ; generally he uses a stick, or if deprived of that, he is apt to lay his hand on any article of furniture that is near him, with the view of steadying himself. 78 LECTURE VII. — MODE OF OCCURRENCE OF SHOCK. He keeps his feet somewhat apart, so as to increase the basis of sup- port, and consequently walks in a straddling manner. One leg is often weaker than the other, the left more frequently than the right. Hence he totters somewhat, raises the weak foot but rslightly off the ground, so that the heel is apt to touch. He often drags the toe, or, walking ilat-footed, drags the heel. This peculiar strad- dling, tottering, unsteady gait, with the rigid spine, the erect head, while the patient looks straight forward, gives him the aspect of a ■man who walks blindfolded. The patient cannot generally stand equally well on either foot. One leg, usually the left, immediately gives way under him if he attempts to stand on it. He often cannot raise himself on his toes, or stand on them, with- out immediately tottering forwards. His power of walking is always very limited ; it seldom exceeds half a mile or a mile at the utmost. He cannot ride, even if much in the habit of doing so before the accident'. He loses both grip and balance. There is usually considerable difficulty in going up and down stairs — more difficulty in going down than up. The patient is obliged to support himself by holding on to the balusters, and often brings both feet together on the same step. A sensation as of a cord tied round the waist, with ocasional spasm of the diaphragm, giving rise to a catch in the breathing, or hiccup, is sometimes met with, and is very distressing when it does occur. The motor power and sensation will be found to be variously modified, and will generally be so to very diiferent degrees in the different limbs. I have fully described the various modifications of motjon and sensation in cases of dii-ect spinal injury in lecture II., and would refer to this ac- count, which will be found closely to resemble the phenomena that result from nervous shock in railway collisions. Sometimes one limb only is affected, at others the arm and leg on one side, or both legs only, or the arm and both legs, or all four limbs, are the seat of uneasy sensations. There is the greatest possible variety in these re- spects, dependent of course entirely upon the degree and extent of the lesion that has been inflicted upon or induced in the spinal cord. Sensation only may be affected, or it may be normal, and motion may be impaired ; or both may be affected to an equal, or one to a greater and the other to a less, degree. And these conditions may happen in one or more limbs. Thus sensation and motion may be seriously im- paired in one limb, or sensation in one and motion in another. The paralysis is seldom complete. It may become so in the morBjadvanced stages after a lapse of several years, but for the first year or' two it is (except in cases of direct and severe violence) almost always partial. It is sometimes incompletely recovered from, especially so far as sensation is concerned. The loss of motor power is usually greater, and, as a rule, is always more apparent than that of sensation. 'In many cases sensation un- doubtedly continues perfect, whilst the motor power is seriously im- paired. In other cases, agai n, motion appears to be more seriously affected than sensation, simply because it is so much easier to test and to appre- ciate the full extent of the loss of motor than of sensory power. The loss of motor power is especially marked in the legs, and more in the extensor than in the flexor muscles. The extensor of the great toe is especially apt to suffer. The hand and arm are less frequently the seats of loss of motor power than the leg and foot ; but the muscle of the ball of the thumb, or the flexors of the fingers, may be so affected. CHANGES IN SENSATION. 79 It will be found that these symptoms of paraplegia are much more marked when the patient stands up than when he lies down. In this respect, indeed, the form of partial paralysis that we are now consider- ing resembles those forms of the disease that arise from other causes than injury. A patient who can scarely stand, and who walks with a feeble, tottering, jerking gait, will, when he lies down, readily move his limbs in any direction, and exercise a considerable amount of power either in flexion or extension. Whether this is due, as Matthew Baillie supposed, to the increased pressure of the cord by the spinal fluid, or to the greater venous congestion of the lower portion whilst the patient is standing than when he is lying down, may be matter of speculation, but the fact is certain that in all cases of incipient and partial pai-aple- gm, the symptoms are most marked when the patient stands, and sub- side to a great extent when he lies down. The loss of motor power in the foot and leg is best tested by the ap- plication of the galvanic current, so as to compare the irritability of the same muscles of the opposite limbs. The value of the electric test is, that it is not under the influence of the patient's will, and that a very true estimate can thus be made of the loss of contractility in any given set of muscles. The loss of motor power in the hand is best tested by the force of the patient's grasp. This may be roughly estimated by telling him to squeeze the surgeon's fingers, first with one hand and then the other, or more accurately by means of the dynamometer, which shows on the index the precise amount of pressure that a person exercises in grasping. It is in consequence of the diminution of motor power in the legs that those peculiarities of gait which have just been described are met with, and they are most marked when the amount of loss is unequal in the two limbs, as the paraplegia is partial. The sphincters are very rarely affected in the cases now under consideration. Sometimes there is increased frequency of micturition, but I have rarely met with reten- tion of urine or with cases requiring the continued use of the catheter ; nor have I observed in any case that the contractility of the sphincter ani had been so far impaired as to lead to involuntary escape of flatus or fasces. Modification or diminution of sensation in the limbs is one of the most marked phenomena in these cases. In many instances the sensibility is a good deal augmented, espe- cially in the earlier stages. The patient complains of shooting pains down the limbs, like stabs, darts, or electi-ical shocks. The surface of the skin is sometimes over-sensitive in places in the back (as in Case 19), or in various parts of the limbs, hot, burning sensations are ex- perienced in it. After a time these sensations give place to various others, which are very differently described by patients. Tinglings, a feeling of 'pins and needles,' a heavy sensation, as if the limb was asleep, creeping sensations down the back and along the nerves, and formications, are all commonly complained of. These sensations are often confined to one nerve in a limb, as the ulnar for instance, or the musculo-spiral. The existence of numbness does not necessarily imply the loss of the sense of touch. The fingers may feel 'numb ' and yet be well able to detect the difference between hard and smooth, soft and rough,. moist and dry things. Numbness, more or less complete, may exist independently of, or be associated with, all these various modifications of sensation, with pain, tingling, or creeping sensations. Its extent will vary greatly ; it may be confined to a part of a limb, may influence the whole of it, or may 80 LECTURE VII. — MODE OF OCCURRENCE OF SHOCK. extend to two, three, or even to the four limbs ; its degree and extent are best tested by Brown-Sequard's aesthesiometer. Coldness of one of the extremities dependent upon actual loss of nervous power, and defective nutrition, is often perceptible to the touch, and may be accurately determined by the clinical thermometer ; but in many cases it is found that the sensation of coldness is far greater to the patient than it is to the surgeon's hand, and not unfrequently no appre- ciable difference in the temperature of two limbs can be determined by the most delicate clinical thermometer, although the patient experiences a very distinct and distressing sense of coldness in one of the limbs. The condition of the limbs as to size, and the state of their muscles, will vary greatly. In some eases of complete paraplegia, which has lasted for years, as in Case 4, it has been remarked that no diminution whatever had taken place in the size of the limbs. This was also the case in Case 2, where the paralysis was partial. It is evident, therefore, that loss of size in a limb which is more or less completely paralysed is not the simple conse- quence of the disuse of the muscles, or it would always occur. But it must arise from some modification of innervation, influencing the nu- trition of the limb,' independently of the loss of muscular activity. In most cases, however, where the paralytic condition has been of some duration, the size of the limb dwindles ; and on accurate measure- ment it will be found to be somewhat smaller in circumference than its fellow on the opposite side. Tlie state of the muscles as to firmness will also vary. Most commonly when a limb dwindles the muscles become soft, and the inter-muscular spaces more distinct. Occasionally in advanced cases a certain degree of contraction and of rigidity in particular muscles sets in. Thus the flexors of the little and ring fingers, the extensors of the great toe, the deltoid or the muscles of the calf, may all become the seats of more or less rigidity and contraction. The electric irritability of the muscles of the partially paralysed limb is much lessened, sometimes destroyed, in certain groups of muscles, whilst it continues more or less perfect in others. The body itself generally loses weight ; and a loss of weight, when the patient is deprived of all exercise, and is rendered inactive by a semi- paralysed state, and takes a fair quantity of good food, which he digests sufficiently well, is undoubtedly a very important and a very serious sign, and may usually be taken to be indicative of progressive disease in the nervous system. When the progress of the disease has been arrested, though the patient may be permanently paralysed, we often see a considerable increase of size and weight take place. As nerve action becomes enfee- bled, the grosser corporeal elements attain preponderance — adipose mat- ter is deposited. This is a phenomenon of such common occurrence in ordinary cases of paralysis from disease of the brain, that I need do no more than mention that it is also of not unfrequent occurrence in those forms that proceed from injury, whether of the cord or brain. The condition of the Genito- Urinary organs is seldom much deranged in the cases under consideration, as there is usually no paralysis of the sphincters. Neither retention of iirine nor incontinence of flatus and faeces occurs. Sometimes, however, irritability of the bladder is a prominent symptom. The urine generally retains its acidity, sometimes markedly, at others but very slightly so. As there is no retention, it does not become alkaline, ammoniacal, or otherwise offensive. Priapism does not occur in these cases as in meningeal irritation, or in fractures with laceration of, or pressure on, the cord. OKDEK OF SYMPTOMS. 81 The sexual desire and potver are usually greatly impaired, and often entirely and permanently lost. Not invariably so, however. The wife of Case 18 miscarried twice during the twelvemonth succeeding her husband's accident. The pulse varies in frequency at different periods. In the early stages it is usually slow. In the more advanced it is quicli, near to or above 100. In one case I found it unequal at the two wrists. It ig always feeble, and sometimes irregular or intermitting. The skin is usually cold and clammy. The order of the progressive development of the various symptoms that have just been detailed is a matter of great interest in these cases. As a rule, each separate symptom comes on very gradually and insidiously. It usually extends over a lengthened period. . In the early stages, the chief complaint is a sensation of lassitude, weariness, and inability for mental and physical exertion. Then come the pains, tinglings, and numbness of the limbs ; next the fixed pain and rigidity of the spine ; then the mental confusion, and signs of cere- bral disturbance, and the affection of the organs of the sense ; the loss of motor power, and the peculiarity of gait. TJie period of the supervention of these symptoms after the occurrence of the injury will greatly vary. In cases of severe and direct concussion of the spine, the symptoms are usually immediate and distinctly marked. In the cases of general nervous shock, and of slight and indirect concus- sion of the cord, no immediate effects are produced, or if they are, they are transitory, and commonly after the first and immediate effects of the accident have passed off there is a period of comparative ease, and of remission of the symptoms, but not of recovery, during which the patient imagines that he will speedily regain his health and strength. This period may last for many weeks, possibly for two or three months. At this time there will be considerable fluctuation in the patient's con- dition. So long as he is at rest, he will feel tolerably well ; but any attempt at ordinary exertion of body or mind brings back all the feel- ings and indications of nervous prostration and irritation so character- istic of these injuries ; and to these will gradually be superadded those more serious symptoms that have already been fully detailed, which evidently proceed from a chronic disease of the cord and its membranes. After a lapse of several months — from three to six — the patient will find that he is slowly but steadily becoming worse, and he then, perhaps for the first time, becomes aware of the serious and deep-seated injury that his nervous system has sustained. Although there is often this long interval between the time of the occurrence of the accident and the supervention of the more distressing symptoms, and the conviction of the serious nature of the injury that has been sustained, it will be found, on close enquiry, that there has never been an interval, however short, of complete restoration to health. There have been remissions, but no complete and perfect intermission in the symptoms. The patient has thought himself and has felt himself much better at one period than he was at another, so much so that he has been tempted to try to return to his usual occupation, but he has never felt himself well, and has immediately relapsed to a worse state than before when he has attempted to do work of any kind. It is by this chain of symptoms, which, though fluctuating in intensity, is yet continuous "and unbroken, that the injury sustained, and the illness subsequently developed, can be linked together in the relation of cause and effect. 82 LECTL'KE yil. — PATHOLOGY OF OOXCUSSIOX OF SPINE. PART II. ON THE PATHOLOGY OF CONCUSSION OF THE SPINE. Haying thus described tlie various symptoms that may arise from these shocks to and concussions of the spine, let us now briefly enquire into the pathological conditions that lead to and that are the direct causes of these phenomena. I have pointed out and discussed at some length the pathological con- ditions that are found within the spinal canal in those cases of more or less complete paralysis that result from direct and violent blows upon the back without fracture or dislocation of the bones entering into the formation of the vertebral column. We have seen that in these cases the signs of spinal lesion are referable to extravasation of blood in various parts within the spinal canal, to rupture of the membranes of the cord, to inflammatory effusions, or to softening and disorganisation of the cord itself. In those cases in which the shock to the system has been general and unconnected with any local and direct implication of the spinal column by external violence, and in which the symptoms, as just detailed, are less those of paralysis than of disordered nervous action, the pathological states on .which these symptoms are dependent are of a more chronic and less directly obvious character than those above mentioned. We should indeed be taking a very limited view of the Pathology of Concussion of the Spine if we were to refer all the symptoms, primary and remote, to inflammatory conditions, either of the vertebral column, the sheaths of the spinal nerves, the meninges of the cord, or the sub- stance of the medulla itself. Important and marked as may be the symptoms that are referable to such lesions as these, there are undoubt- edly states, both local and constitutional, that are primarily dependent on molecular changes in the cord itself, or on spinal anaemia induced by the shock of the accident acting either directly on the cord itself, or in- directly, and at a later date, through the medium of the sympathetic, in consequence of which the blood distribution to the cord becomes dis turbed and diminished. In spinal concussion there would indeed appear to be two distinct and indeed widely opposed conditions induced, viz. spinal anaemia and spinal inflammation. It is of greab importance to bear in mind that these two conditions — entirely distinct, and indeed opposed as they are pathologi- cally — may yet give rise to many symptoms that have much in common. There is, however, this wide difference between them, that 'anaemia of the cord ' is rather a functional disease — a clinical expression possibly, more than a well-proved pathological fact— whilst, on the other hand, the intra-spinal inflammations, whether they affect the membranes of the cord— the cord itself or both— are well recognised and easily deter- minable pathological states, the conditions connected with which are positive organic lesions that he at the bottom of the functional disturb- ance. There is then this essential difference between the two affections, that whereas the sign of functional disturbance may be much the same in both, in one it is underlaid by organic disease and structural change, in the other by no appreciable pathological condition. We will first consider the pathology of the inflammatory states of the cord or its membranes that may proceed from concussion of the spine, SCANTINESS OF ANATOMICAL KNOWLEDGE. 83 and then consider that condition of so-called spinal anaemia that may result from 'nervous shock.' They doubtless consist mainly of chronic and sub-acute inflammation of the spinal membranes, and in chronic myelitis, with such changes in the structure of the cord as are the inevi- table consequences of a long-continued chronic inflammatory condition developed by it. It would at first sight appear a somewhat remarkable circumstance, that notwithstanding the frequency of the occurrence of cases of con- cussion of the spine in railway and other accidents, there should be so few instances on record of examinations of the cord after death in these cases. But this feeling of surprise will be lessened when we reflect on the general history of these cases. If in these, as in cases of direct in- jury of the spine with fracture or dislocation, the effects were immediate, severe, and often speedily fatal, surgical literature would abound with the details of the post-mortem, appearances presented by them, as it does with those of the more direct injuries just alluded to. But as in these cases of spinal concussion the symptoms are remarkably slow in their development and chroTiic in their progress — as the patient will live for years in a semi-paralysed state during which time the original cause of liis sufferings has almost been forgotten — as he seldom becomes the in- mate of a hospital — for the chronic and incurable nature of his ailments does not render him so much an object for such a charity as for some asylum or for private benevolence — and as the cause of his death does not become the subject of investigation before a coroner's court, there is little opportunity, reason, or excuse for a post-mortem investigation of that structure, which is probably the one that is least frequently ex- amined in the dead-house, tIz. the spinal cord, as it is the one the cor- rect pathological investigation of which is attended by more difficulties than that of any other organ in the body. Hence it is that as in most other chronic nervous diseases that are only remotely fatal — as in cases of hysteria, neuralgia, and m nine-tenths of those of epilepsy, we have no opportunity of determining in cases of concussion of the spine very remotely fatal, what the anatomy of the parts concerned would reveal of the real cause of the obscure and intricate symptoms presented during life. So rare are post-mortem examinations of these cases that no in- stance has occurred to me in hospital or in private practice in which I could obtain one ; and, with one exception, I can find no record in the transactions of societies or in the periodical literature of the day of any such instance. The only case indeed on record with which I am acquainted, in which & post-mortem examination has been made of the spinal cord of a person who had actuallv died from the remote effects of concussion of the spine from a railway collision, is one that was published in the ' Transactions of the Pathological Society' by Dr. Lockhart Clarke. The patient, who had been under the care of Mr. Gore, of Bath, by whom the prepa- ration was furnished, was a middle-aged man, 52 at the sime of death, of active business habits. He had been in a railway collision, and, without any sign of external injury, fracture, dislocation, wound, or bruise, began to manifest the usual nervous symptoms. He very grad- ually became partially paralysed in the lower extremities, aijd died three years and a half after the accident. Mr Gore has most kindly furnished me with the following particulars of the case. Immediately after the collision the patient walked from the train to the station close at hand. He had received no external sign of injury— no contusions or wounds, but he complained of a pain in his back. Being most unwilling to give in, he made every effort to get about in his business, and did so for a short time after the accident, though 84 LECTURE VII. — PATHOLOGY OF CONCUSSION OF SPINE. with much distress. Numbness and a want of power in the muscles of the lower limbs gradually but steadily increasing, he soon became dis- abled. ,His gait became unsteady, like that of a half-intoxicated person. There was great sensitiveness to external impressions, so that a shock against a table or chair caused great distress. As the patient was not under Mr. Gore's care from the first, and as he only saw the case for the first time about a year after the accident, and then at intervals up to the time of death, he has not been able to inform me of the precise time when the paralytic symptoms appeared ; but he says that this was cer- tainly within less than a year of the time of the occurrence of the acci- dent. In the latter part of his illness some weakness of the upper ex- tremities became apparent, so that if the patient was off his guard a cup or a glass would slip from hfs fingers. He could barely walk with the aid of two sticks, and at last was confined to his bed. His voice became thick and his articulation imiserfect. There was no paralysis of the sphincter of the bladder until about eighteen months before his death, when the urine became pale and alkaline, with muco-purulent deposits. In this case the symptoms were in some respects not so severe as usual, there was no very marked tenderness or rigidity of the spine, nor were there any convulsive movements. The cord was carefully examined by Dr. Lockhart Clarke, by whom the case has been published.' On examination, traces of chronic inflammation were found in the arachnoid and the cortical substance of the brain. The spinal meninges were greatly congested, and exudative matter had been deposited upon the surface of the cord. The cord itself was much narrowed in its antero-posterior diameter, so that in many places this was not more than half of the transverse diameter. This was particularly the case in the cervico-dorsal region. The narrowing was owing to absorption of the posterior columns, which, of all the white columns, were exclusively the seat of disease. These had not only to a great extent disappeared, but the remains were of a dark-brownish color, and had undergone im- portant structural changes. This case is of remarkable interest and practical value, as affording evidence of the changes that take place in the cord under the influence of ' concussion of the spine ' from a rail- way accident. Evidences of chronic meningitis — cerebral as well as spinal — of chronic myelitis, with subsequent atrophy, and other organic changes dependent on mal-nutrition of the affected portion of the cord- being manifest.'' ' Transactions of the Pathological Society of London, 1866, vol. xvii. p. 21. '' The detailed report of the examination made by Dr. Lockhart Clarke is so valuable that I give it in full :— ■ On examining the spmal cord, as it was sent to me by Mr. Gore, I found that the membranes at some parts were thickened, and adherent at others, to the surface of the white columns. In the cord itself, one of the most striking changes consisted in a diminution of the antero-i5osterior diameter, which, in many places, was not more than equal to half the transverse. This was particularly the case in the upper portion of the cervical enlargement, where the cord was consequently much flattened from behind forward. On making sections, I was surprised to find that of all the white columns, the posterior were exclusively the seat of disease. These columns were dark- er, browner, denser, and more opaque than the antero-lateral ; and when they were ex- amined, both transversely and longitudinally, in their preparations under the micro- scope, this appearance was found to be due to a multitude of compound granular corpuscles, and isolated yrunules, and to an exuberance of wavy fibrous-tissue dis- posed in a longitudinal direction. It was very evident that many of the nerve-fibres had been replaced by this tissue, and that at certain spots or tracts, which were more transparent than others, especially along the sides of the posterior median fissures, they had wholly disappeared. Corpora amylacea, also, were thickly interspersed through the same columns, particularly near the central line. ' The extremities of the posterior horns contained an abundance of isolated ANATOMY OP SPINAL MENINGITIS. 85 It is well known that two distinct forms of chronic or sub-acute in- flammation may affect the contents of the spinal canal as the results of injury or of idiopathic disease, viz. inflammation of the membranes, and inflammation of the cord itself. In spinal meningitis the usual signs of inflammatory action in the form of vascularisation of the membranes is met with. The meningo-rachid- lan veins are turgid with blood, and the vessels of the pia-mater are found much injected, sometimes in patches, at others uniformly so. Serous fluid, reddened, and clear, or opaque from the admixture of lymph, may be found largely effused in the cavity of the arachnoid. Ollivier' states that one of the most constant signs of chronic spinal meningitis is adhesion between the serous lamina that invests the dura- mater and that which corresponds to the spinal pia-mater. This he says he has often observed, and especially in that form of the disease which is developed as the result of a lesion of the vertebrse. He has also seen rough cartilaginous (fibroid ?) laminae developed inthe arach- noid. Lymph also of a purif orm appearance has often beea found under the arachnoid, between it and the pia-mater. In distinguishing the various pathological appearances presented by fatal cases of chronic spinal meningitis, Ollivier makes the very im- portant practical remark — the truth of which is fully carried out by a con- sideration of the cases related in Lectures II. and III. — that spinal meningitis rarely exists without there being at the same time a more or less extensive inflammation of the cerebral meninges ; and hence, he says, arises the difficulty of determining with precision the symptoms that are special to inflammation of the membranes of the spinal cord. When myelitis occurs, the inflammation attacking the substance of the cord itself, the most usual pathological condition met with is softening of its substance, with more or less disorganisation of its tissue. This softening of the cord as a consequence of its inflammation may, according to Ollivier, occupy very varying extent of its tissue. Some- times the whole thickness of the cord is affected at one point, some- times one of the lateral halves in a vertical direction is affected ; at other times it is most marked in or wholly confined to its anterior or its posterior aspect, or the grey central portion may be more affected than the circumferential part. Then, again, these changes of structure may be limited to one part only— to the cervical, the dorsal, or the lum- bar. It is very rare indeed that the whole length of the cord is affected. The most common seat of the inflammatory softening is the lumbar region ; next in order of frequency the cervical. In very chronic cases of myelitis, the whole of the nervous substance disappears, and noth- ing but connective tissue is left behind at the part affected. Ollivier makes the important observation, that when myelitis is con- secutive to meningitis of the cord, the inflammatory softening may be confined to the white substance. But though softening is the ordinary change that takes place in a cord that has been the seat of chronic inflammation, yet sometimes the nervous substance becomes indurated, increased in bulk, more solid than natural, and of a dull white colour, like boiled white of egg. This induration of the cord may coexist with spinal meningitis, with granules like those in the columns; and in some sections the transverse commissure ■was somewhat damaged by disintegration. The anterior cornua were decidedly smaller than natural, and altered in shape, but no change m structure was observed. Dr Clarke observes that the appearances presented by the cord bore a striking resemblance in the limitations of the lesion to the white substance to what is met with in Locomotor Ataxy. • Vol. ii. p. 237. 86 LECTURE VII. — PATHOLOGY OF CONCUSSIOX OF SPINE. congestion, and increased vascularisation of the membranes. The case of the Count de Lord at (p. 5) is an instance of this induration and enlargement of the substance of the cord, and others of a similar nature are recorded by Portal, Ollivier, and Abercrombie. It is important to observe, that although spinal meningitis and myelitis are occasionally met with distinct and separate from each other,, yet that they most frequently co-exist. When existing together, and even arising from the same cause, they may be associated with each other in very varying degrees. In some cases the symptoms of men- ingitis, others those of myelitis, are most marked, and after death the characteristic appearances present a predominance corresponding to that assumed by their effects during life. I have given but a very brief sketch of the pathological appearances that are usually met with in spinal meningitis and in myelitis, as it is not my intention in these Lectures to occupy your attention with an elaborate enquiry mto the pathology of these affections, but rather to consider them in their clinical relations. I wish now to direct your attention to the symptoms that are admitted by all writers on diseases of the nervous system to he connected with and dependent upon the pathological conditions that I have just detailed to you, and to direct your attention to a comparison between these symptoms and those that are described in the various cases that I have detailed to you as characteristic of ' Concussion of the Spine ' from slight injuries and general shocks of the body. The symptoms that I have detailed at pp. 73 to 82, arrange them- selves in three groups : — 1st. The cerebral symptoms. 2nd. The spinal symptoms. 3rd. Those referable to the limbs. In comparing the symptoms of ' Concussion of the Spine ' arising from railway and other accidents, as detailed in the cases I have related, with those that are given to and accepted by the Profession as dependent on spinal meningitis and myelitis arising from other causes, I shall confine the comparison of my cases to those related by Abercrombie and Ollivier. And I do this for two reasons ; first, because the works of these writers on diseases of the spinal cord are universally received as the most graphic and classical on the subject of which they treat in this country and in France ; and, secondly, because their descriptions were given to the world before the railway era, and consequently could in no way have been influenced by accidents occurring as a consequence of modern modes of locomotion. ]. With respect to the cerebral symptoms. It will be observed that in most of the cases that I have related, there was more or less cerebral disturbance or irritation, as indicated by headache, confusion of thought, loss of memory, disturbance of the organs of sense, irritability of the eyes and ears, &c. ; — symptoms, in fact, referable to subacute cerebral meningitis and arachnitis. On this point the statement of Ollivier is most precise and positive. He says that it is rare to find inflammation of the spinal membranes limited to the vertebral canal, but that we see at the same time a more or less intense cerebral meningitis. In the cases that he relates of spinal meningitis, he makes frequent reference to these cerebral symptoms — states that they often complicate the case so as to render the diagnosis difficult, especially in the early stages. In the post-7nortem appearances that he details of patients who have died of spinal meningitis, he describes the morbid conditions met with in the cranium, indicative of SYMPTOMS OF MEXIXUITIS. 87 increased vascularity and inflammation of the arachnoid. This com- plication of cerebral with spinal meningitis is nothing more than we should expect. lb may arise from two causes .—Either from the head having been injured at the same time and m the same way as the spine, or as a simple consequence of inflammation running along a continuous membrane. In both the fatal cases of meningitis of the spine recorded by Abercrombie, evidences of intra-cranial mischief are described. 2. The spinal symptoms that occurred in the cases of ' Concussion of the Spine ' which I have related, consisted briefly of pain at one or more points of the spine, greatly increased on pressure, and on movement of any kind, so as to occcasion extreme rigidity of the vertebral column, Ollivier says that one of the most characteristic signs of spinal meningitis is pain in the spine, which is most intense opposite the seat of inflammation. This pam is greatly increased by movement of any kind, so that the patient, fearing the slightest displacement of the spine, preserves it in an absolute state of quiescence. This pain is usually accom- panied by muscular rigidity. It remits, being sometimes much more severe than at others, and occasionally it even disappears entirely. According to some observers, the pain of spinal meningitis is increased by pressure. But the correctness of this observation is doubted by Ollivier, who says that in chronic myelitis there is a painful spot in the spine where the pain is increased on pressure, and he looks upon this as indicative of inflammation of the cord rather than of the membranes. 3. The third group of symptoms dependent on concussion of the spine are those referable to the limbs. They have been described at pp. 77, 80, and may briefly be stated to consist in painful sensations along the course of the nerves, followed by more or less numbness, tingling, and creeping ; some loss of motor power affecting one or more of the limbs, and giving rise to peculiarity and unsteadiness of gait. No paralysis of the sphincters. These ai-e the very symptoms that are given by Ollivier and others as characteristic of spinal meningitis, but more particularly of myelitis. In spinal meningitis, says Ollivier, there is increased sensibility in different parts of the limbs, extending along the course of the nerves, and augmented by the most superficial pressure. These pains are often at first mistaken for rheumatism. There is often also more or less rigidity and contraction of the muscles. In myelitis the sensibility is at first augmented, but after a time becomes lessened, and gives way to various uneasy sensations in the limbs, such as formications, a feeling as if the limb was asleep {engour- dissement). These sensations are first experienced in the fingers and toes, and thence extend upwards along the limbs. These sensations are most complained of m the morning soon after leaving bed. They intermit at times, fluctuating in intensity, and in the earlv stages are lessened after exercise, when the patient feels better and stronger for a time, but these attempts are followed by an aggravation of the symptoms. Some degree of paralysis of movement, of loss of motor power, occurs in certain sets of muscles— or in one limb. Thus the lower limbs may be singly or successively affected before the upper extremities, or vice versa. Occasionally this loss of power assumes a hemiplegic form. All this will vary according to the seat and the extent of the myelitis. There is usually constipation in consequence of loss of power m tiie lower bowel. It is very rare that the bladder is early affected, the patient having Voluntary control over that organ until the most advanced stages of the disease, towards the close of life, when the softening of the cord is complete. 88 LECTURE VII. — PATHOLOGY OF CONCU.SSIOX OF SPINE. OUivier remarks, that in chronic myelitis 23atier)ts often complain of a sensation as of a cord tied tightly round the body. The gait {demarche) of patients affected with chronic myelitis is peculiar. It is unsteady, rolling, like that of a partially intoxicated man. The foot is raised with difficulty, the toes are sometimes depressed and at others they are raised, and the heel drags in walking. The body is kept erect and carried somewhat backwards. If we take any one symptom that enters into the composition of these • various groups, we shall find that it is more or less common to various forms of disease of the nervous system. But if we compare the groups of symptoms that have just been detailed, their progressi ve development and mdeSnite continuance, with those which are described by Ollivier and other writers of acknowledged authority on diseases of the nervous system, as characteristic of spinal meningitis and myelitis, we shall find that they mostly correspond with one another in every particular — so closely, indeed, as to leave no doubt that the whole train of nervous phe- nomena arising from shakes and jars of or blows on the body, and described at pp. 73 to 82 as characteristic of so-called ' Concussion of the Spine,' are in reality due to chronic inflammation of the spinal membranes and cord. The variation in different cases being referable partly to whether meningitis or myelitis predominates, and in a great measure to the exact situation and extent of the intra-spinal inflamma- tion, and to the degree to which its resulting structural changes may have developed themselves in the membranes or cord. We Avill now proceed briefly to consider the second pathological state to which the symptoms of many of these cases of Concussion of the Spine from indirect and often slight injuries may be referred — I mean that state which is now recognised as Spinal Anaemia. And especially the so-called ' Ansemia of the Posterior Columns of the Cord.' As has already been stated, this is a condition which we rather recog- nise clinically than pathologically, by analogy than by A\vect post-mortem demonstration, by therapeutical rather than by physiological tests. But yet it is a condition that is now fully recognised as probable, in lieu of positive evidence, by the best and most modern writers on nervous dis- eases, and one the probable existence of which we may accept. I have given you the views of Ollivier and Aberci'ombie on the true pathological state of myelitis and meningitis. Let me refer you to those of the most recent writer on nervous diseases, Hammond, of New York, on the subject of Spinal Anemia.' In his work you will find a very complete and exhaustive account of the idiopathic forms of it which in niany respects closely resemble the traumatic which we are now con- sidering. The Functional Paralysis or Paresis met with in Spinal Anaemia is a very common sequence of Spinal Concussion. It chiefly affects the lower extremities — one or both — but may be hemiplegic. There is complete anaesthesia involving large tracts of the surface of the limbs and body, usually without reference to any distinct nerves or to their anatomical distributions. The skin is cold and pallid. Motor power may be completely lost, or it may be diminished or even ab- sent in one group of muscles and not in another. There is diminu- tion or even complete loss of electric irritability in the affected mus- cles. In this condition there are usually some of the more general symptoms of hysteria ; notably the ' globus ' or the emotional state. There is also very commonly either incontinence or retention of urine. I have known no urine passed for three or four days in such cases, ' On Diseases of the Nervous System, by Dr. Hammond, New York, 1873. SYMPTOMS OF SPINAL ANiEMIA. 89 and yet on introducing a catlieter the bladder has been found to contain only perhaps 30 to 24 ounces — a proof that the secretion of the kidneys is arrested as well as the expulsive power of the bladder lost. In this Paresis there is no atrophy or rigidity of muscles ; the limbs, though cold, motionless, and more or less devoid of sensation, do not waste ; and however long the patient lies in bed no bed-sore forms. Recovery eventually occurs ; often very rapidly, and possibly under the influence of some mental emotion — by the grief of a death, by the necessity for exertion. By these various signs may Paresis or functional, be diagnosed from true or organic, Paralysis. LECTURE VIII. ON SPINAL ANa:MIA, HYSTERIA, SHOCK AND UNCONSCIOUSNESS AS CONSEQUENCES OF CONCUSSION OF THE SPINE. An.^mia of the spinal cord is that condition which has long been recognized by physicians in one of its forms as giving rise to a group of symptoms which collectively are known familiarly as constituting the disease called " Spinal Irritability." Most commonly the disease stops here, but there is another form in which it advances beyond the stage of irritation and enters that of paralysis. The symptoms of this condi- tion are those of exhaustion, associated, as all conditions of nervous exhaustion are apt to be, with neuralgic pains or hypersesthesia, which often assumes such prqmiuence as to overshadow the allied conditions of a paralytic charactei'. These symptoms may develop themselves suddenly after the receipt of an injury of the spine, more especially in persons who by a previous state of weak or ill health are predisposed to their occurence, or they may occur more gradually in those whose health is broken down, whose nutrition is impaired, and who consequently become anaemic as the result of disturbance of the system induced by the injury to which they have been subjected. It is a condition that is most apt to occur in the young, more especially in women, under the age of 35. I have, however, seen many unequivocal instances of this condition in men, and in individuals of both sexes, several years older than this. The symptoms of spinal anaemia are as follows : There is always, and as the most prominent symptom, considerable pain in the spine. The pain in the spinal column is greatly increased by pressure, whether superficial or deep ; by flexion, rotation, or downward pressure on the spine. It is augmented by pressing deeply into the inter-verlebral spaces on either side of the spine, and by the application of a hot sponge. The pain is not much, if at all, complained of when the body is at rest, or when the back is not pressed upon. It is more of the na- ture of tenderness on pressure than of actual permanent pam. This tenderness may be limited to one spot in the spine, and if so, is usually seated jn the cervico-dorsal region. It may occupy several points, or it may extend over the whole vertebral column. It is always associated, when traumatic— and I am only speaking now of spinal anaemia, the result of injury— with cutaneous hyperaesthesia, often of a very intense character, diffused more or less extensively over the posterior part of the back, usually as far as the lateral median lines. In fact it corre- 90 LECTURE Vlir. — ON SPINAL ANAEMIA, ETC. sponds exactly to the distribution of the superficial branches of the posterior primary divisions of the dorso-spinal nerves. This hyperaes- thesia is often so intense that the mere approach of the finger will occa- sion involuntary shrinking on the part of the patient, that it would almost appear as if the dress rather than the skin were the seat of the exalted sensibility. But intense as it may be, when the patient's atten- tion is fixed on the approach of the surgeon's finger, yet if his mind is occupied by having his thoughts directed to other matters, the hand may be placed upon the back and carried down the spine without the slightest sign of suffering. It is much the same with movements of the body. If the surgeon flexes or rotates the spine, in order to test the existence of pain, the patient will cry out, writhe with agony, and com- plain loudly of the torture inflicted upon him ; but if his attention is otherwise engaged he will rise off the couch on which he is lying, stoop, dress and undress liimself without the slightest sign of suffering. This, which often throws suspicion on the bona fides of the patient, must not, for reasons that will be given in the Lecture on Diagnosis, be taken as an evidence of malingering. That he does suffer pain when his atten- tion is directed to the part that is touched ■ or moved there can be no doubt ; that this pain is not permanent, or that it disappears when his attention is actively engaged elsewhere, and is as much dependent on the patient's mental condition as upon the state of the spinal cord, is equally certain. In the more intense cases of anaemia of the spinal cord there is pa- ralysis, more or less complete, of sensation, and often quite complete of motion in the lower extremities. Below a certain level in the dorso- lumbar region, in the greater part, if not in the whole, the nervous system appears to be completely exhausted, and its action almost entirely suspended. It is equally incapable of receiving and of transmitting impressions. The legs and feet are cold ; there is no reflex sensibility or movement in them ; they are' not susceptible to the electric stimulus, either as regards muscular irritability or cutaneous sensibility. They are, of course, utterly unable to support the patient. The knees bend under him in a flaccid manner if an attempt is made to place him on his feet, and the legs fall heavily and lifelessly on the bed when raised from it. But notwithstanding all this local nervous ex- haustion, it will be found that the sphincters are not paralysed, and the general health though enfeebled may be fairly good. The intelli- gence is usually perfect, though the brain and the eyes easily become fatigued, and the patient is tlius equally incapable of sustained intel- lectual effort, or of continuous reading. The condition in fact is one of complete exhaustion of the spinal system below a certain level, that level itsually corresponding with a line drawn round the body from the tenth dorsal vertebra. The condition of the inferior divisions of the cord, and of the nerves of the lower extremities in spinal ansemia, very closely resembles the perversion and suspension of functions met with in certain of the sensory nerves in the exhaustion of cerebral aiiiemia. The impairment of vision amounting at last to complete amaurosis, the tinnitus aurium going on to deafness of one or both ears after pro- longed lactation and profuse hajmorrhagos, are of this kind. Purely functional conditions dependent on the affected nerve being incapable alike of the reception and the transmission of sensory impressions. As I have already remarked, this condition, which we call anaemia of the cord, is scarcely a patliological one. It is never fatal, and hence no opportunity has been afforded to pathologists of examining the condition of the parts after death. It is rather by clinical infer- ence than by positive pathological observation that such a state can be VARIKTIES OF SHOCK — MORAL. 91 termed one of ansemia ; and in this uncertainty as to its true pathology, it may perhaps scarcely be desirable to attempt to give an explanation of the method by which such a condition of the cord is brought about. Whether it is by a concussion or vibratory jar in consequence of which its molecular condition is so disturbed that its functions become for a. time perverted or suspended, or whether, as may not improbably be the case, the primary lesion has been inflicted upon the sympathetic system of nerves, in consequence of which the vascular supply to the cord may have become interfered with, and the symptoms that have just been described have directly resulted horn a diminution of arterial blood transmitted to it, as the result of the disturbance of the vaso- motor action of the sympathetic is uncertain. That the sympathetic is disturbed in many of these cases would appear to be probable, from the- fact that this so-called spinal anaemia is frequently associated with derangement of function of the abdominal or thoracic organs, as shown by palpitations, vomitings, &c. We will now proceed to the considei-ation of a condition of the nervous system that occasionally occurs as a result of spinal concussion, which appears in its clinical history, in its symptoms, and probably in its pathology, closely allied to anaemia of the cord, and which for want of a better name we are apt to call " Hysteria ," that word which serves- as a cloak to ignorance, and which simply means a group of symptoms all subjective and each one separately common to many morbid states. But before proceeding to speak of hysteria as a result of concussion of the spine, let me say a few words about the different varieties of ner- vous shock, leading up to complete unconsciousness, that may result from these accidents. It is important to observe that a serious accident may give rise to two- distinct forms of nervous shock, which may be sufficiently severe to occasion complete unconsciousness. The first is mental or moral, and the second purely physical. These forms of " shoc"k " may be developed separately, orTlTey may co-exist. It is most important, not only so far as a prognosis of the patient's future state, but also so far as the recog- nition of his immediate condition is concerned, to diagnose between these two, and if co-existing to assign to each its proper importance. The mental or moral form of unconsciousness may occur without the infliction of any physical injury, blow, or direct violence to the head or spine. It is commonly met with in persons who have been exposed to- comparatively trifling degrees of violence, who have suffered nothing more than a generaFshock or concussion of the system. It is probably dependent m a great measure upon the in fluence of fear ; it partakes, more of the character of syncope than of the true concussion of the- bram, or of that extreme depression of the system that is consequent upon the infliction of a severe physical shock. It is never followed by those secondary effects that are so commonly met with after a shock has- been inflicted by a direct injury to the head, spine, or, indeed, to the body generally. If it is followed by any after symptoms, these are usually of an emotional and possibly of an hysterical character. It will be found that as the patient recovers from the immediate and primar3r depression of the shock, he, or mare frequently she, becomes greatly agitated, nervous, or truly hysterical, often manifesting great excite- ment, and being soothed and pacified with difficulty. This form of shock, even though it be attended by unconsciousness, is not followed by those after phenomena indicative of real or organic lesions of the brain, the cord, and their membranes, which so commonly result from physical shock. It is this condition that is so apt to lead to an emo- tional state, which, for want of a better term, may be called hysteria. -/ 92 LECTURE VIII. — ON SPINAL ANEMIA, ETC. This mental state is one much more frequently- met,. with amongst women than men ; but in men it is occasionally found as one of the sequelfe of railway injuries. I say of rai lway injuri es, because it is the rarest thing possible to meet with it alter accidents o f any other kin d. During a hospital practice of thirty years rcan^"scarceTy recall to mind a single case in which the emotional or hysterical state that I am about to describe has been met with after, or as a consequence of, any of the ordinary accidents of ciyil life. But I have seen many instances of it after railway concussions. Is this due to the frantic terror_ which of ten seizes upon" the sufferers from railway collisions, or is it due to some peculiarity in the accident, some vibratory thrill transmitted through the nervous system by the peculiarity of the accident? I am disposed to think that [terror; has much to do with its production. It must be remembered tliat railway accidents have this peculiarity, that they come upon the sufferers instantaneously without warning, or with but a few seconds for preparation, and that the utter helplessness of a human be- ing in the midst of the great masses in motion renders these accidents peculiarly \terriblej In most ordinary accidents, as in a carriage acci- dent from a runaway horse, the sufferer has a few minutes to prepare, is enabled to collect his energies in order to make an effort to save him- self, and does not feel the utter hopelessness of his condition in his struggle for life and safety. The crash and confusion, the uncertainty attendant on a railway collision, the shrieks of the sufferers, possibly the sight of the victims of the catastrophe, produce a mental impression of a far deeper and more vivid character than is occasioned by the more ordinary accidents of civil life. Hence, I think, the greater degree of mental shock that accompanies them, and of the hysterical state that is apt to be induced by them. The symptoms indicative of this emotional or hysterical condition are as follows : — The patient, after having been subjected to the disturbing influences of a railway accident, by which he has become greatly alarmed iind agitated, but in which he has not received any direct or serious physical injury, may, for a few hours, or even for a day or so, possibly go about his business, but in a constrained and unnatural manner, be- fore the emotional symptoms develop themselves. Those then manifest themselves usually in the first instance by a violent fit of sobbing and weeping. He becomes alternately irritable and morose in character, emotional to a high degree, so that he bursts into tears, sobs if spoken to, especially in a kind manner, and at other times becomes irascible, and even threatens his family and those around him with violence. He becomes utterly unfitted for business or for the ordinai-y duties of life. Notwithstanding these nervous symptoms, his digestive organs do their duty naturally and well, and his various functions are healthily per- formed. He does not lose flesh, but he has a despondent and haggard look of countenance. It is alike impossible to reason with him or to console him. He nurses his symptoms, and dwells upon his sufferings, his losses, and his wrongs. If he has been struck on any part of the body, this will usually become the seat of pain. This pain is diffused ; does not affect the anatomical course of any particular nerve, and 'consists, in a great measure, of skin-tenderness. It is usually the spine that is thus complained of ; and although the patient suffers pain, which he describes m exaggerated language as of the most agonising and excruciating character, when lightly touched, not only over the vertebral column itself, but on almost any part of the skin of the back, he will move freely, walk about, get up and sit down, dress and undi'ess himself, without such restrictions of his movements as would necessarily arise from the suffering that is the result of organic CIRCUMSTAXCES TENDING TO INDUCE HYSTERIA. 93 disease. There is an obvious want of consistence between the freedom of his movements and the pain that is complained of on pressure on the affected part. ^ sensitive does he become to the touch that as soon as the surgeon lays his finger upon his coat,~5^efore the skin could have been impressed, he will start away as if he had been seriously hurt, and in some cases even he becomes nervous and excited if any person stands behind him. There is, in fact, that unconscious exaggeration of symp- toms, and especially of pain, which is common to all hysterical people, that si mulation o r nervous niimicry of real disease which has been so well described by^rodie and byTaget. This state of things will last indefinftely without any very material change. There may be daily or weekly fluctuations, but the patient neither gets materially better nor worse. This state will continue, indeed, as long as the mind is im- pressed by the prospect of impending litigation. When once that has been removed, recovery, provided there be no organic complication, will take place so rapidly as to lead to the suspicion that the whole of the sufferings Avere purposely simulated, and that the patient was a malin- gerer. This conclusion may possibly be correct in some cases, but in others it is certainly unjust. Anxiety of mind has much to do with the development of the symptoms that I have just been mentioning. They arise in the first instance from the agony of fear into which some indi- viduals are thrown on the occurrence of any great catastrophe. It is not given to everyone to be able to preserve calmness of mind in the midst of the crash and confusion of a railway collision, though it be not of the most serious nature ; it is not given to everyone to be one of those whom si fractus illabatur orbis, impavidmn ferient ruinm. This state is maintained by anxieties connected with the collapse of business, and possibly of impending pecuniary difficulties occasioned by the forced relinquishment of work consequent upon the injury that the patient has sustained, and it is continued indefinitely by the harass of mind consequent on the litigation in which the sufferer becomes in- volved in prosecuting his claim for compensation. These anxieties once removed, the mental tone speedily becomes restored, that power of self- control which has been lost is regained, and the emotional condition and its concomitant phenomena, which are consequent upon a temporary suspension of the power of will, speedily disappear. It is far too common a practice to treat this state either as being under the patient's control, or as being a condition of no material moment, inasmuch as it does not arise from permanent organic injury or dis- ease. It is unjust, as well as irrational, to treat the condition as one of little moment. It is true that we are apt to speak lightly of hysteria in women. But in feaTity even in their case it is often a most formidable as wel'l as intractable disease. We only know it by its effects. We use the term ' hysteria' to hide our ignorance of what this condition really consists. To me, I confess, the sight of a man of middle age, pre- viously strong and healthy, active in his business and in all the relations of life, suddenly rendered ' hysterical,' not merely for a few hours or days, by some sudden and overwhelming calamity that may for the time break down his mental vigour, but continuously so, for months and even years, is a most melancholy spectacle, and is a condition th^ cer- tainly to my mind is an evidence of the infliction in some way of aseri- ous, and, for the time, disorganising injury of the nervous system, though, happily, that injury is not in general o| a permanent nature, or attended by organic changes. This emotional or hysterical state not unfrequently occurs as an mde- pendent affection, without any concomitant complication, yet cases every now and then occur in which there is real, possibly permanent and 94 LECTUKE \III. — ON SPINAL AN^.MIA, ETC. organic injury, inflicted upon some part or organ of the body, the symp- toms of which become mixed up with and obscured by those arising from the purely emotional state. This complication of hysteria and real mjury is one that is extremely difficult to unravel, and it is just this condition that taxes the diagnostic skill of the surgeon to the very utter- most, and in which so much conflict of opinion is apt to occur between different practitioners as to the real value to be attached to any given set of symptoms. - The diagnosis of hysteria following shock has to be made, 1. From organic disease of the spine or elsewhere, and 2. From incipient soften- ing of the brain. The diagnosis of this hysterical state, therefore, and the separation of those phenomena that are purely nervous or hysterical from those that are the result of structural lesion, becomes one of very great importance. In making it, there are three principal points to which attention should be directed. The 1st is the mental state ; the 2nd is the character of the local nervous symptoms, such as pain and paralysis ; and the 3rd is the condition of the bodily health. 1. The mental state has already been described, and I need not refer to its character, but there are a few points in connection with it that deserve special attention in its diagnostic aspect. The first is that it ■develops very speedily after the accident, possibly at the very moment of the catastrophe, or very shortly afterwards, at most in a few hours or a day or two. In this respect it diSers materially from those mental conditions that go on slowly and progressively as a consequence of chronic irritation of the brain or its membranes, and which require a ■considerable time for their development. Then, secondly, the mental condition, and indeed all the symptoms of this state, are more or less continuous ; they are not progressive ; they are just as severe at the end of two or three days as after the lapse of a year or two. There may be fluctuations, but there is never a steady progress in the symptoms. Then again, there is a tendency to exaggerate everything connected with the patient's own ailments, and a disinclination, if not a complete in- ability, to entertain a hopeful view of his state , he prophesies every possible evil, such as paralysis and insanity, as impending over him. 2. The pain is very peculiar, and differs entirely from that which is the result of organic disease. It partakes of the general characteristic ■of hysterical pain, consisting rather in diffused cutaneous hyperesthesia, than in any defined neuralgic affection, such as arises from pressure upon the nerve trunks on their exit from the spinal column ; and still less is there any of that distinctly circumscribed or localised tenderness on pressure, confined to one spot, where it is persistent and greatly in- creased on movement of any kind, which is so characteristic of inflam- matory pain. It is unattended by any objective phenomena. Thus, although the patient will not allow you to touch, without the manifesta- tion of the most acute suffering, any portion of the skin of his back, yet there is perfect flexibility of the spine, perfect power of moving the body, and an utter absence of all rigidity of the muscles. There is no objective sign whatever with which the pain can be connected. Eemem- ber that pain in a part is not per se and independently of objective signs an indication of disease of the part which is its seat. Yet although this IS undoubtedly the case, it must be admitted that a long-continued and persistent localised pain is indicative of a morbid state of the nervous system— either in the nerves of the part itself, or as a reflex neuralgia dependent on central irritation. 3. The functions of the various organs of the body are usually well and healthily performed. The temperature is normal, the ophthalmo- PliOGNOSIS GEXERALLY FAXOl'UAHLK. 95 scope niakes no revelation, and the pulse, though usually quick and weak, is regular. Tlie rapidity of the pulse will vary greatly and very suddenly. There is no more derangement of bodily healtli than would naturally ensue from the life of indolence of body and vacuity of mind that is usually led by patients of this kind. It may be observed, in con- nection with this matter, that the persons who suffer from this kind of fmotional or hysterical manifestation after comparatively slight injuries will often be found to be those who previously had had their nervous energies exhausted by overwork or dissipation, or who had suffered greatly from anxiety of mind from business losses or worries. It will also generally be found that they are individuals of little intellectual at- tainment or mental resource ; and certainly one condition which more than another maintains the emotional state is the utter want of occupa- tion either of body or mind to which such patients voluntarily resign themselves. One of the conditions which may possibly be dependent upon this very state, but which certainly at the same time tends to maintain it, is the utter inability to occupy the mind in a healthy and active manner. Prognosis. — My experience of these cases leads me to consider the prognosis as much more favourable than might have been anticipated, or than I was at one time disposed to consider it. Patients suffering in the way that I have been describing, usually make good recoveries in a comparatively short space of time. But never until the anxieties of litigation and the harass of a trial have passed away. Until this ordeal has been gone through, it is hojieless to expect an improvement or even a mitigation in the symptoms. On the contrary, there is usually an aggravation of them for a few weeks previous to the trial, and not un- commonly a most distressingly painful manifestation of them in the «ourt of law itself — the plaintiff, when undergoing examination in the witness-box, commonly breaking down, suddenly bursting into tears, -sobbing, or screaming hysterically, and having to be carried out of court in a most melancholy state of utter prostration. These scenes, painful as they may be to witness, are not, happily, the preludes to, or indica- tions of, any serious aggravation of the symptoms, but more commonly than not, their last active development. But although experience of these cases has now shown that the purely hysterical or emotional state that results from a railway shock is not an indication of permanent organic or even serious disease of the nervous ■system, yet it requires much care and no little experience to avoid fall- ing into the fatal error of attributing symptoms that are in reality de- pendent upon organic mischief of the brain or cord with those that are of this purely emotional character. But the error may be avoided by bearing this in mind, that no organic or permanent injury can possibly exist without developing objective signs of soiuo kind— those objective signs to which I have had such frequent occasion in these Lectures to refer, and which, consequently, I need not detail here. These objective signs will stand out prominently in the midst of the variety of subjective symptoms which at once characterise and constitute this hysterical state. These cases also clear themselves up in their progress. What is obscure at first becomes evident as the sun at noonday after a time. If, there- fore, you are in any doubt as to their real nature, wait and watch. This maxim is peculiarly applicable when we are called upon to effect a diagnosis between hysterical shock and incipient brain-softening. There is of course no difficulty in determining the fact of the hysteria in all those cases in which the well-known and characteristic symptoms of this condition occur in the young, especially in women. But, when met with in the middle-aged or elderly, and more particu- 96 LECTURE Viri. — ON SPINAL ANyEJIIA, ETC. larly in men, the diagnosis is by no means easy. In such cases the emotional state alternating with fits of irritability and of hypochondria- sis closely resembles the early stages of cerebral softening. But the diagnosis may usually be effected by attention to this point, viz. : whether the symptoms have developed early after the accident and to their full extent, or have come on slowly and progressively at a late period. If early and fully, it is obvious that time would not have been sufficient for the development of cerebral softening. If slowly and pro- o-ressively, and if dependent on this condition, other and unmistakable signs of mental decadence or of paralysis will soon show themselves, and time will certainly clear up all doubt on the diagnosis. The hypochondriasis of oxaluria and the peculiar nervous state asso- ciated with that condition have many points of resemblance to hysterical shock ; and indeed it is quite possible that oxaluria may be occasioned by the mental anxiety and depression consequent on a railway injury. In all cases of doubt the microscopical examination of the urine will at once solve the difficulty as to the diagnosis, though it does not deter- mine whether the oxaluria be the cause or the consequence of the ner- vous depression with which it is associated. In primary oxaluria, how- ever, I am not aware of diffused hyper£esthesia being a permanent symptom as it is in most cases of hysterical shock. Unconsciousness, insensibility, stupor, or syncope frequently occur in connection with concussion of the spine and shocks to the nervous sys- tem in railway and other accidents. It is impossible to overrate the importance of the production of unconsciousness by and at the moment of the occurrence of the accident. It is of itself, and irrespective of any other condition, the evidence of the infliction of a severe shock upon the brain, even though no blow has been inflicted upon the head, and the violence has only consisted in a general concussion or jar of the whole body. If the brain be in any way concussed to such an extent as to become unconscious of surrounding conditions and of all external mfluences, an immediate or primary impression of the most serious character must have been inflicted upon it, and any after or secondary consequence may become possible. Xo after consequence, indeed, can possibly be so serious as is that immediate annihilation of all sense and consciousness on the receipt of the injury, which is manifested by the sudden production of insensibility. The commotion that the brain substance sustains at the moment that the patient is stunned may lead to changes that may eventually result in the worst possible forms of organic disease, paralysis, epilepsy, or cerebral softening. But for the unconsciousness to be of full and grave clinical value it must be immedi- ate ; it must be contemporaneous with the receipt of the injury ; it must be the direct and instantaneous effect of the physical shock that the brain has sustained directly by a blow on the head, or indirectly by general concussion of the body transmitted to it. It is only under these circumstaiices that it is of the nature of true concussion of the brain, and that it is really grave. This kind of unconsciousness, which is physical in its cause, and may bo full of importance in its results, has, I ^believe, always this peculiarity, that on the sufferer regaining his con- ^sciousness there will be found to be a loss of recollection of something if not of all that is connected with the accident. The memory will be perfect up to one point ; but then there will be a gap which the patient cannot possibly fill up ; there may even be loss of memory (and this does 1^ not unfrequently occur) of some of the circumstances that immediately preceded the infliction of the injury. Thus, for instance, a driver will remember his horses running away, but he will not recollect how he was thrown from the coach-box, an event which necessarily occurred, before SVMPTO^rS OF SACKODYNIA. 97 he struck his head upon the ground, and thus was rendered uncon- seioiis. This loss of memory of events immediately antecedent to, as well as those actually connected with, the infliction of the injury, is a Tery remarkable circumstance, and may be taken as a positive proof that the brain-substance has sustained a severe commotion or physical lesion. The chain of memory is broken abruptly at some occurrence often of a very trivial cliaracter antecedent to the accident, and the gap left can never be filled up by any mental effort on the part of the patient. But there is another kind of unconsciousness of a totally different character : this is the emotional, not physical, form of insensibility. This form of unconsciousness partakes more of the character of syncope than of shock. It differs from the true physical stunning in this, that it does not usually occur at the moment of the accident, but generally immediately afterwards. It arises from shock to the mind, and not from physical lesion of the brain structure. It is the result of terror, of the horror of the situation, of the painful sights witnessed, possibly of the pain suffered by the patient from the infliction of some wound. This form of syncopal unconsciousness differs from physical insensibility not only in not being immediate, and in occurring a few moments after the accident, but especially in not being followed by the obliteration of all recollection of the event. Indeed the concomitant circumstances of the accident which has occasioned it are usually most strongly, minute- ly, and indelibly impressed on the memory. It is of the character of swoon or faint rather than of brain shock, and leaves no after conse- quences of a serious character. LECTURE IX. OK THE COMPLICATIONS OF CONCUSSION OF THE SPINE, AND ON THE INFLUENCE OF INJUEY OF THE PERIPHERY OF NERVES ON THE CENTRAL PORTIONS OF NERVOUS SYSTEM. Independently, of those lesions which are more especially referable to the nervous system and the organs of sense, there are several compli- cations which are specially apt to occur in cases of concussion of the spine. These complications often assume a very prominent character, and tend to divert attention from the real and primary injury of the nervous system. These complications consist of sacrodynia, vomiting, discharge of blood from the bowels, laceration of mucous membrane of rectum, mucous desquamation from colon and rectum, suppression, retention, and incontinence of urine, ha?maturia, diabetes, and phlebitic throm- bosis. We shall consider them briefly and solely as complications of the condition I am now describing. In addition to them I shall say a few words on the effects of peripheral injuries of nerves on the nervous centres. Sacrodynia. — Severe blows on the sacral, gluteal, and lower lumbar regions frequently occasion concussion of the spinal cord, and even of the brain. Even though the symptoms of concussion of the nervous centres arise from more direct injury of the spine or head, yet in the accident that causes them the sacro-lumbar region may be violently struck. This is very frequently the case in railway collisions, where the sufferer is thrown forwards and then jumped backwards against the hard seats or unstuffed partitions of second and third class carriages. The 98 LECTURE IX.— COMPLICATIOI^S OF CONCUSSION. effect of such blows or bumps as these is to develop a class of symptoms that may exist independently of those of spinal concussion, or that may be associated with them, and by this association not only very materially to complicate the diagnosis of the case, but to add greatly to the patient's sufferings and disabilities. This group of symptoms, to which I give the name of Sacrodynia, are as follows : Soon, but not necessarily immediately, after the accident the patient feels a diffused pain over the whole of the sacral and sacro- lumbar regions. It is usually most intense over the sacrum, and more especially over the sacro-iliac synchondrosis ; but it is by no means con- fined to this part. It extends upwards as high as the fourth or even the third lumbar vertebra, and laterally perhaps to within an inch or two behind the trochanters. But the sacrum is the focus of greatest in- tensity. When the sacro-iliac junction also is the seat of suffering, it is in the majority of cases the left one. Over the whole of this region there is tenderness on pressure, and the pain is greatly increased by movements of all kinds. There is no nocturnal exacerbation. There is no external sign of injury, in the way of swelling, heat, or discolora- tion. The patient cannot hold himself erect without an increase of the pain, hence he has a tendency to stoop slightly forwards, and perhaps to incline to one side. Advancing the lower extremities increases the pain greatly, the patient therefore walks with difficulty, takes short steps, leans on a stick, and when one side is more painful than the other, drags the leg on that side. As I have already said, the left side is more commonly the one that is most j)ainful, hence it is that the left leg is so frequently ' dragged ' in these cases. The greater frequency and the greater degree of sacrodynia on the left side than on the right, and the consequent drag of the left leg, are very notable circumstances. They occur in at least three-fourths of all tlie cases. The only explanation that I can give of it is this. In a railway collision, when a person is thrown forwards he naturally thrusts out his right hand more than the left, in order to save himself, and to clutch at some object for support. In doing so he turns the whole of the right side forwards, and when thrown back again on to the seat or partition in the rebound of the car- riage, he strikes first, and with greatest violence, the left side of the pelvis, which is slightly rotated backwards. The duration of these symptoms is very prolonged. When once they have fairly set in, they will last for many months, often for a year or two. This condition is a very serious one, not on account of any danger to life or limb, but owing to the pain in standing and moving incapacitat- ing the sufferer for all active exercise and exertion, and thus materially restricting the enjoyment and usefulness of life. In its pathology sacrodynia seems to resemble coccydynia, as it does indeed in its symptoms and duration. The pain does not follow the anatomical course of any nerve, and cannot therefore be referred to the class of neuralgias. It appears to be the result of direct bruising of the extensive planes of aponeurotic and fascial structures in this region, with sprain of the various ligamentous structures there met with. Tlie sacro- vertebral, the ilio-lumbar, the sacro-iliac, and tlie great sacro- sciatic ligaments may all be more or less strained in the bumps, twists, and wrenches to which the pelvis and lower part of the spine are sub- jected in the accidents under consideration. And according as the vio- lence falls more or less directly on one or other of those ligaments, so the patient will suffer more or less in the parts where it is situated. The long duration of the pain in these cases of sacrodynia is just what we find in all cases of ligamentous strain elsewhere. NEKVE COMPLICATIOMS. 99 The diagnosis of sacrodynia has to be made from 1. Eheumatism. 2. Spinal concussion. 1. From rheumatism, whether it shows itself in the form of lumbago or sciatica, the diagnosis is easily made by attention to the seat of the pain, which, in lumbago, is above the ilium and on either side of the lumbar spine ; in sciatica, along the course of the greater and upper sciatic nerves, and by the absence of nocturnal exacerbations or of cli- matic influences in sacrodynia. The following method may be relied on as effecting at once the diagnosis between sacrodynia and sciatica. Place the patient In the recumbent position, fix the pelvis and extend the leg, then place one hand on the knee so as to prevent its being bent, and with the other draw up the foot forcibly so as to depress the heel and thus put the sciatic nerve on the stretch. If the pain be due to sacrodynia it will not be increased by this manoeuvre ; if due to sciatica, it will be greatly aggravated when the nerve is thus stretched out. The total absence of those constibutional derangements which are common in rheumatism, and the usual co-existence of a state of great nervous de- pression iu sacrodynia, will tend to make the diagnosis more easy. 2. From spinal concussion the diagnosis is not always so easy, and indeed I have frequently seen these cases of sacrodynia mistaken for and treated as cases of spmal concussion. The mistake is the more liable to occur as the dragging of the leg seems paralytic, when in reality so far from being dependent on loss of innervation, it is in reality due to the pam that is occasioned when any attempt is made to move the leg for- wards, and thus to put the injured ligaments on the stretch. From the nervous symptoms resulting from spinal concussion the diagnosis may thus be made by attending to the seat of the pain, and by the absence of all the special symptoms that characterise the nervous lesion. But it IS very important to bear m mind that in a very large proportion of cases sacrodynia is associated with spinal concussion, and that the symp- toms of the two conditions co-exist. The diagnosis must then be effect- ed by a careful examination of, the spine whilst the patient is lying down in the prone position, and the pelvis is freed so as to take off all weight from it, and to prevent all movement between it, the sacrum, and the lumbar vertebrae. The dragging of the limb which gives this paralytic appearance to patients suffering from sacrodynia may be diagnosed from true paralysis by finding that when the patient is recumbent the movements of the foot, the electric sensibility and irritability, are perfect. The diagnosis from coccydynia, and from the diffused pain of an irri- table ulcer of the rectum, is readily made by the ordinary examination, digital and ocular, of the parts. Nerve ComjjUcations.— Any affection of the nerves of the face is neces- sarily a very serious complication, as it indicates either primary or sec- ondary mischief of the basic meninges or of the base of the brain itself. The portio dura of the seventh nerve is the trunk that is most fre- <:iuent]y thus affected. The motor nerves supplying the muscles of the eyeball are rarely so ; the lingual nerve but rarely. ' Any loss of power, however slight, about the muscles of the face, &c., must be carefully watched, and cannot but be regarded as a serious ex- tension of mischief upwards. Drooping of the angle of the mouth or of the eyelid, inability to whistle, to sniff, to knit the brows, a deviation of the tongue to the sides (not to be accounted for by loss of teeth), are all important signs. In some cases instead of paralysis there is spasm of the muscles sup- plied by the facial nerve. In this case the spinal accessory will very commonly be found to be similarly affected, and there will be twitch- 100 LECTURE IX. — COMPLICATIONS OF CONCUSSION. ings often of a very marked character every few minutes, not only of the side of the face, but of the muscles supplied by the spinal accessory, so that the head is jerked downwards, and to the sides. This unilateral clonic spasm of these nerves is not unfrequently the precursor of epilepsy or of hemiplegia. I have seen cases of concussion of the spine with no external sign of injury, and few, if any, serious symptoms in the early stages, gradually go on through a long series of progressive developments, extending through many months, to clonic spasm of the muscles supplied by the facial and spinal accessory nerves, spasm of a clonic character excited by touching the skin of the face, brushing the hair on the affected side of the head, pressing upon a tender spot in the cervical spine, exercising pressure with the finger over the suboccipital or supra- scapular nerves, and terminate at last in creeping paralysis of the leg, short but fre- quently recurring epileptiform seizures and hemiplegia. The fifth pair of nerves as a whole, or in any of their branches, ap- pears to be remarkably free from paralytic affections. I have never seen anaesthesia of the face as a consequence of general nervous shock, or as a sequence and complication of spinal concussion. The only condition approaching to paralysis of any branch of the fifth that I have had occa- sion to observe has been numbness of the teeth on one side, sometimes in the upper, at others in the lower jaw. But in these cases there has always been a direct blow on the face, and the numbness was primary and immediate, though in some cases very persistent. Hyperaesthesia of the fifth is equally rare. Syphilis. — The question may arise as to how far the symptoms may arise from syphilitic disease of the brain or cord or their meninges rather than from concussion of the nervous centres. I have seen sev- eral instances of this not only after railway collisions, but in accidents in a gymnasium, by the overturning of a carriage, &c. When the patient is actually suffering from the more advanced forms of constitutional syphilis, the difficulty in the diagnosis, and in the de- gree of relation that the symptoms bear to syphilis, or to injury, may be very great. The error must not be committed of looking at the paraly- sis as necessarily the result of syphilitic disease of the cord or its mem- branes merely because it co-exists with manifestations of constitutional syphilis. The paralysis of a syphilitic patient may be traumatic, and not in any way connected with or dependent on the specific taint in the system. Careful attention to the history of the case and the mode of progression of the symptoms may do much to unravel the tangle of this complication ; but there are two or three points that deserve special consideration. Thus the ptosis strabismus and double vision which are so common in the syphilitic forms of brain disease are very rare after spinal concussion. Thus also the comparatively early occurrence of epileptiform or comatose symptoms in the specific constitutional disease should be noted. In concussion of the spine also there will be spinal tenderness and pain in movement of a marked character, which does not occur in syphilitic disease. The following case will illustrate some of these points : — Case 43. Fall in Gymnasium — Bloiv on Back — Slotv Development of Spinal Symptoms — Constitutional Siiphihs—Were Symptoms due to In- jury or Syphilis?— An officer, aged '27, fell whilst ' playing tricks' with a companion in a gymnasium, and was struck in the middle of the back. He suffered a good deal at the time, was laid up for a week, and grad- ually got about so as to be as active as before. He contracted syphilis, and had secondary symptoms. Two years and a half after the accident he began to drag the right leg, which became wasted, was cold and CASE 44.— BLOW ON JSTKCK — VOMITING MANY MONTHS. 101 numb ; his sight became affected ; there was external strabismus of the left eye and double vision ; he had some scaly syphilides occasionally appearing on the body ; the right leg was found on measurement to be rather more than half an inch smaller than the left ; there was no spinal pain or tenderness on pressure of any part of the vertebral column. Were these symptoms referable to the accident or to the constitutional syphilis ? The history of the case, the lengthened interval between the fall and the paralytic symptoms, the existence of secondaries, the ab- sence of all signs of spinal irritation, and the strabismus, all pointed to syphilis as their cause. He was treated with large doses of iodide of potassium, iron, and v-nth galvanism, and made a good recovery. Extreme cardiac debility is a ver}^ frequent complication of spinal concussion. The heart's action is extremely feeble, the sounds faint and distant, the pulse weak and compressible, and the patient liable to attacks of cardiac syncope. This condition often lasts many months, and may possibly become permanent. It is a question for investigation whether it results from direct shock to the heart through the cardiac nerves, or whether it is occasioned more indirectly by the injury that may possibly have been sustained by the sympathetic. I have more than once observed great difference in the size of the pulse in the two wrists as a secondary effect of spinal concussion, and probably of impli- cation of the sympathetic. The next complication to which I wish to direct attention is vomiting. Now vomiting in such cases may be of two kinds : there is the ordinary vomiting that occurs on recovery from concussion of the brain from any cause, and which tends so materially by driving the blood to the head to restore consciousness. But there is another kind of vomiting which is apt to occur in a more continuous manner as a consequence of concus- sion of the upper part of the cervical spine. The characteristics of this vomiting are, that it continues for weeks or months, that the contents of the stomach are ejected without force or strain, that they consist chiefly of masticated food that has undergone but little change, and that in consequence of the persistence of this condition the patient's health and strength become greatly wasted. The following case will illustrate this point. Case 44. Blotu on Cervical Spine— Long-continued Vomiting— Partial Farahjsis.—G. D., a man about 27 years of age, met with an accident in a railway collision, in the early part of April, 1S67, in which he was probably struck across the nape of the neck. For ten days he was con- fined to his bed, suffering severely from pain in the upper part of the neck. Mr. Gisborne, of Derby, who saw him, states that at this time he was pallid, looked anxious, complained of pain in the back of the head; was restless at night, and had constant sickness after taking food, whether fluid or solid. His pulse was slow, his breathing op- pressed from a sense of suffocation, accompanied by very uncomforta- ble sensations about his heart. The patient made little improvement, and was brought up to London, where I saw him on May 13. 1 found him looking thin, pale, and anxious. He stated that he had not had a day's health or freedom from pain and distress since the time of the accident. He complained chiefly of pain m the back of the head. This pain was increased by moving the head to and fro, by rotating it and bv pressing it down on the spine. It occurred at the moment ot the accident, when he felt a shock as if he had received a blow from a sledge-hammer, which was immediately followed by a severe pam shoot- ing down to the region of the heart, and by an attack of vomiting. Mr. Evans, of Derby, under whose care the patient had been, confirmed the account he gave of himself. Vomiting had continued daily ever since 102 LECTURE IX. — COMPLICATIONS OF CONCUSSION. the accident, in fact he vomited several times in the coui-se of each day, und had done so up to the time of my seeing him. The breathing had also been affected, being shallow, panting, and oppressed. When he received the blow, he had a sense of suffocation, and great oppressioa about the region of the heart. I saw G. D. again on November 5. I found him worse in certain material respects. The vomiting continued, and he complained much of pain in the back of the head ; but in addi- tion to this he had partial paralysis of the right arm and leg. The arm was numb, with a feeling of tingling throughout it, but more particu- larly along the course of the ulnar nerve. The fingers were contracted, he had a difficulty in opening them, and the grasp of the hand was ex- tremely weak. The right leg was weak, numb, and cold. On measur- ing it, I found that in the middle of the thigh it was one inch less in circumference than the left one on a corresponding line, and that the right calf was five-eighths of an inch smaller than the left, showing clearly that the nutrition of the limb had been affected. On enquiring into the particulars of these new symptoms, I learned from Mr. Evans that the patient had had a ' fit ' on June 16, and that on his recovery from a state of unconsciousness the symptoms of paralj'sis had manifest- ed themselves. On December 6, I again saw G. D., in consultation with Dr. Rey- nolds. At this time we found that there were twitchings in the muscles of the right limbs, that the loss of power in them had been progressive, and that although the vomiting had been less frequent, the paralytic symptoms had appeared to increase. The patient was thinner, more haggard and worn in appearance, than at his last visit. It is important to note that I had frequent opportunities of observing the vomited mat- ters ; they were perfectly sweet in odour ; there was no bile or acid, or glairy mucus about them, no appearance, in fact, of disease. They seemed to consist simply of partially digested food. It would appear from the symptoms of vomiting, suffocation, and oppression about the chest, that the patient had received an injury somewhere about the origin of the pneumo-gastric nerve in the course of the respiratory tract, and indeed, the pain that he suffered at the back of the head would in- dicate that this was the seat of his disease. He was put under treatment consisting of rest, active counter-irritation by repeated blistering, and small doses of calomel. The case came to trial, and so far as all com- pensation claims were concerned, they were favourably adjusted, and the patient improved, but very slowly. On January i9, 1871, nearly four years after the injury, Dr. Evans wrote to me that G. D. still suffered from pain at the back of the head, aggravated at times. When very bad, he became sick and vomited as before, but these attacks were less frequent than they used to be. The paralytic affection of the right leg and arm had improved : he could now use these limbs more freely, and could bear a moderate amount of exercise. There was also a de- cided improvement in the muscular development in the limbs, and the measurement of the two legs was equal ; but he suffered from want of sleep, and was at times much depressed in spirits. Although his im- provement had been considerable, it is evident that at this period it was far from complete. Another symptom closely allied to vomiting is Hiccough, which, though less serious, is often very distressing and painful. Intestinal Complications.— In consequence of the strain to which the body is subjected, considerable intestinal disturbance not unfrequently takes place, and occasionally this will be followed by copious evacuations of blood per a^ium, continuing through a period of many months. In one case which I attended with Mr. R. Dunn, these bloody stools con- CASE 45.— FALL— COLITIS— KECOVKRY. 103 tinned for nearly a twelvemonth. They are altogether unconnected with hffimorrhoids, and usually consist of dark, semi-coagulated blood. The evacuation is accompanied by a good deal of faintness. In other cases again, one of the most marked symptoms consists of a copious discharge-of intestinal mucus in large shreds and flakes, and in very considerable quantity. It would appear as if the shock had in some way damaged, possibly lacerated or inflamed, the mucous membrane of the colon. This condition was very strongly marked in the following case. Cane 45. Shock from FaU—Lacerailon of Mucous Membrane of liec- tvm — CoUth— Epithelial Besquamalion.— Miss W. was injured in Feb- ruary 1868, by falling heavily upon the ground in consequence of put- ting her foot into a hole in a door-mat in the waiting-room of the rail- way station at Spalding.' She was a woman of active habits, a danc- ing-mistress by profession. She was seen by Sir Cordy Burrows and Dr, Taaffe, of Brighton, who referred her to me. At the time of our e.xamination we found that she was suffering from a concussion of her spine and a shock to her general nervous system, and that she had in addition some injury to the lower bowel. This proved on examination to be a longitudinal fissure of the mucous membrane at the posterior part of the anus and lower part of the rectum. She had suffered since the time of the accident from constant pain in the back, confusion of thought, numbness in her limbs, and a feeling as if cold water were running down her back ; a sensation of being grasped on both sides of the pelvis ; a sense of constriction as if by a tightened cord round her abdomen, and also round the chest, just below the breasts. She suffered great paiq in the abdomen when the bowels were moved, and about June 4 she noticed that she was passing shreds with the faeces, which on microscopical examination proved to be portions of the epithe- lium of the lower bowel. She had since almost daily continued to pass these shreds, with, at times, some muco-purulent discharge. I saw her again about this time, and found that she was suffering from ulceration of the mucous membrane of the rectum, in which there was a fissure. I advised the usual operation of partial division of the sphincter, which was done, with considerable relief, which continued for about three weeks, when the symptoms returned, the portion of the mucous mem- brane inside the anus appearing healed, but the upper portion of the lower bowel was very much irritated. This patient continued to pass enormous quantities of large flakes of shreddy epithelium mixed with mucus. This continued for a great length of time. On November 13, 1869, a year and three-quarters after the accident, I found that this epithelium was still being discharged, though in lessened quantity. Miss W. was very nervous and weak, scarcely able to walk ; in going down- stairs had to do so backwards, and was quite unfit for her profession, ' This case involved an important legal point which has a direct bearing upon, and shows the responsibility entailed by, persons engaged in business or profession. It amounts to this, that a person who opens his house for the purpose of gain ren- ders himself liable for any injury sustained by one of his clients, patients or cus- tomers, on entering or leaving that house, that is occasioned by the negligence of himself or his servants. But he is not liable in the case of any individual coming to the house as a mere visitor. Thus, as was stated in this case by Mr. (now Lord) Coleridge, if a patient or client in going to the house of a medical man or solicitor to consult him professionally, tripped in a hole in the carpet or fell over a loose stair-rod, and injured himself, his professional adviser whose counsel he was about to seek and pay for would be liable for the injury sustained. But if the per- son come as a friend, or simple visitor, and the house was opened not for the pur- pose of gain, the occupant would not be liable. The case of Miss W. was tried at Guildhall on June 28, 1869, and a verdict for large damages was taken by consent. 104 LEC'TUltK [X. — CUMPLICATIOXS OF OOXCrSSIOX. which, indeed, she was obliged to relinquish. From this time she slowly improved, and eventually recovered, but for a long time contin- ued to suffer from sacrodynia and epithelial discharge. Since this case occurred, I have seen several others in which laceration of the rectal mucous membrane resulted from falls or blows in the sacral region. The three following cases illustrate various complications of shock in the nervous system in ordinary accidents and in railway collisions, in derangements of the thoracic and abdominal organs. Case 46. Fall on Ice — Hcematuria and Hmmorrliage from the Boweh, with Contractions of the Flexors of the Legs, following Falls on the Back. — A lady was sent to consult me by Dr. Graves, of Gloucester, on July 23, 1872, and gave the following history : She was unmarried, and aged 57. Twenty years ago she fell on her back on the ice and was severely shaken. The same evening she had hfematuria. This was soon arrested by treatment, but had recurred occasionally. A few months after this she slipped in going down stairs, and struck her spine against some of the steps. The accident was followed by severe pain and loss of pov/er in her limbs, and eventually by contraction of the flexors of the feet, so that her heel was raised nearly an inch from tlie ground. Subsequently haemorrhage from the bowels took place, which had con- tinued from time to time. The blood was usually bright, but sometimes dark-coloured. She had no piles or obvious cause for the bleeding. Case 47. Shock to Nervous Sijsteni in Railway Collision — Various Complications connected tvith the Thoracic and Abdominal Organs. — Mrs. T. aged 28, a healthy strong woman, was in a railway collision on November 13, 1869. She was jerked off her seat, fell to the bottom of tlie carriage, where she was bumped backwards and forwards against the edges of the seats. She became insensible, and was a good deal bruised across the loins. I saw her in consultation with Dr. Sedgwick, on No- vember 26, a fortnight after the accident. She was then in an extremely prostrate state. On examining the back, there seemed to be some slight prominence of the third lumbar vertebra, and a twist of its spinous process to the right side. She had vomited repeatedly for twenty-four hours after the accident, then several times daily dunng the following week, and latterly only occasionally. The vomiting was alto- gether independent of the food that she took. The abdomen was very sensitive to the touch. She suffered great pain, referred to the upper part of the rectum in defsecation, and for eight days after the accident she passed great quantities of blood per anum. She suffered greatly from palpitation of the heart, nervous agitation, frequent interruptions of sleep, and frightful dreams. Her sight had become weakened, so that she was unable to read. There was a remarkable difference in the pulse at the two wrists, that in the left radial was so small and indis- tinct that it was impossible to count the beats ; that on the right was moderately full and strong, 88 in the minute. This continued for sev- eral days, but gradually the pulsation in the left radial had become fuller and nearly equal in volume to that in the right. She remained in bed for nine days, when the railway surgeon who saw her advised her to get up and move about. She attempted to do so,but suffered exces- sive pain in the back, extending up to the head, and found she was quite unable even to stand, the attempt making her much worse for several days. When 1 saw her on the 26th, the condition above de- scribed generally continued. The spine was excessively tender, with violent pain on movement of any kind, more especially on pressure and rotation. When the pelvis was fixed and the body rotated, the pain was very intense. The urine was healthy in character ; there was no irrita- bility of the bladder. The treatment prescribed was rest, hot fomenta- EETENTIOX OF ritIXE AFTEK SPINAL INJUUV. 105 tions to the back, small doses of percliloride of mercury and bark ; binder wliicli plan she graduall}' mended. The points of interest in this case were the continuance of vomiting for several days, the passage of blood per anum, severe palpitations of the heart, the" difference in the pulse in the two wrists, which gradually disappeared, the twisting of the spinous process of one of the lumbar vertebra?, and the general shock to the nervous system as indicated by the nervous agitation, the failure of sight, insomnia, &c. Case 48. Severe Shock in Baihvai/ Collision — Blow on Right Side — Long-continued Vomiting — (rrndua'l Development of Paraplegia, with Rigidity and Signs of Spinal Jleningitis. — W. B. was in a railway col- lision on November 6, 1867. I saw him for the first time on March 28, 1868. He gave the following history. At the time of the accident he was struck on the right hypochondrium and across the loin on that side ; he was severely shaken but not rendered unconscious ; he was able to walk some little distance ; he got on to the step of an omnibus and drove home. About half an hour after the accident he vomited a quantity of blood.' He gradually lost power in the lower extremities, and when I saw him, presented the following symptoms : Theie was no pain on pressure on any part of the spine, but considerable tenderness over the sacrum. The vomiting with which he had been seized imme- diately after the accident continued daily for about two months, and then ceased. There were slight paralytic symptoms about the face, some dropping of the mouth on the right side, a slight twist of the" tongue, and dilatation of the left pupil. His mental condition was very emotional, approaching to the hysterical state. He had lost from two to three stone m weight in the course of four months. There was incontinence of fseces, and partial loss of control over the bladder. The abdominal muscles were extremely rigid, hard, and tense ; the lower limbs were quite powerless. The muscles of the thighs and legs were rigid, so that the knees and ankles could only be bent with difficulty, and any attempt at movement caused extreme pain. There was no sign of palsy or of muscular relaxation, but the limbs lay stretched out in a rigid manner like those of a corpse. On making an attempt to bend the joints the whole limb was lifted up. There was almost complete loss of sensation below the knees. The skin could be pricked, pinched, and the cuticular hairs pulled, without any feeling. No reflex action was excited on tickling the soles of the feet. There had been no cramps or convulsive movements m the limbs. There can be little doubt that this condition, which slowly supervened after the accident, was depend- ent upon spinal meningeal inflammation. The urinary organs frequently suffer from the concussion to which the spine and pelvis are subjected. In some cases there occurs a combi- nation of retention and partial suppression of urine which is very remarkable and peculiar to this class of injuries. Case 49. Blow on upper part of the Cervical Spine— Retention of Urine for three days.— In a man about fifty years of age, who had re- ceived a severe blow in a railway collision on the upper part of the cers'ical spine, whom I saw in consultation with Mr. Heath, in June 1874, there had been retention of urine for nearly three days after the accident, but without any great distension of the bladder. It then began to dribble away, and the organ emptied itself without need of the In another case which I saw some years ago with Dr. Bonny, the retention of urine had lasted for forty hours, and in another case, no urine had been passed till the third day, by a young man of 22. In none of these cases does the bladder appear to have become over-dis- 106 LECTURE IX. — COMPLICATIONS OF CONCUSSION. tended. It would therefore seem that there had been suppression or arrest of secretion to some extent, as well as retention. It is possible tjiat there is suppression for a time — that the kidneys do not secrete for many hours, after having been concussed. As they recover from the effects of the shock they slowly begin to secrete again, and then the bladder, which has been temporarily jmralysed — stunned, as it were — fills up to a certain point, and incontinence of urine sets in with partial retention. Throughout the course of these cases of nervous shock or of spinal concussion, there may be every possible degree of retention or incontinence of urine, singly or combined, dependent upon more or less paralysis of sensation or of motion, or both combined. Hmmaturia will occasionally occur, and m those cases in which I have seen it, the bleeding has always been venous. When this symptom is met with it will be associated with diminished secretion of urine. Diabetes I have never seen occur as a consequence of any of these inju- ries of the spine, but have several times met with it as a consequence, sometimes temporary, at others more enduring, of injury to the poste- rior part of the brain. I have, however, seen spinal concussion in pre- viously diabetic subjects. In these cases the injury to the nervous sys- tem very seriously aggravates the diabetic symptoms, increases the quantity of sugar, and materially hastens a fatal result. Phlebitis. Among the distant complications of spinal injury it is necessary to include embolism and thrombosis of the larger veins. I have seen this happen m several cases, and I would especially refer to Oases 23 and 37, in which this occurrence will be found described as one of the more remote symptoms. This plugging of the veins, phlebitis, if you choose to call it so, commonly occurs in the lower extremities, and I imagine that it must be looked upon as a consequence of the absorption of blood that has been extravasated into the spinal canal. In both the cases to which I refer, that would appear to have been the nature of the lesion that occasioned the paraplegia. These cases of phlebitic embolism, consequent upon spinal concussion and intra-spinal hemorrhage, resemble, therefore, in their cause, very closely, similar conditions of veins that are not unfrequently met with consequent on the absorption of disintegrating masses of blood coagu- lum, and extravasations into the general areolar tissue. In one of the cases referred to the patient nearly lost his life from acute inflammatory congestion of the lungs, with efiusion into the pleura, undoubtedly due to embolism of the pulmonary vessels. The complication of pregnancy with spinal concussion is always a serious one, not so much in regard to the duration of the pregnancy as to the prospect of recovery from the injury to the nervous system. Pregnant women who suffer from spinal concussion do not appear to .me. to have any special tendency to miscarry, but they are peculiarly slow in recovering from the symptoms of nervous shock or paralysis, "after the confinement is over. Not only do these symptoms continue during pregnancy, but there is usually little prospect of amelioration for some months after parturition, more especially if lactation be permitted, which tends still furtlier to retard recovery. We will now proceed to discuss a subject of great importance, and one that has not as yet received the attention it deserves, viz., the 'influence exercised by injury of the periphery of a nerve in e.ccitiny slowly, but progressively, disease in the nervous centres. It has long been known to surgeons that incisions or punctures of nerves are often followed by reflex phenomena of a serious and painful character. And it is remarkable that these phenomena are chiefly met with when the cutaneous filaments of the nerves of the upper extremity INJURIES TO PERIPHEUAL NERVES. 107 are the seat of lesion. In fact it is rather when the peripheral termina- tions than when the nerve-trunks are wounded that they manifest them- selves. And in some cases they would appear to have led to symptoms- which were clearly indicative of central nervous irritation. Wounds of this description were more common formerly than now, for they often occurred during the ordinary operation of venesection. And without gomg so far back as the account given by Ambrose Pare, of the painful contraction of the muscles of the arm with which Charles IX. of France was affected for three months after an accident of this description, I would refer you to the works of Joseph Swan for several cases in illus- tration of it. In one case especially, the patient, a woman, who ,had been bled in the median vein suffered severe pain afterwards up to the shoulder for two days, and was seized with violent convulsions, which suddenly ceased on Mr. Swan making a transverse incision, about an inch in length, above the opening in the vein, so as to divide the wounded cutaneous nerve. I have seen more than once, in cases of dis- location of the fingers or of fracture of the phalanges, patients suffer much from cramps and contractions of the muscles of the forearm and arm almost of a tetanic character. The digital nerves, indeed, are those the injury of which is especially apt to be followed by painful reflex contractions of the muscles of the arm, and in some cases by more serious after-consequences indicative of lesion of the nervous centres. Messrs. Banks and Bickersteth ' have especially directed attention to this subject in a series of most interest- ing cases. In none of these, however, did the irritation assume a cen- tral character. But that cases do occasionally occur in which in conse- quence of lesion of the digital nerves by bruise or crush, symptoms of progressive mischief of the central portions of the nervous system may develop themselves is as undoubted, as it is pathologically interesting and clinically important. That irritation, whether it be physiological, traumatic, or pathological, of the periphery of a nerve may give rise to acute disease in the nervous centres, is familiarly illustrated by the convulsions of dentition, by tetanus induced by the wound of a nerve in the foot or hand, and by muscular contractions dependent upon intestinal irritation. It is also a fact admitted by physiologists, that the lesion of a nerve-trunk may be propagated upwards to the cord, and produce secondary disease there. There is a class of cases, however, occasionally occurring in surgery, of which I have now seen several instances, in which it would appear that the injury done to the peripheral termination of a nerve in one of the extremities, may induce slow and progressive disease, leading on to structural changes of a chronic character in the brain and spinal cord, rather than those which take the form of acute convulsions or tetanic attacks. These cases are important, not only in their clinical and pathological, but in their medico-legal aspect. The following is a good illustration of them. Case 50. Crushed Finger — Tetanic Spasms — Symptoms of Cerebral Softening— Death.— A. gentleman, aged 60, in good health, when travel- ling to the city on March 24, 1866, on one of the suburban lines of rail- way had one of his fingers crushed between the door and its frame on the hinge side. The accident gave rise to great pain, and to some loss of blood. The sufferer returned home faint and exhausted with the shock. He was seen and the finger dressed by Dr. Wightman who found there had been considerable contusion and laceration of its extremity, but that the bones were uninjured. The wound healed = Liverpool Medical and .Surgical Reports, vol. iii. p. 64. 108 LECTURE IX. — COMPLICATIONS OF CONCUSSION. slowly but satisfactorily, yet the patient, who was in robust health and weighed about twenty stone at the time of the accident, lost flesh, be- came weak, and never seemed completely to rally from the shock that he had sustained. In the course of a month, twitchingjs, shooting pains, and cramps in the arm, somewhat resembling slight tetanic spasms, developed themselves. On April 29 he had a slight fit. This was followed by numbness, sensations of pins and needles in the hand and arm, twitchings of the face, a sense of weariness and of weakness, and althougli he had previously to the accident been a strong man, he was now unable to undergo even slight exertion without much feeling of fatigue. He, however, returned to his business as a house agent, and for six months continued it intermittently. He was then obliged to relinquish it, grew slowly and gradually worse, and eventually died, wiith symptoms of cerebral softening, on September 13, 1867. Pre . lously to this he had been seen by Mr. Le Gros Clark, and a con- sultation had been arranged on the day of his death, which was sudden. The question arose as to how far these symptoms were connected with the accident, and after a careful review of all the circumstances of the case, we came to the opinion that the injury received in the hand was the exciting cause of the affection of the nervous system which ulti- mately resulted in his death. The circumstances that mainly led to this conclusion were the following : That up to the time of the accident the patient had been in robust health ; that the injury was immediately followed by severe and prolonged nervous shock, and by signs of local nervous irritation in the arm ; that he never subsequently recovered from these symptoms, which were continuous, without a break, and though at times somewhat fluctuating, were, upon the whole, slowly progressive, the disease whicli originated in the injury having, in point of fact, an uninterrupted history from its origin to its fatal termina- tion ; that the hand and arm of the injured limb were the primary seats of the local disease which sprearl upwards to the nervous centres ; and that death resulted from cerebral disease which presented all the signs of softening of the brain. The widow of the patient brought an action against the Company,- under Lord Campbell's Act, and obtained a verdict. Since this case occurred I have seen at least two very similar to it. In one of these a medical man sustained an injury of the finger, this was followed by pains and convulsive twitches in the arm, a progressive break-down in health, and death in about a year. We have yet to learn the history of the future of patients who have suffered disorganising injuries or been subjected to serious operations on the extremities. Ee- covery from accident or operation does not necessarily imply complete restoration to previous state of health or the prospect of prolonged life. It need scarcely be said that any ordinary surgical injury to the head, trunk, or limbs may complicate the effects of a concussion of the spine. As has already been stated (Lecture VII.), the usual symptoms of ner- vous shock arising from spinal concussion are less marked in the majority of those cases in which there is a severe physical lesion elsewhere. But yet instances of this complication are not very unfrequent. I have seen many. There is this important practical point connected with them, that in consequence of the depressed vital power of the limbs— their coldness, the feebleness of the circulation, and the loss of innervation — repair of injury in these cases is far slower than under ordinary circum- stances. This is especially the case in the lower extremities. Wounds, even though of a very superficial character, being little more than abra- sions, will heal very slowly — months being occupied in the repair of a lesion that would in a strong and healthy person require only weeks. CONCUSSION OF EYEBALL. 109 Thus union of fractures is also delayed, and the callus, when formed, is soft and yielding. In contusions of the limbs the extravasated blood is but slowly absorbed, and the part struck may long continue to be the seat of coldness and neuralgic pain. The vasomotric actions may bo seriously disturbed ; the limbs becoming deeply congested, cold and cedematous. This state of things may last for many months, and may possibly in some instances be dependent on deep-seated venous em- bolism. LECTURE X. IMPAIRMENT OF VISION COMPLICATING INJURIES OF THE NERVOUS SYSTEM. The eye often suffers from injuries of the nervous system. It may suffer primarily by the same violence that affects the head or spine, or it may be secondarily affected in two distinct ways ; either by injury to its delicate organisation, direct or indirect, or by some reflex action dependent on the disturbance of the action of the nervous system, spinal or ganglionic. The various affections of the eye that may thus be developed are all necessarily accompanied by more or less impairment of vision, or even by its complete loss. This is the sign by which the damage to the eye is usually at once recognised, and it is this impair- ment that constitutes the great importance of injuries of the eyeball. These various injuries will therefore be considered as giving rise to this particular symptom or effect ; and we shall proceed to study ' im- pairment of vision ' as it arises from the following nervous lesions. 1. Concussion of the eyeball, and direct shock to the optic nerve. 2. Injury of the face, implicating the branches of the fifth nerve. 3. Injury of the spinal cord. 4. Ini'ury of the sympathetic nervous system. 1. Concussion of Eyeball. — The impairment of vision that arises from simple concussion of the eyeball occurs immediately on the receipt of the injury. It is at its worst at the moment of the occurrence, and may either slowly disappear or become permanent, in consequence of the ultimate development of secondary changes in the structure of the globe, by which complete destruction of vision may ultimately be pro- duced, either by changes taking place in the retina or choroid, or by the development of cataract. This concussion of the globe may be produced in two ways. 1. By a direct blow upon it. 2. By a blow on the head or face, but not actually on the eyeball itself. A smart direct blow on the eyeball may at once paralyse the retina without giving rise to any organic mischief, laceration of tissue, or effusion of blood in the eyeball itself. In this way it illustrates forcibly and resembles closely the effect of a blow on the head that occasions concussion of the brain without organic injury of the cerebral sub- stance. The following case illustrates such an injury and its effects. A gentleman about 30 .years of age, in full health and vigour, whilst in a booth at Ascot Races'was struck full in the right eye by the cork of a champagne bottle. He felt faint, sick, and was slightly collapsed. He immediately lost the sight of the eye struck. He came up to Lon- don at once. I saw him the same evening, about four hours after the 110 LECTURE X.— IMPAIRMENT OF VISION. accident. He was still faint and suffering from nervous depression. On examining the eye the pupil was found to be widely dilated, so that the iris formed a very narrow linear circle round it, slightly broader towards the inner than the outer side. All power of distinct vision was lost, but the patient could distinguish the light. The dilated pupil was quite immovable. The pupil of the uninjured eye acted well as ,soon as the shock was recovered from. I ordered rest in a darkened room ; cold evaporating lotions to the e_ye ; purges ; moderate diet. Mr. Critchett co-operated with me in the management of the case. He made a very careful ophthalmoscopic examination, but could detect no sign of internal injury, or of extravasation into the globe. After a time Calabar bean was applied to the eye, and the pupil, after continu- ing dilated for some weeks, began slowly to contract, vision returning in proportion as it did so. Here was a case of simple nervous shock to the eyeball, producing paralysis of the optic nervous apparatus, attended m the first instance by evidence of shock to the nervous system, and but slowly and gradu- ally subsiding. It is a fact well known to all practical surgeons that a blow on the head or face may, without impinging on the eyeball, so severely shake or concuss the globe that the vision becomes seriously and perhaps permanently affected. In these cases the injury done to the eye is mechanical. It is dependent on concussion transmitted through the Ijones of the head or face to the structures within the orbit. That such concussion may occasionally be productive of serious injury to the structures of the globe, is evident from the fact that dislocation of the lens has been known to occur as a consequence of such shock, without any direct injury having been inflicted on the eyeball itself. Dr. D'Eyber (Gazette Medicale de Paris, 1840) relates the case of a patient who became affected by cataract in consequence of the wound of the eyebrow by a stone, without any injury to the eye itself. And I have seen cataract developed three or four months after the receipt of a blow on the malar prominence and eyebrow, received in a railway col- lision by a woman otherwise healthy, about 40 years of age, without any injury having been sustained directly by the eye itself. In this case, which was seen and most carefully examined by two dis- tinguished ophthalmic surgeons, Messrs. Hancock and Haynes Walton, as well as by myself, it was evident that the concussion which the head generally hud sustained had so jarred the lens that its nutrition was interfered with, and a cataractous condition became slowly developed. If such serious organic mischief can declare itself in the interior of the globe as a consequence of a general jar or shake of the head, it is ■not unreasonable to suppose that in many of those cases that we witness, in which, after a general shock to the system, obscuration and impair- ment of vision gradually manifest themselves, and in which, white atrophy of the optic disc is discovered by ophthalmoscopic examination, the injury to the eye, functional and organic, is due to a shake or jar of its nervous structures, by which their nutrition becomes seriously but slowly impaired, and organic changes become secondarily developed in them. , In this way we can account for cataract developing itself as the result of blows on the eyebrows or cheeks. Branches of the fifth pair of nerves, whether frontal or infra-orbital, becoming implicated and irri- tated, and the nutrition of the globe being subsequently impaired in a way that will be described in the next section. 3. From Injuries of the 5th Fair of Nerves. — But independently of the indirect infliction of shock thus transmitted to the delicate struct- LOSS OF SIGHT FROM INJURY OF FIFTH NERVE. Ill iires of the eyeball from blows on the surrounding and neighbouring osseous prominences, there is yet another way in which the eye may suffer secondarily from injuries of the face, viz., in consequence of wound or irritation of the branches of the fifth pair of nerves. There are numerous scattered cases proving clearly that wounds of the eyebrow or of the cheek, and even severe contusions of these parts, have been followed by impairment, and eventually, by loss of vision. This observation dates from the very earliest records of medicine. It is as old as the writings of Hippocrates, who speaks of loss of vision consequent on wounds of the eyebrow, and who makes the very ac- curate and pertinent observation, that vision is less impaired when the wound is recent, but that it becomes progressively worse as cicatrisation becomes older. Many of the older writers mention cases illustrative of the loss of vision after injuries of the eyebrow. Fabricius Hildanus and La Motte both relate cases m which blindness followed wounds of the outer angle of the orbit. Morgagni relates, on the authority of Valsalva, the case of the wife of a surgeon who was wounded on the eyelid by the spur of a cock. Vision was immediately lost, but eventually recovered by the use of friction over the infra-orbital nerve. This was probably rather a case of concussion of the eyeball than of sympathetic amaurosis. Mor- gagni relates another case, that of a lady who, in consequence of the upsetting of a carriage, was wounded by some splinters of glass in the upper eyelid. There was no injury to the eyeball, but still vision be- came gradually impaired, so that by the fortieth day after the accident it was almost completely lost. Wardrop (On the Morbid Anatomy of the Human Eye, vol. ii. p. 194, ■et seq. Lond. 1834) relates several cases in which wounds of the branches of the fifth were followed by loss of vision. Thus, a gentleman received an oblique cut in the forehead, which, from its direction, must have injured the frontal nerve. It was not accompanied by any bad symp- toms, and soon healed. But the vision became gradually impaired, and in a few months was completely lost. A sailor was struck by a ramrod on the eyebrow, where the frontal nerve passes out. Vision was immediately lost and was never regained. An officer at the siege of Badajos was struck by a piece of shell on the eyebrow, over the course of the frontal nerve. Vision became gradu- ally imperfect, and in a few months was completely lost. Wounds of the infra-orbital nerve are also sometimes followed by loss of vision. Wardrop and Beer both mention cases of this kind. To this category also belong those cases in which the patient becomes amaurotic from irritation of the dental nerves by the crowding of teeth, by pivoting a tooth, by caries, or, as in the case related by Dr. Gale- zowski (Arch. gen. de Med.) in which a wooden toothpick, broke and lodged in a carious tooth, produced amaurosis, which was cured by the extraction of the tooth. I have seen amaurosis follow the extraction of a nasal polypus. That a simple contusion of the eyebrow, without wound of any kind, may produce amaurosis, is positively stated by Chelius, who says, ' 1 have seen a case of complete amaurosis occur suddenly eight days after a blow on the region of the eyebrow, though there was not any trace of it on the skin. The pupil was natural and movable, and there was not the slightest pain.' (South's translation of Chelius' System of Surgery, vol i. p. 430.) Eondeaii (Affections oculaires reflexes, p. 53 ; Paris, 1866), relates two cases that illustrate this subject. The first is that of a saddler, who in falling received a wound on the left eyebrow. This wound was 112 LECTURE X. — IMPAIRMENT OF VISION. followed by photophobia and lachrymation of the left eye, and without any pain, by gradual loss of vision in it, at the end of three months. The ball became flaccid and atrophied, the sclerotic yellowish in tint, the iris discoloured, and the pupil immovable. Fifteen years afterwards the right eye became similarly affected, and in eight or ten months he became completely blind. The second case related by Rondeau is that of a bathman, who was wounded on the left eyebrow by some fragments of broken porcelain. The resulting cicatrix became the seat of continued dull aching pains, intermixed with lancinating neuralgic seizures, extending over the left side of the cheek and head. Three weeks after the accident the sight of the left eye began to fail, objects became cloudy and indistinct. This increased, so that in six weeks vision was completely lost. About this time the right eye became affected with photophobia, deep-seated pain, and impairment of vision. On ophthalmoscopic examination of the left eye it was found that the retina was congested, large venous trunks being seen to enter it here and there. The retina had lost its transparency, especially around the central spot, the borders of which all were ill-defined. The general colour of the bottom of the eye had lost its brightness, so that the choroid was partly marked by the prevailing greyish tint. The same appearances were found in the right eye, but to a less marked extent, the retina being brighter and more natural in colour. From all this it is evident that amaurosis has been frequently observed to follow injuries of the eyebrow and side of the face. It is by no means necessary that a wound should have been inflicted, a simple contusion is sufficient. Wardrop makes the very important observation {loc. cit. p. 193) that it is only when the frontal nerve is wounded or injured, and not divided, that amaurosis takes place. Indeed, in some cases the amaurosis has been cured by making a complete division of the nerve, as Rondeau states was done by Dr. Filer in a case of amaurosis following concussio;i of the frontal. In fact it appears to be irritation of a branch of the fifth, as in lacerated wounds, in dental caries, and not its clean and complete section, that disposes to amaurosis. This is in accordance with the view expressed by Brown-Sequard, who states that ' the immediate effects of the section of a nerve, or its ab- sence of action, are very different from those that are observed as the result of its irritation ; that is to say, of its morbid action, which gives rise to veritable derangements in the nutrition of the part supplied by it.' (Journal de Physiologic.) The loss of vision may come on instantaneously, as in the case related by Wardrop of the sailor struck by a ramrod on the eyebrow, or after the lapse of a few days, as in the case recorded by Chelius, where the loss of vision came on eight days after a blow on the eyebrow. Or after a longer lapse of time, as in most of the recorded cases. In the great majority of cases the impairment of vision is at first slight, and gradual- ly goes on to complete loss of sight. The fact then being incontestably established that loss of vision may follow a contusion or wound of the eyebrow or cheek, irritating and in- juring one of the branches of the fifth pair of nerves, the question that naturally presents itself is, in what way can the irritation of a' distant branch of the trifacial nerve, unaccompanied by any direct injury of the eyeball or of the structures of the orbit, produce instantaneously, or remotely, loss of vision ? Some observers, who have noticed the occurrence of amaurosis after injury to the branches of the fifth nerve, have attributed this to the prop- INFLUENCE OF FIFTH NEKVE ON THE EYEBALL. 113 agation of irritation along the sheath of the nerve, until it reaches the trunk of the ophthalmic division, whence it extends to the sheaih of the optic nerve and. to the retina. But there is no evidence of the propa- gation of such inflammation, and, in any case, this would be an insuf- ticient mode of explaining those cases in which blmdness had suddenly supervened. That the section of the trunk of the fifth nerve produces important changes in the eye is well known to physiologists, and has been incon- testably determined of late years by the experiments of Snellen, Schiff, and others. And whether these experiments explain the morbid changes that occur in the eye as a consequence of the section of this nerve by the supposition that ' neuro-paralytic ' inflammation is set up in the globe, or that the surface, by losing its sensibility, becomes more liable to the action of external irritants, matters little to the practical surgeon ; they at least serve to establish more fully the clinical fact previously ascer- tained.' Wardrop says, ' The distribution of the first branch of the fifth pair, or ophthalmic branch, explains how . . . wounds of the frontal, infra- orbital, and other branches of nerves which form anastomoses with the ophthalmic ganglion, are sometimes followed by amaurosis ' (p. 153). And no doubt he is correct ; and that it is in this anatomical arrange- ment that we must find the solution of what is certainly a surgical, or rather a physiological riddle. It is to the intimate connection that exists between the frontal nerve, which is the direct continuation of the ophthalmic division of the fifth with the sympathetic and the ciliary nerves, that we must refer these various morbid phenomena resulting from irritation. Whether this irritation of the frontal exercises an in- jurious influence by causing a hypersemic state of the vessels of the retina and iris is doubtful, but the fact, as the result of clinical obser- vation, is certain, that in some cases it is the primary and determining cause of loss of vision. 3. Impairment of Vision from Spinal Injury. — One of the most frequent and most troublesome effects of spinal injury is a certain degree of impairment of vision. This may assume different characters at different periods after the injury, and may come on at any time afterwards. As we have just seen in cases in which amaurosis follows injury of the supra-orbital nerve, so in the instances in which impairment of vision follows spinal injury, some considerable interval often intervenes between the occurrence of the injury and the development of the eye-symptoms. This is by no means necessarily so, but it does often happen, and if in consequence of bodily suffering or weakness the patient be confined to bed, and be not called upon to use his eyes, it may be long before he discovers that his vision is enfeebled. This is particularly apt to be the case, as the atten- ' Meynert has described a root of the trigeminus nerve as proceeding from the an- terior ganglion of the corpora quadrigemina, which is characterised by containing large vesicular cells. This he regards as the anterior sensory root of the fifth nerve. Merkel, who has examined the subject more recently, has arrived at the same con- clusion as Meynert in regard to its origin, but believes that the function of the root is trophic, not sensory. Merkel founds his opinion partly on pathological evidence, which indicates that the trophic disturbances in the eye after injury to the fifth nerve may have a cerebral origin, and partly on physiological experiment. In the rabbit the root, from the quadrigeminal origin of the fifth, does not fuse with the sensory root of the fifth, but runs separately along the median side of this root. In an experi- ment he made, whilst the sensory root of the fifth was destroyed, this portion was uninjured, and only very transitory trophic disturbance was the result. If these ob servations' be correct, it follows that trophic changes in the eyeball will occur only when the quadrigeminal root of the fifth is affected. 114 LECTUUE X. — IMl'AIiniKXT OF YISIOX. tion of the surgeon may not be directed to the state of the eyes in the lirst instance, the symptoms being entirely subjective^ and there being no external evidence of anything wrong with the eyes. The first and most frequent symptom that is complained of, is a dim- ness or weakness of the sight, so that the patient cannot define the out- lines of small objects, and cannot see in an obscure light. If he attempt to read, he can define the letters often even of the smallest print for a few seconds or minutes, but they soon run into one another, become ob- scured and blurred and ill-defined. Glasses do not materially, if at all, improve this condition. There is often in the eai'ly stages a certain amount of double vision — usually associated with slight irregularity in the axes of the eyes, scarcely amounting, however, to a squint. This blurring or indistinctness of vision is often more observable with respect to near than to distant objects. After a time the patient usually begins to suffer from irritability of the eyes in addition to the impairment of sight. He cannot bear a strong light, not even that of an ordinary window, in the daytime ; he sits with his back turned towards it, or has it shaded. He cannot bear unshaded gas or lamp-light. In consequence of this irritability of the eyes the brows are involuntarily contracted, and the patient acquires a peculiar frown in order to exclude the light as much as possible from the eyes. This intolerance of light may amount to perfect photophobia, and is then associated with a congested state of the conjunctiva, and accompanied by lachrymation. One or both eyes may be thus affected. Sometimes one eye only is in- tolerant to light. This intolerance to light is associated with impair- ment of vision. It is usually accompanied by musca? volitantes and spectre-rings ; and stars, spots, flashes, and sparks, white-coloured and flame-like, are also complained of. The appearance of a fixed lumi- nous spectrum — a line, circle, or coloured bar — across the field of vision IS sometimes complained of. There is an undue retention of images in many cases, and when the patient has looked at any bright object, the sun or the fire, supplementary spectral colours, often of the most beautiful character, of varying degrees of intensity, will develop them- selves in succession. The patient becomes, in some cases, conscious of the circulation in his own eye, which becomes visible to him. Double vision is frequent with both eyes open. But there may be double or even treble vision with one eye. A patient may see two lights, or, perhaps, two lights distinctly and" the shadow of a' third, with one eye only. This happens independently of injuries to the nervous system, but has often been denied, and I have known a patient stigmatized as an impostor because he said he had double vision with one eve. But I am acquainted with two medical men who suffer from this pecu- liarity. This double or even treble vision with one eye is now recognised by ophthalmologists as a distinct affection, under the term polyopia monophthalmica. I know not the explanation, but of the fact "l am certain. In other cases the patient loses the power of correctly judging of the distance both of near and far objects. From the description of the various symptoms of the impairment of vision that supervene on spinal injury, it would appear that the failure of sight may arise from one of four conditions, or from a combination of two or more of these. Mr. John Tweedy, who has paid much atten- tion to this important subject, has favoured" me with the following lucid explanation of the ocular phenomena attendant on spinal concussion. There is, firstly, asthenopia, or simple weakness of sight : the patient is unable to accommodate for near objects for more than a few minutes. Either the nerve-supply to the ciliary muscle is impaired, so that the , EXTERNAL APPEARANCE OF TJIK EYE. llf* musclp soon becomes fatigued and is unable to maintain sufficient ten- sion to keep the crystalline lens properly adjusted, or there is weakness of one or both of the internal recti muscles, and the patient cannot, con- sequently, keep up due convergence of the eyes— an essential element in the adjustment of the eyes for near objects. Associated with either or both of these may be, secondly, a certain degree of amblyopia, a paresis of the retina or optic nerve. The retina may be capable of re- ceiving for a time accurate impressions, which may be readily transmit- ted along the optic nerve to the brain, but, sooner or later, a state of exhaustion is induced, a state not unlike the 'pins and needles' expe- rienced in other weakened or injured sensory nerves. Thirdly, the power of accommodation of the eye may be completely lost, the patient being quite unable to read or write, or to see clearly any near object, although the retina and optic nerve may be quite healthy and distant vision normal. It is desirable that this condition should be recognised, as it has an important bearing on prognosis and treatment. For in- stance, it sometimes happens that a short time after the receipt of an injury to the head or spine a patient finds that he is unable to see to read or write, but that his distant vision remains good. Unless great care be exercised, this condition may be taken as indicative of com- mencing amaurosis. If, however, a little of the extract of Calabar bean be instilled, tension of the accommodative apparatus is induced, and, for the time, vision for near objects is good, and, may be, normal. If there be in addition to the paralysis of accommodation some anomaly of re- fraction, hypermetropia, myojiia, or astigmatism separately or conjoined, matters are still worse. If hypermetropia exist, the distant vision will also be impaired when the power of accommodation is lost, for then even parallel rays of light are not sufficiently converged to come to a focus on the retina, and circles of diffusion are formed. If astigmatism be present, the optical inconveniences with which this condition is always attended are greatly increased by failure of accommodation. If, then, any of these anomalies exist, properly selected spectacles will be necessary to enable the patient to n.e accurately even distant objects. It must not, however, be forgotten that the loss of power of accommo- dation is always of grave significance, and may be the forerunner of serious nutrition changes in the deeper structures of the eye, changes which may eventuate in blindness. Fourthly, there may be irritability of the eye and photopsia depending on hypersemia of the retina, or on inflammation of it and of the optic nerve. In ordinary erethitic am- blyopia the symptoms are not constant, but vary in intensity at difiier- ent periods of the day, being usually worst in the morning. They vary also with the state of health and with the condition of the mind, being less marked when the health improves and when the patient is in good spirits. They are, moreover, influenced by the state of the weather and surrounding circumstances, everything of a depressing character having a tendency to aggravate the symptoms. The objective appearances presented by the eye, and the ophthalmo- scopic manifestations seen in the interior of the globe in these cases, have been carefully studied by Mr. Wharton Jones and Dr. Clifford Allbutt. Mr. W. Jones, in his admirable and scientific work ' On Failure of Sight after Railway and other Injuries,' states that the pupils are usual- ly half closed, the eyes sunken, dull and watery, the veins of the eyeball congested. The movements of the pupils are sometimes normal, some- times sluggish, but sometimes more active than usual. This will nec- essarily depend upon whether the eye is affected by simple asthenopia, or whether there is some hypersemic or inflammatory state already devel- oped in its interior. 116 LECTURE X. — IMPAIRMENT OB^ VISION. The ophthalmoscopic appearances were found to vary greatly. In some cases, as Mr. Wharton Jones most justly observes, the morbid state on which the failure of sight and other subjective symptoms depend, may be at first confined to some central portions of the optic nervous ap- paratus, and no ophthalmoscopic evidence of implication of the retina or optic disc may present itself till a more advanced stage of the case. Sooner or later, however, whether as the effect of primary changes in the fundus, or as the result of a slowly progressive inflammatory affec- tion propagating itself from the intra-cranial portion of the nervous ap- paratus towards its periphery, and thus inducing morbid changes in the optic nerve and disc, we find that the ophthalmoscope reveals changes in the fundus of the eye. ' The disc is seen to be whitish, and somewhat congested ; the retinal veins are large, though the fundus usually pre- sents an anaemic aspect, with perhaps some pigmentous degeneration of the retina round the disc ' (p. 44). Dr. Allbutt, who has investigated this subject with great care and acumen, and in a truly scientific spirit, furnishes the following detailed and accurate account of the appearances presented in these cases, which I prefer giving in his own words : — ' Having seen, then, that there are changes in the eye symptomatic of spinal diseases, our second inquiry is, Of what kind are these changes? Confining ourselves to the optic nerve and the retina with their vessels, and omitting all reference to injection of the conjunctiva, or the state of the pupil, what kind of changes are dependent upon disturbance of the spine? I find that they may be well classified under two heads: — 1. Simple or primary atrophy of the optic nerve, sometimes accompanied at first by that slight hyperaemia and inactive proliferation which make up the state I have called chronic neuritis. This sort of change I have never found as a result of spinal injuries, but I have often mef; with it in chronic degeneration of the cord and in locomotor ataxy. 2. A somewhat characteristic hypersemic change which I have not seen in chronic degeneration oV in locomotor ataxy, but in cases of injury to the spine only. The retinal arteries do not dilate, but become indistin- guishable ; while the veins begin to swell and become somewhat dark and tortuous. The disc then becomes uniformly reddened, and its borders are lost, the redness or pinkness commencing with increased fine vascu- larity at the inner border, and which thence invades the white centre and the rest, so that the disc is obscured or its situation known only by the convergence of the vessels. In many cases, rather than redness, I have observed a delicate pink — pink which sometimes passes into a daf- fodil colour. In one case in particular — a railway accident — which I ex- amined in consultation with my friend and colleague, Mr. Teale, this daffodil colour of the whole field was very curious ; no disc was to be distinguished, but the dark vessels stood out in beautiful relief. The other eye presented the more common appearances of hyperemia and serous effusion, with slight swelling. It is to be remarked that this state is generally or always of long duration ; it passes very slowly up to its full development, and then shows a disposition to end in resolu- tion rather than in atrophy. In those cases which I have been able to watch diligently for many months the pinkness seems slowly to have re- ceded, leaving an indistinct but not very abnormal disc behind. Some- times the sight suffers a good deal in these cases, sometimes but little or scarcely at all. I have never seen true optic neuritis with active prolif- eration as a sequel of spinal disease.'— Xawce^, 1870, vol. i. p. 76-77. One or other of these conditions occur in the majority of cases of spinal injury, such as we are describing in this work. Dr. Allbutt says, ' It is tolerably certain that disturbance of the optic-disc and its neigh- NERVE-RELATIONS BETWEEN THE CORD AND EYE. 117 bourhood is seen to follow disturbance of the spine with sufficient fre- quency and uniformity to establish the probability of a casual relation between the two events. ' Dr. Allbutt goes on to say that of thirteen cases of chronic spinal disease following accidents, he found eight cases of sympathetic disorder of the eye. My experience fully accords with that of Dr. Allbutt. I find that in the vast majority of cases of spinal concussion unattended by fracture or dislocation of the vertebral column, there occurred after a few weeks distinct evidence of impairment of vision. Dr. Allbutt, in the very important practical communication to which I have referred, makes the interesting remark, which will be supported by the experience of all surgeons, that in the severer forms of spinal injury, those that prove fatal in a few weeks, these evidences of eye disease are not met with ; for out of seventeen such cases he found no evidence of eye disease in any one instance. This is a most important observation, and one that bears strongly on the cause of these affections. It also affords a most complete answer to an objection that has often been urged in these cases, viz., that as sympathetic affection of the eye is rarely met with in severe in- juries of the spine, such as fractures and displacement of the ver- tebra, with transverse lesion of the cord, its occurrence in the less severe and more obscure forms of injury can scarcely be looked upon as the direct result of the spinal mischief. It would appear, how- ever, from the observations of Dr. Allbutt, which I can entirely con- firm, that it is in these very cases that it is met with, and not in the severe and rapidly fatal ones. That a certain portion of the spiilal cord exercises a direct influence on the eyes, has been incontestably established by the experiments of modern physiologists. It has been long known that the upper cervical portion of the spinal cord and its intra-cranial prolongation control the movements of respiration, and hence it is well known to physiolo- gists as the 'respiratory tract '—so also the lower dorsal and lumbar divisions exercise an influence on the genito-urinary apparatus, and are known as the ' genito-spinal.' But it has been reserved for the more modern researches of Budge and Waller, who in 1851 demonstrated that the filaments of the sympathetic that supply the eye take their origin from that part of the spinal cord which is contiguous to the origin of the first pair of dorsal nerves, and that the portion of the spinal axis which extends from the fifth cervical to the sixth dorsal vertebra, and according to Brown-Sequard, even as far as the tenth dorsal, possesses a distinct influence on the organs of vision. Hence, by these physiolo- gists it has been termed the ' ciho-spmal,' and by Claude Bernard the 'oculospinal,' axis.' It has been determined, as the result of numerous experiments by these physiologists, that the partial division of this cilio-spmal axis oc- casions various disturbing influences on the size of the pupil, the vas- cularisation of the conjunctiva, and probably of the deeper ocular tis- sues, and on the state of the blood-vessels of the ear, exactly similar to those that are occasioned by the section of the cervical sympathetic. The conclusion that must necessarily be deduced from these observa- tions is, that this portion of the spinal cord— the ocido-spinal axis- includes within itself both vaso-motor and oculo-pupillary filaments which are connected with the cervical portion of the sympathetic. Claude Bernard has pointed out clearly the fact that the vaso-motor and the oculo-pupillary nerves possess different reflex actions. By di- ' Rondeau, Affections ncidaires refexes, p. 2-2, et seq. 1J8 LECTURE X. — IMPAimiENT OF VISION. Yiding the two first dorso-spinal roots lie finds that the ocu]o-pupillar phenomena are produced without occasioning the vaso-motor effects in vascular injection and increase of temperature. Whereas, by dividing the ascending sympathetic filament between the second and third rib, the vaso-motor phenomena are developed in the head without any influ- ence being exerted on the eye through the medium of the oculo-pupil- lary filament. He sums up his observations as follows : ' The vaso- motor and the oculo-pupillary nerves do not act in the same way. . . . Thus, a slight irritation of the auricular nerve only occasions vas- cularisation in the corresponding side, whilst the same irritation pro- duces reflex movements in both eyes at the same time. The reflex vascular actions do not appear to be capable of being produced on the opposite side to that which is irritated {d'une mainerecrois&e), and be- sides this they are limited and do not extend beyond a certain deter- mined line of circumscription. All this is in striking contrast with the oculo-pupillary actions which are, on the contrary, general and crossed.' — Rondeau, op. ctt. p. 24. These physiological observations have an important practical bear- ing on afEections of the eye and loss of vision consequent on injuries of the spine. Clinical observations support the results of physiological experiment in the connection that subsists between the oculo-sjiinal axis of the cord and the integrity of vision. Thus — without going so far back as the account that Plutarch gives of the injury sustained by Alexander the Great, who was in danger of losing his sight from the effect of a blow inflicted by a heavy stone on the back of the neck — the records of surgery contain numerous illustrations of the injurious influence of blows on the sight — of blows inflicted on the lower cervical and upper dorsal spine. Thus Rondeau relates that he saw the following case at an asylum for the blind ; A lad aged 1? fell, when five years of age,, down a staircase, striking the shoulder and the back of the neck against the edge of the steps. He did not lose consciousness, but some days afterwards he became quite blind. Under treatment his sight gradually returned, so that at the end of a month he could distinguish the light, and in the course of four years he could discern objects placed near to him. Beyond this no improvement took place, and when Rondeau saw him he found the pupils dilated and the optic disc in a state of white atrophy, more marked towards the centre than at the circumference. The influence on vision of bloii's and injuries of that part of the spine situated "at the root of the necTi and between the shoulders, is well illustrated by many of the cases narrated in this work, and explains the statement made by Dr. Allbutt, of Leeds, in his interesting and important observations to which reference has already been made at p. 116, that those injuries and concussions of the spine that occur high up are more injurious to vision than such as are inflicted on the lower portion of the vertebral column. To what is this impairment of vision due ? Dr. Allbutt, who has studied the subject with much care, gives his opinion, in which I fully coincide, so clearly that I cannot do better than quote his own words : — ' In default of a series of autopsies, we seem to be led towards the con- jecture that hyperemia of the back of the eye, following injury to the spine, is probably dependent upon a greater or less extension of the men- ingeal irritation up to the base of the brain. Now, have we any reason to suppose that spinal meningitis does creep up into the encephalon ? We have : for, setting aside tlie curious head symptoms such patients often present, here the actual demonstration of autopsy comes to aid us. It is tolerably well known to careful pathologists that encephalic menin- OPHTHALMOSCOPIC appp:aran7TERf)SSE0irS NERVE. 127 The general aspect of the limb was the same. The pronation and flex- ion of the forearm and wrist were marked ; but the power of supination was not completely lost— in fart, existed to a considerable degree, but was not perfect. So also with regard to extension of the hand from the wrist. The knuckles conld be brought up nearly to their proper level. Now this imperfect power of supination and of extension of the hand was doubtless due to the supinator longus and extensor carpi radialis longior — muscles supplied by the radial nerve — retaining their power, and thus being able to act ; whilst the short supinator and the short ex- tensor of the wrist, both supplied by the posterior interosseous nerve, were completely paralysed. Hence the imperfection of the supination and extension that existed. There was further proof of the fact of the radial nerve having continued to maintain its action in the fact that sensation was not lost in its terminal cutaneous branches. The tem- perature of the hand also had not fallen, as in the first case. Caxe 53. Fracture of Lower Epiphiisis of Hnmerus— Wrint-drop from Paralysis of Posterior Inter osseiis Nerve—Tonic Contraction of Flex- ors. — M. M., aged seven, was admitted as an out-patient under Mr. Heath, and by him transferred to' me. In June 1870, she fell over a croquet hoop, and the lower part of the right humerus was fractured. The arm was at first supposed by her friends to be dislocated, and a non-medical gentleman who was present pulled violently at it for some time, but as he did no good, she was taken to a medical man. Splints were used for seven weeks ; they reached from the tips of the fingers, which were kept extended. When the splints were left off the fingers became flexed at once. Her parents thought they were more so than on admission. She could crochet with the right hand, and could write, but badly ; she had been learning to write with the left hand in conse- quence. She had very marked wrist-drop ; she could, however, easily extend her wrist. Her hand was pronated, and could only be imper- fectly supinated. The fingers were flexed and drawn into the palm of the hand. On the wrist being dropped, tlip last two phalanges of the fingers could be imperfectly extended by the patient. On the wrist being straightened, the fingers became flexed, and could not be extended actively or passively. On forcibly extending the fingers and wrist, tliere was no tension of the palmar fascia, but there was great tension of the flexor tendons above the wrist. The hand was congested and cold. The arm was distinctly smaller than the other. The temperature of the right palm was not high enough to move the index of the thermome- ter— so that it is below 85°, that of the left being 93 -G". The sensibility of the hands was tested by compasses ; it seemed quite as acute in the right as the left. There was some irregularity of the lower end of the outer condyle, which seemed to have been the situation of the fracture, or separation of the epiphysis, which wa- the original injury. Dec. 19th.— 1 ordered a splint to be specially constructed so as to per- mit of gradual extension of the fingers by means of a movable hand- piece worked by a rack and pinion. Jan. lith, 1871.— I ordered her arm to be faradiscd daily. There was at first scarcely any contractility perceptible in the extensors. 9^^.- The splint has been applied, and the arm has been galvanised daily. The contractility of the extensors and supinators has markedly 33^^._'The fingers have become sore from the pressure of the instru- ment The index-finger is but little improved. The middle finger is better, and the little and ring fingers are very much so, being now almost straight. The wrist can be extended perfectly, so that the knuckles can be brought to a level with the back of the forearm. When so extended. 128 LECTURE Xir. — MEDICO-LEGAL ASPIiCTS. the fingers are half bent. But when the wrist is dropped they can be extended by the patient. In doing this they always involuntarily spread out in a fan-shape, owing to the action of the dorsal interossei. It would appear that the chief resistance to proper extension was due to the contraction of the flexor carpi radialis and the flexor tendon of the inde)(- finger, both of which are very tense. I proposed to divide these snbciitaneoiisly ; but the child's friends would not give their con- sent, and the patient was consequently discharged from tne hospital. In this case, also, we had the partial loss of supination and of exten- sion dependent on the paralysis of the posterior interosseous nerve ; whilst those movements that were due to the interossei and lumbricales were perfect. The contraction of the flexors, which had become very marked, was apparently due to the loss of action of their antagonist muscles. It was most marked in the flexors towards the radial aspect of the forearm, and was also associated with a tonic pronation of the limb. The muscles thus injuriously affecting its movement had apparently undergone some rigid atrophy ; and I regret that the child's friends would not allow tenotomy, as it offered a good prospect of cure. The fall in the temperature of the hand was very marked. It amounted to at least 8^" F., and how much more it was impossible to say, owing to the marking of the thermometer not admitting of a lower degree being noted. But the difference between the two hands in this respect was most obvious and very sensible to the touch. This great fall in the tem- perature of the hand is very remarkable when we reflect that it was due to paralysis of a branch of the musculo-spiral which is not directly dis- tributed to the hand ; whilst the other nerves of the hand — the median and ulnar and cutaneous branch — were intact, and gave no evidence of paralysis. The movements of the muscles of the hand itself, and the sensibility of the skin covering it, were normal. LECTURE XII. ON THE MEDICO-LEGAL ASPECTS OF COXCUSSION' OF THE SPINE AND SHOCK OF THE NERVOUS SYSTEM AXD ON THEIR DIAGNOSIS. There is no subject in forensic medicine more important, and there are few more difiScult, than that which relates to the correct estimate of the nature, the extent, and the probable consequences of an injury of the nervous system sustained in a railway collision. The importance of an attentive study of these cases does not consist merely in the great frequency of their occurrence, though in this respect they stand in an unhappy pre-eminence— greatly exceeding in number all other cases put together, in which medicine and law are mutually brought to bear upon, and have to co-operate in, the elucidation of the truth. But the consideration of these cases from a medico-legal point of view is a mat- cer of the greatest importance by reason of the difficulties with which they are surrounded and the obscurity in which they are enveloped. In this respect their investigation resembles somewhat, and is only equalled by, that of cases of alleged insanity. In those cases of injury of the nervous system that become the subject of medico-legal enquiry there is, as in cases of alleged insanity, no mate- rial difficulty experienced in the determination of the various questions that may arise in the more severe and obvious forms of disease. But it INJUUIKS ONLY ONE riESl FOR COMPJiNSATION. 129 is far otherwise in the slighter and more obscure cases. In these, not only may the question be raised as to the actual' existence of the alleged symptoms ; but their existence having been admitted, tlie surgeon must determine the value to be put upon them as evidences of real organic disease, or of mere functional disturbance. And in reference to the idtimate fate of the patient he must state to what extent recovery is likely to take place— and when it may be expected. In addition to all the intrinsic difficulties, which are necessarily connected with such cases, there is under-lying, and greatly disturbing their simple profes- sional aspect, the great question of the amount of pecuniary compensa- tion that should be granted for the consequences of the alleged injury. Here we have a disturbing element that, happily, never intrudes itself into other questions of surgery, and into very few of forensic medicine. But it is an element of disturbance, to the effects of which due weight must be given by themedical attendant in so far as it afEects the morale of the patient, for it is apt to influence him injuriously in more respects than one, by leading him either wilfully or unconsciously to exaggerate his symptoms, just as he is very apt to over estimate his business losses and the pecuniary expenses entailed by the injury. But, remember, if I advise you not to neglect to take this question of pecuniary compensation into your consideration, it is only so far as it afEects the patient's symptoms and the estimate he forms of his own condition. In no other way can you as medical men — either as the sur- geon to the railway company, or still less, if possible, as the private medical attendant of the patient, have anything whatever to do with the matter. This is a question that is altogether out of our province. A medical man who considers it in any way except in its influence on the mental, and through that on the physical, state of the patient, meddles with what neither concerns him nor his profession, and places himself in a false and unenviable position. Let me, therefore, urge upon you, when you are engaged in these compensation cases, never under any cir- cumstances to allow yourselves to be drawn into a discussion as to the amount of money payment to be made to the sufferer, unless the matter is expressly referred to you by the counsel employed by both parties. But even then, I would advise you, if possible, to avoid being placed in the undesirable position of arbitrator. You may be sure that neither party will be satisfied with your decision. The fact is, that a compensa- tion claim for alleged injury is made up of various elements, of which the personal injury is only one. This, which is alone the surgeon's province, in reality often counts for very little in the case. The losses sustained in business ; the expenses, medical and others, directly in- curred by the patient or to which he is liable to be put as the result of the injury, constitute, as a rule, the heavier and more important items in the claim for compensation ; and these are matters that lie in the province of counsel, attorneys, and accountants, and are altogether for- eign to that of the surgeon. Mental sufferings, bodily paia and disa- bility, the diminution of that physical and mental vigour in which the enjoyment of life so largely consists, even complete annihilation of the prospects of a life, weigh lightly in the scales of Justice, which are made to kick the beam only by the weight of the actual money loss entailed by the accident. When a person who has been present in a railway accident, and who alleges that he has been injured, is presented to you for your surgical opinion, you will find that the case has to be regarded from four points of view, viz. : — 1. As to whether he has really been injured. 2. If injured, what is the nature and extent of the injury? 130 LKCTiMiE xii.— medico-lp:gal aspects. 3. Whether the injuries are permanent or not ? 4, If not permanent, then when will he be restored to health ? Now, the difificulty of determining these points, and of answering these questions, more especially the two first, will depend greatly upon whether you are the medical attendant of the patient and are employed on his behalf, or are engaged for the interests of the railway company. If you are the medical attendant of the sufferer from the alleged neg- ligence of the company's servants, or are consulted by him, you will have abundant opportunities of seeing him and of judging of him at different times— often, perhaps, when he does not expect your visit. If you happen to be his regular medical attendant, you will be able to compare his physical and mental state after the accident with what it was previous to that occurrence. But the case is widely different if you are employed on behalf of the railway company, whether as their regu- lar surgeon or for the purpose of advising them with respect to a special case. In these circumstances your position is one of equal difficulty and delicacy. In accordance with the lex non scr'ipfa — that somewhat vague code of honour that goes by the name of ' professional etiquette ' — you cannot, and in no case, or under any pretence whatever, ought you to -visit the patient after you have given him the first attentions required on the occurrence of the accident, and after he has been removed to his own house, except in the presence of, or in consultation with, his own medical man. The patient is not yours — he proljably does not wish to consult or even to see you. Perhaps, you are admitted to an interview with him and to an examination of him only after consultation with his solicitors and by their consent, or in virtue of a judge's order. He most probably looks upon you as being hostile to him, and as coming with the view of making light of his misfortunes. Hence, you will usually have but few opportunities allowed you of seeing the patient — generally only one — at most, two or three. He is always prepared be- forehand for your visit ; he is excited, annoyed, or apprehensive with respect to it ; you do not consequently see him in his usual frame of mind ; and the mental disturbance thus occasioned may re-act injuri- ously upon and greatly aggravate his physical ailments. Above all, you have no opportunity of taking him unawares and unprepared when your visit is not expected, and when you would have a good opportunity of judging whether this symptom or the other in reality exists, or if it ex- ists to the alleged extent. The difficulties that surround an investigation by the railway surgeon are therefore very great and often embarrassing, and frequently render it extremely unsafe for him to come to any very decided opinion upon the case, unless the symptoms presented by it are very marked and of the nature termed ' objective.' Much delicacy and tact also are required in these examinations when they are conducted by the surgeons employed by the railway company. The patient should be dealt with kindly and in a straightforward man- ner ; his tale listened to with patience, and his physical examination conducted with gentleness, care being especially taken to avoid the in- fliction of unnecessary pain, or doing anything that may bear the inter- pretation of cruelty or even harshness. In these surgical examinations no solicitor should be allowed to be present on either side ; and should the patient's legal adviser insist on being in the room, it is better for the examining surgeon to withdraw. This investigation is a purely surgical one. The presence of the pa- tient's own medical adviser is ample protection to his interests, and a solicitor is necessarily out of place in a proceeding which is beyond the limits of his own profession. I have actually known a solicitor attend DESIRABILITY OF A COX.JOIXT KEPOItT. 131 with a short-hand writer to take down notes of the questions and replies —a, practice which I have heard stigmatised by the Lord Chief Justice of England as most reprehensible. After the examination has been made, it is usual and necessary for the surgeon to send in his ' Report ' of the case to the legal advisers of the plaintiff or the defendant. This Report should be full and clear. The symptoms presented by the patient should be described, their prog- ress traced, your opinion given as to the actual condition and the prob- iible future, and whenever practicable, the grounds on which you fouiid that opinion. If the examining surgeons agree on all these points, they may draw up a Joint Report. Should they not be of the same opinion, each must send in a separate one. These Reports are usually considered coniidential, but erroneously so as regards that of the railway surgeon. It has recently been ruled by the Lord Chief Justice (Farquhar v. Great Northern Railway Company) ^ that the Report thus made to the com- pany is not confidential, but that the plaintiff may have access to it. His Lordship said that it was most desirable that a medical man on the part of the company should have an opportunity of seeing the patient in order to ascertain the nature and extent of the injury. But then, on the other hand, the patient should have the corresponding advantage of knowing what reports had been made to the company concerning him. The object of the defendants in an action for compensation for alleged injury in sending their medical man to examine the plaintiff is for their own advantage, not his. It is to determine whether he really has heen injured as alleged ; if so, to what extent, and when he is likely to recover. It is but fair, therefore, to the plaintiff that if he submits to the intrusion of a stranger and suffers himself to be personally and mi- nutely examined by one whom he is apt to regard in the light of a hostile witness, he should be made acquainted with the opinion that has been formed of his case. The plaintiff's course will be very much guided by a knowledge of such opinion. If the patient have been really and seri- ously injured, it is only just and right that he should be made ac- quainted with the candid opinion of the medical man sent to examine him. If he over-estimate his sufferings and find that the defendant's surgeon suspects him, he will be more likely to take a less serious view of his case and to accept reasonable compensation. Whereas, if he be wilfully misrepresenting his condition he will be little disposed to sub- mit himself to the searching cross-examination of counsel if he know that the surgeon employed on behalf of the railway company has de- tected his fraud. In all cases the cause of truth and justice would be materially furthered in these cases if the medical men on either side were to meet and confer upon the case, and determine if possible on some conjoint report. The difference of opinion between them would probably be found to be narrowed down to one or two points — probably to questions connected with the duration rather than with the nature of the alleged injury ; and those unseemly conflicts of opinion which occa- sionally occur in courts of law would be in a great measure avoided. They, not uncommonly, now occur from a medical witness suddenly ' springing ' upon the court, a new theory as to the nature and extent of the injury, or making a positive statement as to the existence of other •symptoms of which the surgeons had never heard, and consequently had no opportunity of verifying or denying. Now let me proceed to tell you generally how to determine an answer to the two first questions that will present themselves to you in all these ■cases, viz., 1 Vide Solicitors' Journal Ann. Reports, Jan. 30, 1875, p. 236. 1:12 LECTURE Xri. — XEDICO-LEiiAL ASPECTS. 1. "Whether the patient has really been injured ; and, 2. If injured, then what is the nature and extenb of the injury ? The answers to these questions involve the diagnosis of the case ; and liere let me tell you how and by what method you may be led to arrive at the truth in this important particular. In effecting a diagnosis you may look upon a patient very much in the same way as a lawyer looks upon a reticent witness in the box. You must take it that you have before you a person who is not disposed to tell the truth. It is your business to elicit the truth ; and just as a skilled counsel employs a certain method which experience has taught the members of his profession tends to elicit that truth— experience con- llrmed, perhaps, by his own sagacity and natural instinct — so the sur- geon employs a certain method to elicit the truth whicli the patient is jierhaps unable to reveal, even though he be willing to do so, and whicli the disease cannot tell us. In making a diagnosis you will find that you have to employ both your senses and your judgment. In fact, a diagnosis is established by a method of observation ; observation being nothing more than the application of the senses, tempered, modified, and improved by the judgment. The mere use of the senses will not enable you to effect a diagnosis. You may see without perceiving. You may hear and not be capable of understanding. You may touch and yet be unable to feel. You must learn how to effect a diagnosis by the combined influence of study and practice. Mere study will not give it to you. No man, however much he may consult books, and however learned he may be in surgical literature, can possibly, by the aid of book-learning alone, distinguish elasticity from fluctuation. No sur- geon understands intuitively the nature of a complicated injury or dis- ease the first time he sees it. You must complement study by practice. You must study in order that you may know what you may expect to find, and this you will learn from the accumulated experience of your predecessors, which is to be found in books, or heard in lectures. To find it you will need the cultivation of your senses. It is, therefore, by that combined influence of study and practice, of learning and judg- ment, that a diagnosis is ultimately efEected. In effecting a diagnosis in these as in all other surgical cases, you will find that the patient will present two distinct classes of phenomena, and it is very important to bear in mind the distinction and the difference that exist both in kind and in importance of those two classes. He will, in the first place, present a series of phenomena which are recognisable by the surgeon himself, however unable the patient may be, from his injury or disease, to explain them. These are commonly called objec- tive, and are described, or ought to be described, in surgical language as ' sigjis.' Let me give you an illustration. A man is brought into the hospital unconscious, with a laceration of his scalp, with a depression of his cranium, and with bleeding from the ear. He is unable to tell you a single word ; but you recognise his condition at once by the local signs just mentioned, coupled with the more general signs, perhaps, of dilated pupil, heavy stertorous breathing, and slow pulse. These are the signs that he presents, and these signs are unmistakable by the sur- geon. They indicate at once, without a word from the patient, without the necessity of putting a question to anyone, what his actual condition is. But there is another series of phenomena presented by the patient which are of less importance than those that I have just mentioned, and that series of phenomena goes by the name of ' sj/mpfoms.' They are subjective — that is to say, they are not recognisable by the surgeon, but are taken upon the statement made by the patient. The surgeon can DIFFEUKXCE BETWEEN SIOXS AND SY:\rPT(>MS. 133 form no Judgment of them except so far as the patient tells him. A man, for instance, comes to the hospital complaining of a violent pain in his head. You cannot possibly determine whether he has got that pain or not, except by his own statement. He tells you he has, and you must take it that he has got it, especially if he presents other phenomena that are corroborative of that statement. Pain is a symptom. All symptoms are taken upon the assertion of the patient, and they are all incapable of proof by the surgeon, except so far as his reliance on the patient's statement is concerned, whatever be the value of that as a matter of proof. You will therefore see that there is an immense differ- ence in point of value as well as in kind between a sign and a symptom. But there is a further difference between the two. A sign indicates not only the fact of a lesion, but it indicates the very nature of that lesion in the majority of cases. It is, or it may be, the lesion itself. A symp- tom merely indicates the fact of there being a disturbance of some kind, but it does not indicate more than that. It in no degree shows what the nature of that disturbance is. In making a diagnosis, then, always bear in mind the difference of value between signs and symptoms, be- tween the objective and subjective phenomena presented by the patient. The symptoms presented by the patient himself are, as I have already said, subjective — they are only known to and must be described by the patient himself ; and here the surgeon gets upon totally different ground, and has to exorcise a considerable amount of caution in effect- ing his diagnosis, because the patient will very frequently do one of three things. He may unconsciously exaggerate his symptoms — that is a condition that is extremely common in nervous and hysterical per- sons ; he exaggerates not only the actual existence of any symptom, but its relative importance to others. One symptom has chiefly attracted his attention, and on that he dwells. He employs exaggerated language in describing it ; he will tell you that he has got an ' agonising ' pain, a ' distracting ' pain ; he will use the strongest expletives in that way in connection with his symptoms, often unconsciously exaggerating the importance of one particular symptom. Then, again, he will some- times, and for various reasons, consciously and designedly either exag- gerate or conceal symptoms. Patients often do both — unconsciously exaggerate and wilfully mislead— and it is very important for the sur- geon not to be deceived in these respects, and to use his utmost powers of cross-examination and of searching enquiry in order to elicit whether symptoms which are described really exist, or whether symptoms which in reality do exist arc designedly kept in the background. Here the diffi- culties of diagnosis become great, but fortunately it is but rarely, except in cases of nervous shock, that the surgeon has to deal with cases in which the phenomena presented to him are purely subjective, and in which subjective cannot be supplemented or corrected by objective phe- nomena which I have already described as being so infinitely more im- portant. Well, then, when we have to give an answer to the first question, viz., whether the patient has really been injured, or whether he is malinger- ing, let me always advise you to look out for some objective symptom- some sign on which you may rely as being beyond the patient's control, incapable even of exaggeration, whether that exaggeration be wilful or unconscious. In the class of cases that we have been considering the chief signs on which you may place reliance as consisting of objective phenomena, the verification of which does not admit of doubt, are, 1. Ophthalmoscopic signs furnished by the examination of the fundus oculi ; 2. Paralytic phenomena ; 3. Alteration in size of a limb ; 4. Diminution of sensi- 134 LECTURE XII.— MEDICO-LEGAL ASPECTS. bility, as determined by the sesthesiometer ; 5. Diminution or loss of electric irritability and sensibility ; 6. Unnatural and persistent rigidity of muscles of the spine or limbs ; 7. Diminution or elevation of the temperature, and, 8. Indications afforded by the state of the pulse, tongue, digestive organs, &c. Indications furnished by one or other of these signs cannot deceive, and not only do they not deceive as to the actual existence of definite lesion of the nervous system, but they go further, and they afford valuable and reliable information as to the ex- tent and degree of that lesion, and thus serve as foundations for the answer to the second question I have put, viz.. Admitting the existence of an injury to the nervous system, what is its nature and extent? But even in regard to objective phenomena you may be deceived, un- less great care be taken. And here I must tell you that an extensive experience in railway compensation cases will probably impress you more with the ingenuity than with the honesty of mankind. A history of deception practised on railway companies by alleged sufferers from acci- dents upon their lines, would form a dark spot on the morality of the present generation. Railway companies, it is true, are not particularly tender-hearted in their dealings with the victims of their own negligence and mismanagement, and too often treat those who have really seriously suffered with a degree of suspicion which is as unjust as it is vexatious. And their officials, too, frequently throw every obstacle that the law can furnish in order to retard or even to frustrate a just and equitable com- pensation for the injuries that have in reality been sustained. But, in justification of the companies, it may fairly be contended that they are so frequently the subjects of a degree of deception that actually amounts to a conspiracy to defraud them, that the public is not free from blame if suspicions are unjustly aroused and manifested in regard to some cases that are in all respects genuine, I will relate two or three instances to you to show how important it is, even when objective signs present themselves, not to be too hasty in concluding that these are the bond- fide results of the injuries sustained. Thus I have known cases in which persons who happened to be in a railway collision, but who were uninjured by it, have attributed to this accident injuries previously and elsewhere sustained, and have actually brought actions for compensation for the old and antecedent injury. I will give you one case out of several that have come to my knowledge. The wife of a ' respectable tradesman ' brought a child about eight years of age to consult nie relative to an inflamed knee-joint. She stated that she and her child had a short time previously been in a collision on a railway ; that the child was thrown out of her lap and struck its knee violently against the edge of the opposite seat. There was an abrasion of the skin covering the patella, corresponding to the seat of the alleged blow. The inflammation of the joint went on from bad to worse, until at the end of about three months I was obliged to amputate the leg. An action was brought against the company by the father of the child, as its next friend, for the loss of its limb consequent on the injury to the knee alleged to be sustained in the collision. The company would certainly have been cast in very heavy damages, if their enquiries had not led them to a knowledge of, and enabled them to establish the fact that, about a week before the collision, the child had fallen at play and cut its knee upon a stone ; that the joint was inflamed and under treat- ment at the time of tlie collision, and that in the railway accident itself it had escaped all injury. In another case a gentleman alleged that he had received an injury of the back in a railway collision. After a time he began to suffer from albuminuria. His condition was attended by many anomalous symp- CASES OF IMPOSTURE. 135 toms, and occasionally with the presence of a small quantity of blood in the urine. It continued for many months, resisting the treatment to which he was subjected by his own medical attendant, by myself, and by several physicians who saw him in consultation from time to time. The case came to trial. The plaintiif received heavy damages, and very speedily got rid of his albuminuria. From circumstances that subse- quently came to my knowledge I was siitisfied that the albumen had been skilfully mixed with the urine. In another case, a patient who had been present in a railway collision continued for nearly twelve months m a state of complete prostration ; suffering, according to his own statement, intensely from pain in his spine, and being utterly incapacitated for business. He could not stand without crutches, and was barely able to walk a few yards with them, dragging one leg in a helpless manner behind him. He received ample solatium, and in less than a month had not only lost the pain in his back, but thrown away his crutches, and had so far recovered his busi- ness aptitude that he was able to travel many hundred miles by railway in the active prosecution of his business. I mention these cases, and I might greatly multiply them, to show you that even when objective symptoms, often of the most marked character, are present, you must not at once conclude that there is neither impos- ture nor gross exaggeration. Diagnosis.— There is a form of deception occasionally practised, against which it is necessary for the surgeon to be on his guard. It consists in concealing the existence of an old-standing chronic disease, and assigning the symptoms and low state of health resulting from it to the accident itself. Thus a person knowing that he suffers from chronic albuminuria, may keep the surgeon in ignorance of the fact, and attribute the wasting, vomiting, cerebral and ocular disturbances consequent on this affection to the shock of the accident. It is difficult to lay down any rules for the guidance of the surgeon in such cases. The diagnosis must at best be left to his practical tact and professional sagacity. But it may be stated broadly that when he finds that the patient presents symptoms of constitutional derangements which are out of all proportion severe as compared with the nervous shock, his suspicions should be roused, and a minute investigation insti- tuted into the patient's antecedent health and the actual state of his organs. I have already spoken of the comparatively small value to be attached to meie subjective symptoms in comparison to what is to be given to objective signs. But yet in a certain, and by no means small, propor- tion of cases of nervous shock, these are the only phenomena that will present themselves to you. These subjective symptoms may be wiltul y invented in order to mislead, or may, if existing, be either consciously or unconsciously exaggerated. „ , . ,, ^■ Malingerers may often be detected by taking off their attention in , conversation ; by desiring them to show their tongue, &c., and then ' finding that some symptom of which they made great complaint, such as pain in the spine on pressure, or a spasmodic movement ot a leg or an arm, was no longer felt, or suddenly ceased. But although undoubt- edly, in many cases, deception may thus be readily enough detected ana exposed, yet this test is by no means an infallible one. In the tirst place the malingerer may be on his guard, and thus frustrate the attempt to entrap him. But even if the pain is not complained ot, or it the spas- modic ierk of the limb ceases when the attention of the patient is callerl off, it does not follow that he is practising a cheat. I have seen a spas- modic jerk of the leg in one case, and a constant tremor ot the hand in 136 LKCTUUK .\II.— MEDICO-LEGAL ASPECTS. another, suddenly cease when the patient was desired to put out his tongue, in cases of disease not resulting from injury, in which there was no suspicion of, and no object to be gained by, malingering. And as to the spinal tenderness, I have found it disappear m hysterical girls when attention was strongly directed elsewhere. We must not, therefore, necessarily consider the cessation of these symptoms when the attention is taken off as evidence of malingering, but we may, I think, fairly take it as evidence that the particular symptom, whether it be pain or spasm, does not arise 'from organic disease, but is the consequence of mere func- tional disturbance, and so far the test is a very important one. When invented, or wilfully exaggerated in order to mislead, the fraud may usually be detected by a surgeon accustomed to these investigations, finding that the symptoms do not bear a due proportion to one another ; that one is brought into greater prominence than the rest, and that the patient contrives to direct attention to, and to lay emphatic stress on it. There is, in fact, an absence of that harmony of symptoms, if I may use such an expression, which characterises all true and real diseases. The same may be said with regard to that mendacious exaggeration which is so constantly found associated with the hysterical or emotional temperament, or with distinct hysterical and emotional manifestations, both in the male and in the female. In such persons the exaggeration does not confine itself to one symptom, but pervades the whole of the condition, mental as well as physical. In making a diagnosis founded on purely subjective symptoms, you must then most certainly take the entire condition of the patient and estimate its value as a whole. Judge if the parts of which it is com- posed are consistent with the alleged conditions, and are in proper har- mony or relation with one another. In these cases you must take the whole group of symptoms. It is most unfair to break it up and to dis- sect each separately. Any one symptom may be common to several con- ditions ; may by itself indicate nothing positive or precise, but in their entirety the symptoms may be indicative of a state of real disease. Thus, for instance, a pain in the head, impairment of memory, confu- sion of thought, inability to maintain a continuous train of thought, incapacity for ordinary business of life, dreams of a distressing charac- ter, weakness of sight, general debility, an irritable temper, muscular weakness, coldness of extremities, quick and feeble pulse, &c., may each individually be referable to a vast variety of constitutional and local conditions, but if taken collectively, and as a group, they certainly indicate a weakened and irritated nervous system, and if following close upon an injury which induces general shock of the nervous sys- tem, or which influences the nervous centres, may be fairly taken as the result of such injury. In reference to this general discussion I may fairly put the matter thus : that one single objective sign, as, for instance, the loss of electric irritability in the muscles of one leg, may be taken by itself and inde- pendently of any other sign, symptom, or abnormal manifestation, as be- ing absolute and irrefragable evidence of paralysis of that limb, conse- quent on spinal lesion. Whereas no one of the subjective symptoms that I have just mentioned is by itself proof of any disease whatever. Any one of them may be the simple consequence of fatigue, of exhaus- tion from excesses, (Sec, but yet taken collectively, they may fairly be taken as evidence of nervous shock. And the weight to be attached to them is, I need not say, greatly increased by the determination of the co-existence of one or more of the objective signs already mentioned. It is important to make the diagnosis between the three pathological conditions that may result from concussion of the spine, viz., myelitis. MYELITIS, MENINGITIS, AND ANAEMIA DISTINGUISHED. 137 meningitis (separately or combined), and anaemia of the cord. And the importance of the diagnosis rests on this point, tliat in the two first con- ditions the primary inflammation is apt to bo followed by such changes in the structure of the cord and its membranes as will leave organic lesions — possibly of a permanent character — wliilst in ana?mia of tlie cord nutritive changes seldom go on to permanent impairment of func- tion ; and the disease is, as a rule, far more amenable to treatment. ' Weakness ' and ' paralysis ' are not con\ertible terms wlien applied to the condition of the muscles of a limb. In ' weakness ' all the move- ments of which a part is naturally capable are perfectly and equably per- formed, though tlieir force is lessened, and the possible duration of their action materially curtailed. But in ' paralysis ' there is either complete ■ loss of all motility of the muscles of a part, or there is an irregularity in tlie movements of which it is normally susceptible ; some being wholly lost, whilst others are more or less persistent. There is a loss of equi- poise between opposite and antagonistic sets of muscles, and thus vari- ous deviations of the part from its natural sliape may be occasioned, such as drooping, contraction, inversion, or extension. la making the diagnosis between spinal anaemia, myelitis, and menin- gitis, there are four conditions to be attended to ; namely, the local symptoms, the influence of therapeutic agents, the temperature of the body, and the ophthalmoscopic appearances. So far as the local symptoms are concerned, it will be found that in spinal anaemia there is always pain at one or more points along the ver- tebral column. This pam is associated with diffused' cutaneous hyper- sesthesia of the back. The pain is severely complained of if the patient is moved by the surgeon, but it will be observed that he may move him- self in dressing and undressing without exhibiting any evidence of suffering. Although there is much cutaneous hyperjesthesia, there is often a good deal of deep-seated tenderness, especially on pressing on either side of the spinous process in the mter-vertelDral spaces. The paralysis, if any, is incomplete, there is no affection of the sphincters, no cramps or chronic spasms ; there is often a general emotional or hys- terical condition associated with the spinal symptoms ; the general ap- pearance of the patient is anaemic, the pulse quick, feeble, and compres- sible. These symptoms are not progressive, will rapidly attain their culminating point, and there remain stationary for a great length of time. In myelitis the pain in the spine is localised, there is little if any cutaneous hypersesthesia. The localised pain is greatly increased by all movements of flexion, rotation, or by pressure downwards. It is greatly increased by percussion, the application of heat, or any act, indeed, which influences the spinal column sufficiently deeply to convey an im- pression to the contained inflamed medulla. There is in these cases always a sensation as if the cord were tied tightly round the body on a line corresponding with the seat of inflammation. The paralysis is often quite complete, the sphincters are affected ; there is atrophy of the limbs, their nutrition being acutely interfered with. In meningitis the general symptoms more or less closely resemble those of myelitis, for indeed it is almost impossible to find meningitis existing without a certain inflammatory implication of tiie cord. Theo- retically, the two diseases may be considered apart, but clinically they are almost invariably associated. In meningitis, however, there are these additional symptoms, clonic spasms, often of a painful character, frequently more or less permanent contraction of certain muscles or groups of muscles, and in both myelitis and meningitis there is, as a rule, a total absence of the hysterical condition. 138 LECTURE Xtl. — MEDICO-LEGAL ASPECTS. There are two tlieriipeutic tests which are of considerable value in confirming the diagnosis between these several conditions. Spinal anaemia is always benefited by strychnine and iron. It is usually con- siderably aggravated by the bromides. The reverse is the case in men- ingo-myelitis. In this condition strychnine greatly aggravates the symptoms which the bromides commonly have a tendency to alleviate, those at all events that are dependent upon the concomitant cerebral irritation. The ophthalmoscopic appearances are also of considerable service from a diagnostic point of view. In spinal anaemia we have a pallid condition of the optic disc, which in the more advanced cases may pro- ceed to white atrophy. In the inflammatory states of the cord and its membranes, more especially m meningitis, there is considerable hyper- emia of the fundus of the eye. There are six special conditions from which the diagnosis of spinal concussion has to be made. They are : 1. The secondary consequences of cerebral commotion ; 2. Rheumatism ; 3. Hysteria ; 4. Injury to nerve trunks ; 5. Typhoid fever ; 6. Syphilis. 1. From the secondary effects of cerelral commotio?i it is not difficult to diagnose the consequences of concussion of the spine in those cases in which the mischief is limited to the vertebral column. The tenderness of the spine, the pain on pressure and movement, the rigidity of its muscles, and the absence of any distinct sign of cerebral lesion, will sufficiently mark the precise situation of the injury. But it must be remembered that the two conditions of cerebral and spinal concussion often co-exist primarily. The shock that jars injuri- ously one portion of the nervous system, very commonly produces a cor- responding effect on the whole of it, on brain as well as on cord ; and, as has been fully pointed out in various parts of these Lectures, the sec- ondary inflammations of the spine, which follow the concussion, even when that is primarily limited to the vertebral column and its contents, have a tendency to extend along the continuous fibrous and serous mem- branes to the interior of the cranium, and thus to give rise to symptoms of cerebral irritation. 2. From rheumatism the diagnosis may not always be easy, especially in the earlier stages of the disease, when the concussion of the spine and the consecutive meningitis have developed pain along the course of the nerves, and increased cutaneous sensibility at points. By attention, however, to the history of the case, the slow but gradually progressive character of the symptoms of spinal concussion, the absence of all fixed pain except at one or more points m the back, the secondary cerebral complications, the gradual occurrence of loss of sensibility, of tinglings and formications, the slow supervention of impairment or loss of motor power in certain sets of muscles — symptoms that do not occur in rheuma- tism—the diagnosis will be rendered comparatively easy ; the more so when we observe that in spinal concussion there is never any concomi- tant articular inflammation, and that although the urme may continue acid, it does not usually become loaded with lithates. But although the diagnosis may not be very difficult from the more acute forms of rheumatism, it is by no means easy to distinguish some of the secondary consequences of concussion of tlie cord from the more chronic and subacute varieties of the disease. In these cases, however, tlie following points if attended to may clear up the nature of the case. In rlieumatism of this form the pain is muscular, is increased by move- ments of the aft'ected muscles, and is influenced by atmospheric vicissi- tudes. In the diffused pains of spinal concussion it will -be found that the central point of the pain is the spine, that it is aggravated by pres- DIFFERENCE FROM TYrHOID FEVER. 139 sure over or movements of the vertebral column, that muscles may be rigid but are not painful, that the pain takes the anatomical course of certain sets of nerves, of those in fact connected with the central spinal pain. In addition to this the history of the case, and the absence of cerebral complications m the muscular forms of rheumatism, will deter- mine the real nature of the case. In some cases of incipient paraplegia one or both knees may swell and become tender from the stress thrown on them m painful efforts to walk, and possibly also from faulty nutrition. This condition may lead to a suspicion of rheumatism ; and, indeed, there may be gouty or rheumatic arthritis of a low form connected with, and partly dependent on, the paraplegic state, the symptoms of which will be evident in the limbs below the knees and quite independently of any affection in (hem. So far as the special diagnosis is concerned of concussion of the roi-d in its primary and secondary symptoms from various other analogous and complicating conditions, I must refer to other parts of these Lect- ures. Thus you will Snd the diagnosis between hysteria and the symp- toms of Concussion of the Cord given in Lecture VIIL p. 94, and that of sacrodynia, one of the most frequent and embarrassing complications or independent phenomena, described at length in Lecture IX. p. 99. 3. Hysteria. — From this manifestation of nervous disturbance I have already pointed out how the diagnosis of spinal concussions can be made (Lect. VIII. p. 94) ; I need not, therefore, repeat the cautions I there laid down. 4. The injury sustained by a large nerve«trunk after its escape from the vertebral canal may lead to more or less paralysis of motion and sensation of the extremity or of the parts supplied by it. In this case- the limitations of the loss of nervous power to the limb or even to one part of a limb — the absence of all central symptoms either in the spine or the head — will determine with suflBcient accuracy the localised nature of the injury. 5. It might at first scarcely appear possible that any chance could occur of mistaking some of the secondary effects of concussion of the spine for the initiatory symptoms of typhoid fever. But yet the diffi- culty may arise, and has actually occurred in two cases in my own expe- rience. There is of course no difficulty in the more advanced stages of typhoid by attention to thermometric indications, diarrhoea, the charac- teristic eruption, the state of the tongue, pulse, &c. But in the early stages the sudden accession of cerebral symptoms, such as frontal head- ache, delirium, somnolence, or maniacal excitement, may mislead the surgeon. And he may incorrectly refer these to an aggravation of the nervous symptoms resulting from the accident, when in reality they are due to this invasion of the initiatory stage of typhoid, which is apt to develop itself with cerebral complications owing to the pre-existing irri- tation of the nervous system. In one case which Dr. Maudsley saw with me, the patient, some weeks after a railway collision in which he- had been severely shaken, became suddenly maniacal, stripped himself naked, and rushed out of the house in the middle of the night in this condition. The cause of this sudden exacerbation of nervous symptoms was very obscure for some days, when it was cleared up by the gradual development of typhoid fever. In such cases as these, indeed, the remark that I have already made more than once is peculiarly applica- ble, viz., to wait for time to clear up the diagnosis. What is obscure to-day will be patent to the most ordinary observer to-morrow. 6. Syphilis. — In syphiloma of the cord and its membranes various symptoms may be developed that closely resemble those presented by spinal concussion ; but here attention to the history of the case, and the 140 LECTl'KK Xiri. — PIIOGXOSIS OF COXCUSSIOiN'. co-existence of syphilitic lesions on the skin or mucous membrane, will determine its true nature. It must not, however, be forgotten _ that a patient suffering from constitutional syphilis may sustain an injury of the spine adding to the ulterior phenomena of spinal meningitis those of a specific character. LECTURE XIII. OS PROGIfOSIS IN COifCUSSIOlN' OF THE SPINE IN ITS CLINICAL AND MEDICO-LEGAL ASPECTS. The prognosis or the determination of the course that the effects of the injury will take, and of the probable state of health of the patient, is one that is surrounded by difficulties of all kinds, and one on which it is often impossible for the surgeon to venture to give a definite opinion. Yet it is on this point that he is commonly most pressed to express him- self dogmatically. The greater his experience the less ready will he be to hazard a joositive opinion. For he will be able to call to mind many cases in which opinions confidently entertained and expressed by surgeons of the greatest eminence, and possibly by himself, have been falsified by the subsequent results. Hence he will seldom venture on anything more confident than a belief in the probability of a given result. The prognosis of a case of spinal concussion involves three consider- ations. 1. As regards the life of the patient. "Will the case terminate fatally or not? 2. If not fatal, whether the injuries are permanent or not? 3. If not permanent, then when will the patient be restored to health ? The prognosis of a serious injury of any part of the nervous system is always bad. I mean by serious, either severe in its primary effects or in its secondary consequences. A serious injury of the brain is never com- pletely recovered from. However long the person may live, and however well he may have got over his accident, traces in some shape or another will continue. Change of character, irritability of temper, lessened apti- tude for work of any kind, impairment of some senses — as of vision, abolition of others — as of taste or smell. All this is familiar to us after such injuries of the brain as produce structural changes. I believe it to be in some respects due to the cord, and that a structural change once effected as the result of injury, is permanent, and leaves more or less in- delible traces of its presence in the modifications it induces in the func- tions of the cord. It is only in this waj that we can explain the extreme tenacity in the persistence of certain symptoms after recovery from the general effects of the injury has long since taken place. 1. So far as life is concerned, it is only in those cases of severe and direct blows upon the spine, in which intraspinal haemorrhage to a con- siderable extent has occurred, or in" which the cord or its membranes have been ruptured, or in other ways so seriously injured that acute softening ensues, that a speedily fatal termination may be feared. In such cases as these the danger is necessarily, cceteris paribus, greater in tlie cervical than in the dorsal— in the dorsal than in the lumbar region. In some of the cases of concussion of the spine, followed by chronic inflammation of the membranes and of the cord itself, death may ■eventually supervene after several, perhaps three or four, years of an in- creasingly progressive breaking down of the general health, and the slow UNFAVOURABLE IN MYELITIS. 141 extension of the paralytic symptoms in extent as well as in degree. I have known several instances in which concussion of the spine has thus proved fatal some years after the occurrence of the accident. And Mr. Gore, of Bath, who has had considerable experience in these injuries, writes to me in reference to the case related p. 83, that this is the third fatal case of wliich he has had more or less personal knowledge, the time from the injury to the occurrence of death varying from two and a half to five years. In these cases, the fatal result is the direct effect of the structural changes that take place in the cord and its membranes. They prove in the clearest and most incontestable manner the possibility of death occurring after a lapse of several years, from the progressive increase of those symptoms, which are dependent upon disease of the nervous sys- tem from concussion of the spine occurring from slight and indirect accidents, and attended by the usual symptoms of such injuries ; the fatal termination being gradually induced by the slow and progressive structural changes which take place in the cord. The case referred to establishes the fact beyond doubt that such a fatal termination is by no means impossible after an interval of several years, in cases of concus sion of the spine in which deep-seated structural changes have developed in the cord. The probability of such a melancholy occurrence is greatly increased if, after a year or two have elapsed from the time of the occurrence of the accident, the symptoms of chronic meningo-myelitis either continue to be gradually progressive, or, after an interval of quiescence, suddenly assume increased activity. In fact, it is the excitation of this very form of disease, viz., chronic inflammation of the spinal cord and its membranes, that constitutes the great danger in these injuries of the spine. When it has once gone on to the development of atrophy, softening, or other structural changes of the substance of the cord itself, complete recovery is impossible, and, ultimately, death is not improbable. Ollivier states as the result of his experience, that although persons affected with chronic myelitis may live for fifteen or twenty years, yet that they more commonly perish within four years. This opinion as to the probable future of patients unfortunately affected by this distressing disease is perhaps too gloomy, so far as the fatal result is concerned, but it is an evidence of the very serious view that a man of such large experience in the diseases of the cord took of the probable issue of a case of chronic inflammation of that structure, and it is doubtless explicable by the fact that Ollivier's experience has necessarily been chiefly drawn from idiopathic or constitutional affections of that portion of the nervous system ; and these may justly be considered to be more frequently fatal than those forms of the disease that arise from accident to an otherwise healthy man not predisposed to such affections. Ollivier takes an equally unfavourable view of the ultimate result of spinal meningitis, and probably for the same reason. He says, ] Is spinal meningitis susceptible of cure ? All observers agree m stating that death is the inevitable result.' In this, however, there can be no doubt that Ollivier was in error. T have seen cases of undoubted spinal meningitis recover. I may instance particularly one of a young lady 14 years of age, with an enormous congenital spinal bifida containing ^^^^ than one hundred ounces of fluid. I cured the disease by repeatea tappings and pressure combined. During the treatment symptoms ot spinal meningitis came on with opisthotonos and convulsive movements, ' Vol. ii. p. 294. 142 LECTURE XIII. — PROGNOSI.S OF CONCUSSION. but complete recovery gradually took place. Ollivier qualifies his state- ment, however, by saying that he has found in one case after death from other disease, old thickening of the membranes of the cord, and that Prank relates another in which a fatal termination did not occur, ihe occurrence of convulsive movements, however, is a most unfavourable sign. They indicate the existence of chronic myelitis, and are usually associated with deep disorganisation of the structure of the cord. They are of a most painful character, and are apt to be excited by movements and shocks of the body, even of a very slight character. With the exception of the case Just mentioned, t have never known a patient recover who has been afflicted by them, progressive paralysis developing itself, and the case ultimately proving fatal. Mr. Gore, of Bath, informs me that he is acquainted with two cases which proved fatal at long periods of time after the accident, in both of which this symptom was present. One of these, a very healthy lad of nineteen, was injured on October 29, 1863, and died May 11, 1866. He suffered from con- vulsive attacks, with extreme pain in the spine, till the latter end of 1864, then the convulsions ceased, but the aching, wringing spinal pain continued ; and his health broke down completely. Phthisis, to which there was no hereditary tendency, developed in the following spring, and he eventually died of that disease two years and a half after the injury. Prom all this it is certain that concussion of the spine may prove fatal ; — first, at an early period by the severity of the direct injury (Case 13) ; secondly, at a more remote date by the occurrence of inflam- mation of the cord and its membranes ; and, thirdly, after the lapse of several years by the slow and progressive development of structural changes in the cord and its membranes (Case 12). 2. But though death may not occur, is recovery certain ? May the efEects of the injury not be permanent though they be not fatal ? Is there no mid-state between a fatal result, proximate or remote, and the absolute .and complete recovery of the patient ? Now this question of permanency of symptoms or of unlimited duration of effects of injury is one that you must approach with great caution, and on which a definite opinion is often impossible. Before proceeding to discuss it let us enquire what is meant by the 'recovery •of the patient ' ? When you are asked, ' In your opinion will this patient ever recover? ' what are you to understand by that question? Is it meant whether there will be a mitigation of the symptoms — an amelioration of health to some, perhaps even a considerable, extent — an indefinite wrolongation of life, so that with care, by the avoidance of mental exertion and bodily fatigue of all kinds, the patient may drag on a semi-valetudinarian existence for fifteen or twenty years ? Is this the meaning of the question ? Is it meant that after a time even he may be able to return to his business — that he may be able to sit in his office or travel about the country? No, certainly not. A man may do all this and yet be far from well — be very far from having recovered. If that question has any definite- meaning, it is whether the patient will in time completely and entirely lose all the effects of the injury he has sus- tained, — whether in all respects, mentally and bodily, he will be restored to that state of intellectual vigour and of cori)oreal activity that he enjoyed before the occurrence of the accident, — whether, in fact, he will ever again possess the same force and clearness of intellect, the same aptitude for business, the same perfection of his senses, the same physical energy and endurance, the same nerve, that he did up to the moment of his receiving the concussion of his spine. In considering the question of recovery after concussion of the spine. PAliTIAL ItECOVEBY. 143 we Lave to look to three points : first, the recovery from the ])rimary and direct effects of the injury ; secondly, from the secondary and remote consequences of it ; and thirdly, the time when such recovery is likely to take place. There can be no doubt that recovery, entire and complete, may occur in a case of concussion of the spine when the symptoms have not gone beyond the primary stage, when no inflammatory action of the cord or its membranes has been developed, and more particularly when the patient is young and healthy in constitution. This last condition indeed is a most important one. A young man of healthy organisation is not only less likely to suffer from a severe shock to the system from a fall or railway injury than one more advanced in life, but, if he does suifer, his chance of ultimate recovery will be greater, provided always that no secondary symptoms dependent on organic or structural lesions have developed themselves. I believe that such complete recovery is more likely to ensue if the primary symptoms have been severe, the result of direct injury, and have at or almost immediately after the occurrence of the accident attained to their full intensity. I have seen many instances of this, and would refer to Cases 1, 6, 7 as being illustrative of this fact. In these cases, under proper treatment the severity of the symptoms gradually subsides, and, week by week, the patient feels himself strong- er and better, until usually in from six to twelve months at the utmost all traces of injury have disappeared. But incomplete or partial recovery is not unfrequent in these cases of severe and direct injury of the spine. Of this. Case 2 is an excellent illustration. The patient slowly recovers up to a certain point and then remains stationary, with some impairment of innervation in the shape of partial paralysis of sensation, or of motion, or both, usually in the lower limbs. The intellectual faculties or the organs of sense are more or less disturbed, weakened, or irritated, the constitution is shattered, and the patient presents a prematurely worn and aged look. In such cases structural lesion of some kind, in the membranes, if not in the cord, has taken place, which necessarily mtist prevent complete recovery. When, therefore, we find a patient who, after the receipt of severe injury of the spine by which the cord has been concussed, pre- sents the primary and immediate symptoms of that condition, such as have been described in Case 1, we may entertain a favourable opinion of his future condition, provided we find that there is progressive ameliora- tion of his symptoms, and no evidence of the development of any inflam- mation, acute or chronic, of the membranes and the cord. But our opinion as to his ultimate recovery must necessarily be very unfavourable, and the probability of his having been permanently in- jured will be greatly increased, if we find the progress of amendment cease after some weeks or months, leaving a state of impaired innerva- tion, or of more or less complete paralysis. And this unfavourable opinion will be much strengthened if we find that subsequently to the primary and immediate effect of the injury, symptoms indicative of the development of meningo-myelitis have declared themselves. Under such circumstances of the double combination, of. the cessation of im- provement and the supervention of symptoms of intra-vertebral inflam- matory action, partial restoration to health may eventnally be expected ; but complete recovery is hardly possible. When a person has received a concussion of the spine from a jar or shake of the body, without any direct blow on the back, or perhaps on any other part of the body, and the symptoms have gradually and pro- _gressiTely developed themselves, the prognosis will always be very un- 144 LECTURE XIII. — PKOGXOSIS OF CO.XCISSIOX. favourable. And for this reason ;— that as the injury is not sufficient of itself to produce a direct and immediate lesion of the cord, any symp- toms that develop themselves must be the result of structural changes taking place in it as the consequence of degeneration ; and these secondary structural changes being incurable, must, to a greater or less degree, but permanently, injuriously influence its action. The occurrence of a lengthened interval, a period of several weeks, for instance, between the infliction of the injury and the development of the spinal symptoms, is peculiarly unfavourable, as it indicates that a slow and progressive structural change has taken place in the cord and its membranes, dependent upon pathological changes of a deep-seated and permanently incurable character. The progressive decadence of health and signs of disintegration of the nervous system are very slow in these cases. At first the patient merely feels weak, is not quite as well able to do a long day's business or professional work as before ; his friends and family observe a change in his character ; he becomes irritable, or taciturn and sullen ; he looks aged and careworn ; hia incapacity for business increases ; his handwriting is changed for the worse ; the powers of walking are lessened, and the disposition to take exercise diminishes. All this goes on for many months, for a year or more ; then one leg begins to fail, usually the left ; he complains of coldness of the extrem- ities, of various uneasy sensations in the hands — tinglings, &c. ; his vision becomes impaired ; he becomes very emotional, almost hysterical, between the fits of irritability, and at last unmistakable symptoms of paraplegia or of structural brain disease, hemiplegia, possibly aphasia, develop themselves. But the progress of the symptoms, however slow, has been continuous from the time of the accident. There may have been fluctations in their severity, but never a complete interval of the same good health that existed before this occurrence. Abercrombie truly says, ' Every injury of the spine should be con- sidered as deserving of minute attention, and the most active means should be employed for preventing or removing the diseased actions which may result from it. The more immediate object of anxiety in such cases is inflammatory action ; and we have seen that it may advance in a very insidious manner, even after injuries which were of so slight a kind that they attracted at the time little or no attention.' Well, then, when you see a patient suffering from the secondary eflfects of a slight injury of the spine, these effects having developed in an in- sidious but progressive manner, examine him with minute attention ; and if you find evidence of inflammatory action in the cord and its membranes, as indicated by symptoms of cerebral irritation, spinal ten- derness and rigidity, modifications of sensation, as pains, tinglings, and numbness in the limbs, and some loss of muscular or motor power, with a quick pulse, functional derangement of the abdominal and pelvic organs, and a shattered constitution, you must, at any period of the case, however early, give a most cautious prognosis. And if many months — from six to twelve — have elapsed without any progressive amelioration in the symptoms, you may be sure that the patient will never recover so as — to use the common phrase — ' to be the same man ' that he was before the accident. But if, instead of remaining stationary, a progressive in- crease in the symptoms, however slow that may be, is taking place, more and more complete paralysis will ensue, and the patient will prob- ably eventually die of those structural spinal lesions that have been de- scribed, or from the extension of diseased action to the brain and its membranes, and the development of incurable cerebral disease. I have purposely used the words ' progressive amelioration ' for this reason, that it often happens in these cases that under the influence of DURATION OP SYMPTOMS. 145 change of air, of scene, &c., a temporary amelioration takes place — the patient being better for a time at each new place that he goes to — or under every new plan of treatment that he adopts. Fallacious hopes are thus raised which are only doomed to disappointment, the patient after a week or two relapsing, and then falling below his former state of ill-health. In forming an opinion, then, us to the patient's probable future state, it is of less importance to look to the immediate or early severity of the symptoms than to their slow, progressive, and insidious development. Those cases are most likely to be permanently injured in which the symptoms affect the latter course. The time that the symptoms have lasted is necessarily a most impor- tant matter for consideration. When they have been of but short duration, they may possibly be dependent on conditions that are com- pletely, and perhaps easily, removable by proper treatment, as, for instance, on extravasation of blood, or on acute serous inflammatory effusion. But when the symptoms, however slight they may be, have continued even without progressive increase, but have merely remained stationary for a lengthened period of many months, they v\"ill undoubt- edly be found to be dependent on those secondary structural changes that follow in the wake of inflammatory action, and that are incompatible with a healthy and normal function of the part. I have never known a patient to recover completely and entirely, so as to be in the same state of health that he enjoyed before the accident, in whom the symptoms de- pendent on chronic inflammation of the cord and its membranes, and on their consecutive structural lesions, had existed for twelve months. Such a patient may undoubtedly considerably improve, but he will never completely lose the ti-aces of the injury. These will in some respects be permanent, and show themselves in general or local weakness, loss of muscular power, change in character, various head symptoms, each trivial in itself, but collectively important ; a cachectic and prematurely aged look, and digestive derangement. And though, as Ollivier has ob- served, such a patient may live for fifteen or twenty years in a broken state of health, the probability is that he will die in three or four. There is no structure of the body on which an organic lesion is recov- ered from with so much difficulty and with so great a tendency to result- ing impairment of function as that of the spinal cord and brain ; and with the single exception, perhaps, of the eye, there is no part of the body on which a slight permanent change of structure produces such serious impairment and disturbance of function as on the spinal cord. The cases in which complete recovery may be expected are those, then, in which the patient is young, in wliich the symptoms have been the effect of direct injury ; in which they have rapidly attained their maxi- mum of severity ; in which early and continuous amelioration has taken place ; in which they are referable to strain of the ligaments of the spine and to the muscles of the back ; to irritation of the nerves in their exit from the vertebral canal ; to lesion of nerve-trunks rather than of cere- bral mischief ; and, above all, to extravasation of blood into, or to irri- tation of the meninges, rather than a direct primary lesion, or to second- ary structural change of the cord itself. In those cases, also, in which the emotional, the hysterical, or the hypochondriacal element has from the first been largely associated with the signs of special or local lesion, a very favourable prognosis may be given, and a speedy restoration to health usually predicted, the more so when the associations attendant on litigations are removed, which in these cases exercise an important influence in depressing the mental and moral tone of the patient, and thus materially tending to perpetuate his despondent and nervous condition. 146 LECTURE Xril.— PROGNOSIS OF COH-CUSSION. I may take this opportunity of discussing a question which, though it has no direct bearing upon the diagnosis, or even the prognosis, of these injuries, frequently springs out of the consideration of these points in the case ; I mean the discrepancy of opinion that frequently arises amongst medical men, and which develops itself in the evidence given in courts of law, when these cases of alleged spinal injury and nervous «hock become the subject of judicial investigation. That conflicts of opinion as to the relations between apparent cause a,nd alleged effects ; as to the significance and value of particular symp- toms, and as to the probable result or prognosis of any given case, must iilways exist, there can be no doubt. And this is more likely to happen when the assigned cause of the evil appears to be trifling; when the primary effects of the injury are slight ; when the secondary phenomena ■develop themselves so slowly and so insidiously that it is often difficult to establish a continuous chain of connection between them and the ac- ■cident. Such discrepancy of opinion is in these complicated cases not only inevitable, but legitimate ; and for the conflict of views to which it leads in medical evidence — when these views have relation to matters of opinion only, and not to matters of fact — much and very undeserved blame has been cast on medical witnesses. It is important to observe that it is not as to the recognition of facts, objective symptoms, or positive signs that are presented in any given cases of injury, when the physical lesion is distinct ; but ib is in the in- ferences to be drawn as legitimate deductions from these facts, that con- flict of opinion and discrepancy in evidence may occasionally arise ; and I have no hesitation in saying that in at least nine-tenths of all the rail- way or other accidents that are referred to surgeons of experience for arbitration or advice, there is not only no serious difference of opinion as to the true nature of the injury sustained, and none even as to its probable resulting effects on the patient locally or constitutionally, im- mediately or remotely. But in a certain small percentage of cases in which it may not always be easy to establish to demonstration the re- lation between the alleged cause and the apparent effect, in which the symptoms come on slowly and insidiously, or where they may possibly be referable to constitutional or local conditions quite irrespective of and antecedent to the alleged injury, and in which the ultimate result is necessarily most doubtful, being dependent on many modifying circum- stances ; in such cases, I say, discrepancy of professional opinion may legitimately, and indeed must necessarily, exist. There is no fixed standard by which these points can be measured. Each surgeon will be guided in his estimate of the importance of the present symptoms, and of the probable future of the patient, by his own individual experience or preconceived views on these and similar cases. But, in these respects, such cases differ in no way from many others of common and daily oc- currence in medical and surgical practice. We daily witness the same discrepancies of opinion in the estimate formed by professional men of the nature and the future of obscure cases of any kind. In cases of alleged insanity, in the true nature and probable cause of many compli- cated nervous affections, in certain insidious and obscure forms of cardiac, pulmonary, and abdominal disease ; in such cases as these we constantly find that ' quot homines tot sentenfiw ' still holds good. Even in the more exact science of chemistry, how often do we not see men of the greatest experience differ as to the value of any given test, as to the importance of any given quantity of a mineral, — as of arsenic, mercury, or antimony, found in an internal organ — as an evidence of poisoning. There are in fact two questions usually presented to the surgeon in these oases, the answers to which stand in very different categories ; CAUSES Oi" DISCREPANCY OE' OPIiMON. 147 one being capable of a positive reply, the other being usually open to doubt. The first question is as to the value of any one symptom or group of symptoms as indicative of the fact of the occurrence of injury. The second is that, admitting the injury, what will be the probable duration of the evils entailed by it, and will the ultimate result be a complete cure or only partial recovery ? ISTow, except in some peculiarly obscure and complicated cases, in which the actual state is rendered uncertain by previous diseases or injuries, there cannot be, and in practice there is not, any possibility of a conflict of opinion m the answer to the first question, which relates simply to matters of fact. But it is in reference to the second point that the conflict of opinion so often arises. Here we have not a question of fact to be decided by observation. We have not even a question as to the absolute or relative value of the facts so observed, but we have to draw inferences from facts the existence of which is disputed or perhaps only partially admitted. Even if the surgeons are fully agreed as to the facts of the injury — its cause, its nature, or the reality of the symptoms, the real difficulty — the stumbling-block — then presents itself, which is as to the probable future, for they are required to enter on the debateable land of prophecy, to form part of the gemis irritabile vatum, and to forecast the patient's future. They are asked to speak, and often requested to speak positive- ly, in reply to the questions, on whicii it is impossible to dogmatise, viz., whether the recovery will be partial or complete ; and further than this, if partial only, then to what extent ? If complete, then at what period? Here a difficulty at once arises which is felt throughout the whole domain of pathology. These are questions, the difficulty in answering which is by no means confined to the complicated injuries of the nervous system, but extends to the simplest cases in surgery and in medicine. Thus, for instance, a man breaks his leg close to the ankle-joint. No difEerence of opinion does, or probably can, exist as to the cause of the injury, its nature and extent ; but if asked to give a dogmatic opinion as to the future condition of that man's limb — if he will ever recover so as to be able to use it as well as before it was in- jured,- and if so, how long it will be before he can walk, run, and jump with as much facility and safety as before the accident? Or, if he will not wholly recover, and be permanently injured, to what extent that permanent injury may interfere with his activity, so that though he may be able to walk, whether he will be able to run ; and if he can walk and run, whether he can ever jump? How can it be possible for any surgeon to give a positive answer to such questions, and still less for any body of men to agree on any answer, except that it would be impossible to reply with any degree of precision to questions such as these. So with regard to an injury of the nervous system. The injury is admitted, but the question immediately comes, Is this injury temporary or permanent? Are the symptoms dependent on it referable to functional or organic lesion ? Admitting that strength of mind and clearness of intellect are materially impaired or dimmed, when will they be restored? Admitting that the patient cannot think, read, or cal- culate as he was accustomed to do before the accident, when will he be able to do so as clearly, as continuously, and as correctly as before he was injured? Is it not probable, nay, is it not inevitable, that in the answers to questions such as these, differences, and possibly conflicts, ot opinion will arise ? But such differences are inherent m the very nature of the subject. They are not dependent on any uncertainty that spe- cially pertains to medicine, but on the impossibility of drawing definite and precise conclusions from indefinite premises. It is as unreasonable to cofnplain of the uncertainty of medical science because such questions 148 LECTI'RE XIII.— PROGNOSIS OF CONCUSSION. as these cannot be answered with absolute or even approximate precision, as it would be to complain of the uncertainty of engineering science because any given number of engineers might, and certainly would dif- fer, if they were required to say how many miles an axle with a flaw in it could run without breaking down. The truth is, that such questions cannot be answered in a definite, categorical, or even dogmatic manner, and the surgeon should always decline to give a positive reply to a ques- tion that has reference to the possible future of a case, more especially when the element of time is associated with that of recovery ; when, in other words, he is required not only to say whether the patient will get well, but to state when, or, still worse, to say when he will ' be suffi- ciently recovered to attend to business.' Were public discrepancies of opinion confined to the members of the medical profession it would be a lamentable circumstance, and one which might justly be supposed to indicate something deficient in the judg- ment, or wrong in the morale, of its members. But when we look around us, and enquire into the conduct of members of other profes- sions, we shall find that in every case in which the question at issue can- not be referred to the rigid rules of exact science— whether it be one of Engineering, of Law, of Politics, or of Eeligion — the same conflict of opinion will and does, as a matter of necessity, exist, and the same subjects and the same phenomena will present themselves in very vary- ing aspects to the minds of different individuals, — conflict of opinion being the inevitable result. Look at any great engineering question. Are not engineers of the highest eminence to be found ranged on opposite sides in the discussion of any point of practice that has become one of opinion, and that can- not be decided by a reference to those positive data on which their science is founded? Is there no discrepancy of opinion often mani- fested among gentlemen of unimpeachable integrity in their profession, as to possible causes of that very accident, perhaps, which has oc- casioned the catastrophe that has led to the presence of the surgeon in the witness-box? Is the law exempt from conflicts of opinion, independently of those that are of daily occurrence in its Courts ? Are there no such institutions as Courts of Appeal? Are decisions never reversed? Are the fifteen Judges always of one mind upon every point that is submitted to them? Do we never see conflict of opinion spring up in the Lords and Com- mons, amongst the magnates of the legal profession, on questions that involve points of professional doctrine and practice?' ' ' Reference is often made by public writers to the conflict of opinion whicli is commonly found amongst medical witnesses. Lawyers are most apt to refer to this diversity of judgment — rarely in complimentary terms— most often to suggest or point the conclusion that judgments so divided in their course and so little con- sistent are of slight weight and deserve little consideration. A barrister furnishes us this week with facts that should modify that opinion, if strict analogy can serve to afford an illustration or to point an argument. The analysis of the decisions of Lord Justice Giffard, sitting alone in appeal cases from January to June 1870, shows that of forty-one appeals from various courts, the decisions of those courts were aflSrmed in seventeen oases, reversed in nineteen cases, and varied in five cases. In applying this illustration to the cases of difference of opinion amongst medical experts in courts of justice, it must be remembered that in the great majority of cases to be de- cided — say 90 per cent, of railway compensation cases— medical opinion is unanimous. And such cases do not come into court. It is only where doubts and difficulties arise that a judicial decision in court is ordinarily asked. The cases of agreement, which are most numerous, are settled out of sight. Moreover, it is only fair to take into account the essential elements of mystery, individual vital differences, and special combinations, which surround each medical case, and obstruct the arrival at certainty. In legal decisions, all the conditions are known, and the principles to be PRECISE USE OF TERMS. 149 ■ Is the Church herself free from differences of the widest kind on ques- tions that we are taught are of the most vital importance? Have we not for years past heard questions of doctrine, of practice, of ritual, dis- cussed with an amount of vehemence and zeal, and with a conflict of opinion, to which we can find no parallel in our own profession ? Are not angry passions roused in quarters where they are little to" be ex- pected, and may we not at times be tempted to exclaim, 'Tantmne aninus ■cwlestibus irm ' f The truth is that these conflicts of opinion are common to all the professions and to every walk of life. Religion and Politics, Law and Medicine, and the Applied Sciences, all contain so much that is, and ever must be, matter of opinion, that men can never lie brought to one dead level of uniformity of thought upon any one of these subjects ; and out of the very conflicts of opinion that are the necessary conse- quence of the diversity of views that are naturally entertained. Truth is at last elicited. Y-AT be it from me to do otherwise than to speak with the utmost respect of a learned and liberal profession, when I say that slight dis- crepancies of opinion arising between medical men are often magnified by the ingenuity of advocates, so as to be made to assume a very differ- ent aspect from that which they were intended to present, and are exag- gerated into proportions which those who propounded them never meant them to acquire. Perhaps we are often ourselves not altogether blameless in respect to the misapprehension that may arise. We, as medical men, are guilty of two errors in giving our evidence. We are iipt, in the first place, to be too dogmatic in our opinions ; and secondly, too inexact or too technical as to the language in which we convey them, and in which we state our facts. However necessary it may be for a teacher or practitioner to assume a dogmatic tone in order to press home a truth on a class not over attentive, or on a jiatient not too will- ing, it is well to avoid an exhibition of this quality in a court of law. So also it is well to avoid the use of technical or scientific language for the expression of facts that can be stated in plain English. The same words or modes of expression that would be not only intelligible, but would convey a very definite meaning with them in the discussions of a medical society, would be misunderstood or prove confusing to a jury unacquainted with medical phraseology. Technical language puzzles and confuses, hut does not convince, and medical men, in the statement of facts as well as in the expression of opinions, cannot be too careful in the use of it. But not only is it necessary to avoid being too technical, the medical witness should endeavour to express himself as succinctly and as clearly as possible. We deal habitually with the material rather than the ideal, with facts rather than with words, and are frequently somewhat inexact in the expressions we use. Mere verbal differences, mere diversities in modes of expressing the same thing, are thus some- times twisted into the semblance of material discrepancies of statement and opinion. How often have I heard in courts of law attempts made to show that two surgeons of equal eminence did not agree in their •opinions upon the case at issue, because one described a limb as being ' paralytic,' whilst the other perhaps said ' there was a loss of nervous and muscular power in it," — when one said that the patient ' dragged ^' a limb, the other that he ' walked with a certain awkwardness of gait.' The obvious professional moral to be deduced from this is, that it is applied are ascertainable. The process is one of pure reasoning, free_ from conject- ure. Yet it does not seem to be productive of complete unanimity in the end.' — British Medical Journal, June 18, 1870. 150 LECTURE XIII. — PROGNOSIS OF CONCUSSION. impossible for you to be too precise in the wording of your expressions when giving evidence on an obscure and intricate question. However clear the fact may be to your own minds, remember that it may not be so obvious to others who do not possess the peculiar technical knowledge that you have acquired. If it be stated obscurely, or in terms that admit of a double interpretation, you may be sure that the subtle and practised skill of those astute masters of verbal fence who may be opposed to you, will not fail to take advantage of the opening you have inadvertently given them, to aim a fatal thrust at the valae of your evi- dence. And indeed, the expression that is in itself perfectly definite,, and that admits of no ambiguity in the mind of a medical man, may present a very different meaning to one who does not possess the requi- site amount of anatomical or pathological knowledge to be able correctly to appreciate its true purport. Thus, for instance, the word ' spine ' is used by an anatomist as signifying only the column, whereas a non- medical man will usually employ it as including the cord as well as its enclosing case. In doing so, let me advise you to confine yourselves as- strictly as possible to answering concisely and intelligibly the question put to you. It is seldom desirable to volunteer statements of your own. When you find it necessary to do so in order to make your answer more clear, or to explain away any misconception that may arise as to your meaning, you must not do so until after you have answered the ques- tion put to you. Answer first, explain, if necessary, afterwards. But let me advise you to have recourse as little as possible to independent, statements and unasked-for explanations. Your doing so may place you in a wrong position, in that of an advocate rather than of a witness. It is impossible to impress upon you too strongly how very important it is not only that you should not be a partisan in the case, on one side or the other, but that you should not appear to be so. It is the duty of a medical witness above all others to assist the court in a thoroughly un- biassed spirit and straightforward manner, without reference to the side on which he has been called. A medical witness is not retained to advo- cate the cause of either plaintiff or defendant. It is his duty to give a truthful and clear description of the facts that he has observed, and to the best of his ability an unprejudiced opinion, founded on the infer- ences that he draws from these facts. It is the business of the advocate, and not that of the medical witness, to place the cause of his client in the best possible light by sifting the accuracy of the facts dep6sed to, and to elicit the truth by questioning the validity of the opinions expressed. There is a vei"y important difference in the prognosis of spinal and cerebral affections, according as they arise from disease or injury. Hence a very different estimate of the duration and gravity of such affections is apt to be entertained by the physician and the surgeon. When a given train of spinal or cerebral symptoms, whether acute or slowly progressive, is tlie result of disease, it is invariably indicative of structural changes in the cord or brain ; j)ossibly of an incurable and probably of a progressive character, due to failure of nutrition, as in atheroma of the nutrient arteries, or to remote viscera] disease, as of the kidneys or heart. When the same spinal or cerebral symptoms are the i-esult of injury — the whole of the evil is often produced at once — there will in time be a tendency to repair rather than to degeneration, and the patient is prob- ably otherwise perfectly liealtliy. The difference in* the importance of the same symptom, according as it is the result of progressive degeneration or of sudden injury — as it arises from what may bo termed a medical or from a surgical cause — is CONSULTATIOiSrS NECESSARY. 151 well illustrated by Paraplegia. If this condition arise spontaneously, it IS probably due to softening and degeneration of the cord, and will be incurable. If it be the result of injury, it may be owing to haemorrhage into the spinal canal, and will disappear as the blood Is absorbed. So with Unconsciousness. This condition, however transitory, occurring suddenly independent of injury, is justly regarded by the physician as a symptom of the gravest import, probably of an epileptic nature. Trous- seau, indeed, regards unconsciousness without convulsions, the ' petit mal,' as more serious than the major epileptic seizure with convulsions. But the same importance cannot be attached to it when it follows a head- injury. I do not speak only of the unconsciousness which occurs at the moment of the concussion of the brain, but of that occasional attack of momentary loss of consciousness which may ensue at a later period. Serious as this symptom undoubtedly is, and partaking as it doubtless does of the epileptoid character, it stands in a totally different category, so far as the future of the patient is concerned, to that occupied by the 'petit mal.' It is not, like it, progressive or destructive of mental vigour and capacity, but may, and most probably will, ultimately disap- pear without leaving any impairment of intellectual power. These examples might easily be multiplied. But what I have given will suffice to direct attention to one cause of that conflict of opinion, well known in the prognosis of a case, which is often observed between physicians and surgeons, due to one class of practitioners being accustomed to see a particular set of symptoms develop as the result of pathological lesion, and leading to disoi-ganisation of structure ; the other observing them as occasioned by injury, and tending to repair of tissue. Inequality of knowledge will certainly cause conflict of opinion. He who is content with the knowledge of the pathology of the nervous sys- tem as it existed twenty, fifteen, or even ten years ago, cannot appreci- ate, and hence cannot coincide with, views founded on the more ad- vanced and more accurate investigation of its diseases, and a clearer insight into the physiology of the brain and cord. But even between men equally well informed, conflicts of opinion are on certain points not only unavoidable, but perfectly legitimate, and reflect no discredit either on the science of medicine or on those who entertain conflicting views. On the contrary, such conflicts of opinion may be looked upon as highly creditable to the independence of thought and the individual self-reliance that characterise professional opinion at the present day. The conflict of medical evidence often arises in consequence of a want of proper understanding between the medical men engaged on the oppo- site sides of the case. As matters are now arranged, there is, as I have already shown, no ' consultation,' in the proper sense of the word, be- tween them. The surgeon of the company examines, it is true, the plaintiff before, and in the presence of his (the plaintiff's) own medical men ; but there is no after-discussion of the case, no attempt, as in an ordinary consultation, to reconcile discordant views, and to come to a combined opinion on the case. Neither party knows the exact views of the other on any point, or on the value of any one symptom, until they are heard in court. This is a great evil, and might be corrected by the surgeons on the two sides meeting as ordinary consultants discussing the case together, and, if possible, drawing up and signing a conjoint report. If such a report could be obtained, it might be handed in for the guid- ance of the judge and counsel, and the strictly medical part of the case would be much simplified. In fact, it would be disposed of if all parties concerned had substantially agreed before the trial as to the nature, ex- tent, and probable duration of the plaintiff's injuries and their conse- quences, the tripod on which the medical question always rests. In the 152 LECTURE XIII. — PROGiS^OSIS OF COXCL'SSIOX. event of there being such discrepancy of opinion that an agreement could not be come to on any or all of these points, the judge should ap- point at least two surgeons of known character, and of recognised skill in the particular class of injury under consideration, to draw up a report upon the plaintiff's past and present condition and future prospects. This report would serve to guide the Court in coming to an opinion on the purely surgical part of the case, and afford it that information which men who admittedly know little of a subject on which they are to decide must necessarily be supposed to wish to obtain. The experts or assessors who draw up this report should be appointed by the Court, and not by the litigants. Their position would consequently be an independent; one. They could not be accused of unworthy motives. They could not be calumniated, and their evidence would not be disparaged by grounds less charges of partisanship. The report of such surgical assessors would necessarily be final. It could scarcely be successfully disputed by those medical witnesses from whose conclusions it differed. Hence it would be of paramount impor- tance that none should be selected for such an important post as that of assessor who was not recognised as possessing not only a sound general knowledge of surgery, but such special experience in the diseases result- ing from injuries of the cord and brain, as to render his opinion worthy of all consideration in the eyes of his professional brethren. Such a plan would not interfere with the present machinery of the courts. The case would continue to be tried in the ordinary common law courts, be- fore a jury who would decide on all its facts. Their judgment, and that of the Court, would be guided in all matters of scientific opinion either by a conjoint surgical report, or, if that cannot be arrived at, by the written statement of competent surgical assessors, who, having had free access to the plaintiff and to the medical reports on both sides, could arrive at a definite and unbiassed conclusion as to the natui'e, extent, and probable duration of his injuries and their consequences. It would, I venture to submit, be in the highest degree advantageous to the medical as well as the legal profession. The great inconvenience of the system of indiscriminately subpcsnaing medical practitioners who are but little concerned in the case would be stopped ; conflict of medical evidence would no longer occur. Engendered as it is partly by the want of proper understanding between the medical witnesses, and greatly en- couraged by the want of due scientific knowledge on the part of the Court, it would not survive the necessity of both parties either making a conjoint report or submitting their differences of opinion to the arbit- rament of skilled surgical assessors selected by the Court. And, lastly, the ends of justice would be attained with more certainty than they often are under the present system. The conclusions that may be drawn from the foregoing observations are as follow : — 1. That a serious hardship is inflicted on medical men by the present system of uselessly multiplying medical witnesses in compensation cases. 2. That much evil results from the want of adequate scientific and technical knowledge on the part of the Court. 3. That the Court should be assisted by assessors of known skill and experience in surgery. 4. That such assessors should be appointed by the Court, and not by the litigants. 5. That the surgical witnesses on both sides should be required to meet and to draw up a conjoint report on the case before the trial comes on. Such report to be submitted to the Court for its guidance in the medical and surgical parts of the case. IMPORTANCE OF EEST. 153 6. That in the event of the surgical witnesses being unable to agree on the terms of such a report, the case be referred to the assessors, who will rejjort to the Court on the nature, extent, and probable duration of the plaintiff's injuries. 7. That the report of the assessors be final.' LECTURE XIV. on THE TREATMENT OF CON^CUSSIOJT OF THE SPINE. In the treatment of a case of concussion of the spine the surgeon must bear in mind that he has not to do merely with an ordinary physical lesion, but with one that influences materially the moral and mental condition of the patient, and the symptoms of which are in turn seri- ously aggravated by that very moral depression which it has engendered. It becomes, therefore, a most difficult problem to solve how to combine that treatment which the injury that the spine has sustained may require witlji that calculated to prevent, or at all events not to augment, the hypochondriacal and hysterical states so often resulting from these accidents. The primary and immediate treatment of a case of concussion of the spine presents nothing peculiar or that calls for special attention. The moderate administrations of diffusible stimulants, warm drinks, the repose of bed, and the local application of hot fomentations, if superfi- cial or deep pain is suffered, comprise all that needs be done in these cases. The after-treatment resolves itself into means for the alleviation or cure of those diseases which are the more remote consequences of the injury sustained by the vertebral column and its contents, or of the shock to which the nervous system has been subjected. It includes a variety of therapeutic means, amongst which rest, counter-irritation, electricity, absorbent, sedative, and tonic medicines are the more im- portant. The method of application and the mode of administration of these various local means and constitutional remedies present nothing that is in any way special in the treatment of these injuries. The point that essentially, and at last must guide the surgeon in his choice of remedies, is the pathological condition that lies at the bottom of the secondary disease, induced by the concussion of the spine or the nervous shock to which the patient has been subjected. Is this sub- inflammatory, of the nature of meningitis, myelitis, or meningo- myelitis ? or is it the very reverse, indicative of exhaustion or anaemia of the nervous centres? It is obvious that the determination of this point is of the first importance, and that the treatment which would be proper and beneficial in the one case would be in the highest degree improper and hurtful in the other. Bearing this in mind, let us con- sider more in detail the different means that we adopt. And first with regard to the treatment of the inflammatory state. Best.— The first thing to be done in a case of injury of the spine with concussion of the cord is undoubtedly to give the injured part complete rest. But rest of the spine means the prone or recumbent position con- ' See Lancet, vol. i. 1878 ; and ' Surgical Evidence in Coiarts of Law,' by the Author \Longmans, 1878). 154 LECTURE XIV. — TREATMENT OF CONCUSSION. tinuously maintained ; complete immobility of the body, the avoidance not only of walking and movement of any kind, but even in many cases of standing upright. It entails, consequently, an interruption, often a long suspension, of all the ordinary occupations of life. The idleness which is the necessary result of long-continued enforced rest is, how- ever, apt to act injuriously on the mind, more especially in that large class of labouring or of active business men who with little intellectual culture, have, in illness, no mental resources to fall back upon, their lives having been spent from boyhood in a hard struggle for bare subsist- ence, or in the absorbing pursuit of gain. These men, who are amongst the most frequent sufEerers by railway collisions, truly ' know no Paradise in rest,' and to them the long-continued monotony of a sick room is a source of much mental depression, which is often aggravated by the loss of the means of sustenance, and by the corroding cares of the res angustm domi, consequent on the annihilation of all business income. The consequences entailed by rest thus exercise a most injurious influ- ence in still farther depressing the moral tone and mental elasticity which have already been seriously shaken by the effects of the accident for which repose is enjoined. But notwithstanding these concomitant and unavoidable ills, rest, absolute and complete, is a necessary preliminary to, and accompani- ■ ment of, all other treatment in every case of injury of the spine, whether from direct violence, strain, or wrench, that is accompanied by sympl- toms of concussion of the cord, and above all, by those of meningo- myelitis. The importance of rest cannot be over-estimated in these cases. Without it no other treatment is of the slightest avail, and it would be as rational to attempt to treat an injured brain or a sprained ankle with- out repose, as to benefit a patient suffering from a severe concussion or wrench of the spine unless he is kept at rest. In fact, owing to the extreme pain in movement that the patient often suffers, he instinctively seeks rest, and is disinclined to exertion of any kind. It is the more important to insist upon rest when, however, the cord rather than the column is injured, for not unfrequently patients feel for a time benefited by movement — by change of air and of scene. And hence such changes are thought to be permanently beneficial. But nothing can be more erroneous than this idea, for the patient will invariably be found to relapse and to fall back into a worse state than had previously existed. The truth is, that in most of these cases of spinal concussion there is mental disturbance as well as physical derangement. New scenes benefit the mind and cheer the spirits, but the exertion of travelling in search of them, and the necessity for increased bodily exercise are most injurious to the physical state arid tend greatly to aggravate existing spinal irritation. In more advanced stages of th"e disease, when chronic meningitis has set in, the patient suffers so severely from any, even the very slightest movement of the body, from any shock, jar, or even touch, that he instinctively preserves that rest which is needed, and there is no occasion on the part of the surgeon to enforce that which the patient feels to be of imperative necessity for his own comfort. In order to secure rest most efficiently, the patient should be made to lie on a prone couch. There are several reasons why the prone should be preferred to thQ supine position. In the first place, in the prone state the spine is the highest part of the body, and thus passive venous congestion and determination of blood to the spinal cord, which are favoured and naturally occur when the patient lies on his back, are entirely prevented, and that additional danger which may arise from this cause is averted so long as the prone position is maintained. Then REST OP MIND. 155. again, the absence of pressure upon the back is a great comfort in those cases ill which, in consequence of injury to the vertebral column, it is unduly sensitive and tender. Lastly, the prone position presents this advantage over the supine, that it admits of the application of any necessary treatment. To some patients the prone position becomes very irksome and cannot long be borne. It then becomes necessary to allow them to lie flat on, the back, with the head slightly raised. There is this peculiarity about the maintenance of the supine position in these cases, — that the danger of sloughing of the back is but very small. It is remarkable, indeed, how very rarely this occurs. Hence the prone position is not necessary as a preventive of the complication. The vitality of the paralyzed parts in paraplegia from concussion of the spine does not fall so low as it does in cases of compression or lacera- tion of the cord in fractured spine. Sloughing from pressure upon exposed and prominent parts, which is so common in paralysis after fracture of the spine, does not occur in cases of loss of power from spinal concussion. I do not remember ever to have seen a case in which confinement to bed or couch, even though prolonged for many months, was followed by this serious and often fatal consequence of ordinary traumatic paraplegia. In fact, in all these cases of concussion, bedsore may, with the most ordinary care and at- tention to cleanliness, aud relief from pressure, be entirely prevented. When the patient begins to move about, equal comfort and advantage will be derived from the use of the plaster of Paris jacket, the poroplas- tic jacket, of spinal stays, or a gutta-percha case, to embrace the shoul- ders, neck, and occiput, and support the back. In cases where the- cervical spine alone is affected, the use of a stiff collar is beneficial. But if rest is needed to the spine, it is equally so to the brain. I have repeatedly in these Lectures had occasion to point out the fact that in. cases of concussion of the spine the membranes of the brain become lia- ble to secondary implication by extension of inflammatory action to them. The irritability of the senses of sight and hearing, that is so marked in many of these cases, with perhaps heat of the head, or flush- ings of the face, are the best evidences of this morbid action. For the subdual of this state of increased cerebral excitement and irritability, it is absolutely necessary that the mind should be kept as much as possible at rest, and that disquieting influences and emotion^ should, as far as practicable, be avoided. The patient, feeling himself unequal to the fatigue of business, becomes conscious of the necessity of relinquishing it, though not perhaps without great reluctance, and not until after many ineffectual efforts to attend to it. Under these circumstances th& brain must be allowed to lie fallow for a season. It is seldom necessary to insist on this absolute rest of brain in one who suffers from cerebral irritation. He finds it simply impossible to employ his mind on any subject that requires an effort of the intellect or the strain of sustained attention, without a great aggravation of his sufferings. But if unable to occupy himself with the ordinary business of his life, care must be taken that the patient do not suffer from the meptal inaction and fall into a state of melancholia from the monotony of his enforced idleness ; and attempts should be made to fill up the vacant hours by recreation of some sort. But if rest is thus absolutely necessary in cases of meningitis and myelitis, it is not equally so in those cases of spinal anaemia, which so closely simulate real organic disease, and which are often associated with hysteria. In these cases the patient should be encouraged to move about ; to be much in the open air. If unable to walk, then he must 156 LECTURE XIV. — TREATMENT OF CONCUSSIOX. use a carriage or a chair. But anyway, out-of door life and exercise of some kind, though to a limited extent, will be useful. Sleep.— Next to rest it is most imiDortant to endeavour to secure sleep in cases of concussion of the spine. It is impossible to expect that the nervous system can recover itself so long as the patient passes wakeful nights, or is disturbed by horrible dreams. Unfortunately in these cases narcotics are as a rule not well borne. The various preparations of opium and morphia, whether administered by the mouth or given hypodermically, are not only seldom successful in securing rest or in allaying pain, but are often positively injurious, at least so far as secur- ing sleep is concerned. Chloral hydrate is more advantageous and safer than the opiates. It should be given in tolerably full doses, from 25 to 40 grains, either at once or divided in the course of thenight. Xext to the chloral hydrate, and especially in those cases in which there is dis- tinct meningeal irritation, the bromides are of great service, and indeed, may often be advantageously combined with the chloral, tranquillising the cerebral irritation whilst the chloral more distinctly induces sleep. Local applications. — The local treatment to be applied to the spine will vary according as we have to do with meningo-myelitis or anaemia of the cord. In the inflammatory affection in the early stages, hot fomentations, leeching, or dry-cupping will be of essential service. At a more ad- vanced period repeated blistering will be found to give great relief. I have never found it necessary to employ issues or setons, but if there is evidence of disease in the vertebral column itself, these might be em- ployed with advantage. The pain which I have termed sacrodynia is little infl.uenced by ordinary topical agents. The only means that I have found to ensure a beneficial influence on it have been active stimu- lants or counter-irritants, such as blistering, or the thermic hammer. In the diffuse hyperajsthesia of spinal anaemia the ice-bag and the continuous galvanic currents are often useful. In these cases, also, various embrocations of belladonna, aconite, camphor, &c., will be found to allay pain and comfort the patient. In the more advanced stages cold salt-water douches, or the shower- bath, will prove serviceable. Medicines. — The iodide of potassium is of the greatest value in all those cases in which there are evidences of chronic or subacute menin- gitis. It should be given in full doses, and continued for a considera- ble length of time. It may be well to commence with 5 grains three times a day, and to carry it on gradually until from 15 to 20 are given for a dose. It is particularly in cases of muscular cramps or stiffness that the iodide is of service, and in those forms of fibroid or ligamentous tenderness that are frequent after wrenches of the spine, and that resem- ble rheumatism The bromide of potassium or of ammonium is useful in relieving the cerebral distress, irritation, or pressure, that is so frequently complained of as a concomitant symptom of meningo-myelitis. The employment of the perchloride of mercury in certain forms of paraplegia was strongly advocated by Sir Benjamin Brodie and Dr. Lathiim. The great value of this remedy and of the iodide of potassium IS universally admitted in syphilitic paralysis. In some of the traumatic forms of paraplegia the use of the perchloride is equally efficacious. In ordinary idiopathic paraplegia— in those forms of the "disease that arise from other than traumatic causes, in which the paralysis is rather due to nutritive changes, leading to softening, to disintegration, and dis- organisation of the substance of the cord itself than to inflammatory action developed in an otherwise healthy person — mercurials would un- TREATMENT OF SPINAL AN.EMIA. 157 doubtedly be injurions rather than beneficial. So also in spinal anemia they would be most hurtful. But, on the contrary, in those traumatic forms of paraplegia dependent on pressure from extravasated blood, on inflammation of the meninges, on pressure on the cord from inflammatory effusions, the perchloride of mercury is_ undoubtedly most beneficial. It is in similar cases, and more especially in the more marked cases of meningitis of a sub-acute character — those cases in which there is morbid rigidity and contraction of muscles, that iodide of potassium is so markedly beneficial. Treatment of Sjnnal Ancemia. — When the symptoms are rather those of spinal ansemia than of meningo-myelitis, the preparations of iron and strychnine will be found to be of the highest value ; in fact, as has already been stated in the Lecture on Diagnosis, the tolerance or not of strychnine in these cases will serve as a therapeutic test of considerable value, as to whether the disease be one of spinal exhaustion or of inflam- mation. There is probably no better method of administering these remedies, in the majority of the cases that 1 have mentioned, than by giving a pill three times a-day containing a quarter of a grain of the extract of nux vomica with two or three grains of the dried sulphate of iron, or administering them in the form of the syrup of the phosphates of iron, strychnine, and quinine. But the precise method of adminis- tration signifies little, it is the principle on which I wish to insist, and to- which I wish to direct your attention, that you must treat these cases of spinal anaemia by means of strychnine and iron in some shape or another. In addition to this, you will find it necessary to insist upon a liberal allowance of good food being taken with wine or beer. I have spoken of rest as being absolutely necessary in those cases in which there is meningo-myelitis ; but in cases of spinal ansemia it is desirable that the patient should be as much as possible in the open air, carried out, laid on a mattress, drawn about in a Bath chair, when the season permits. The monotony of the seclusion to a bed-chamber is most in- jurious. Some mental occupation should be insisted upon ; recovery is often materially retarded, and, indeed, the ill-effects in many of these cases of concussion of the spine, followed by an exhausted state of the nervous system, are greatly increased by want of employment, amuse- ment, or mental distraction of some kind. The patient dwells upon his sufferings, becomes morbidly sensitive in mind, or melancholic and hypo- chondriacal. These mental conditions are especially apt to develop themselves in people of active business habits, with few intellectual resources. Such persons, when forced to lead a life of physical inac- tivity, have no means of filling up their time and occupying their thoughts by intellectual pursuits, even of a very simple character ; and it is in them especially that a forced inactivity exercises so very preju- dicial an effect in retarding or altogether preventing recovery. It is in these cases of spinal ansemia, and in such individuals especially, that change of scene is of great benefit. Injurious as travelling, and espe- cially a residence at the sea-side, so commonly ordered in an mconsid- erate off-hand manner is in cases of meningo-myelitis, it is of the utmost value in restoring the lost tone to the nervous system m cases of simple exhaustion of it. . t- ■ Exercise is not advantageous whilst the nervous system contmues m an exhausted or enfeebled state. Patients suffering from spinal anemia may be benefited greatly by change of air and change of scene, then- nutrition improved by the one and their mental tone invigorated by the other ; but they are not improved by being subjected compulsonly to exercise. As they recover they will instinctively and proportionately to the return of strength resume their habits in this respect. 158 LECTURE XIV. — TREATMENT OF CONCUSSION. It is of great importance to keep up the temperature of the body, especially of the extremities, by artificial means. Unless this is done the circulation becomes retarded in the cold feet and hands : nutritive changes are ill-effected ; the blood is cooled down in traversing parts the temperature of which is many degrees below the normal point. Carried back to the heart in this cooled-down state, it tends to depress I its action, and thus to lower the force of the circulation throughout the body, and proportionately to lessen the energy of all those actions de- pendent upon its activity. Electricity in its different forms is of extreme service in many cases of spinal anaemia and in the removal of local paralysis, whether it be con- nected with this condition, be the remote consequence of changes de- pendent on the structural lesions of the cord, or the effect of local injury of some nervous trunk. For the necessary directions to guide the surgeon in the employment of electricity in these various cases, I must refer to the works of Rey- nolds, Althaus, and Duchenne. There is nothing special in the mode of its employment in traumatic cases that deserves particular notice. But there are a few words of caution and advice that I may give you with respect to the class of cases in which it is likely to be beneficial or hurtful. Faradisation will be found of especial service in cases of simple loss of nervous power without any signs of concomitant inflammation, central •or peripheral. Thus it will be found of great use in the paraplegia of spinal anaemia, in the loss of power in the extensors of the foot and toes and the peronei muscles dependent on paralysis of the external popliteal nerve, a form of paralysis that has frequently been referred to in these lectures, and of very common occurrence after spinal concussion ; and lastly, in those localised forms of paralysis of the upper extremity dependent on affection of the supra-scapular, circumflex, or musculo- spiral nerves. The continuous current applied to the spine is particularly useful in spinal anaemia and for the relief of the cutaneous hypersesthesia associ- ated with it. Electricity in any shape is always hurtful when there are symptoms of subacute inflammatory action, especially of the meningeal form, associ- ated with the paralysis, as indicated by muscular rigidity or painful cramp. I think that we may broadly say about this therapeutic rule with respect to the employment of electricity, that it is useful in those cases that are benefited by strychnine and iron ; whereas, in those that are made worse by these remedies, electricity is equally hurtful, in fact, the injury resulting or beneflt to be derived from the use of electricity will be in the exact ratio of the inflammatory or asthenic character of the paralysis. The treatment of spinal ansemia may be summed up in a very few words — a cheerful life, plenty of fresh air, sea or mountain, well-ventilated rooms, repose but not solitude, warm sea-water bathing and douching, skin-friction, good food, iron, quinine, phosphorus, and strychnine. And should the spine be tender, repeated flying blisters to the painful parts ; in fact, an hygienic, dietetic, and medicinal plan of treatment of a tonic character. But whatever treatment be adopted, no speedy benefit can be expected. In the most favourable cases the duration of the symptoms will have to be counted by months, in many by years. For the health may continue permanently broken, or some local nerve lesion will persist in spite of the most careful treatment. When the case involves a claim for compensation, care must be taken USE OF ELECTRICITY. 159 to see that the treatment prescribed is properly carried out, and that the patient does not by neglecting it and nursing his symptoms mislead the surgeon as to the gravity and probable persistence of his condition and the inefficacy of treatment in relieving it. The treatment of various local ailments consequent on or associated with the spinal injury need not detain us, as it must be conducted on general medical and surgical principles. INDEX ABEECROMBIE on injury of spine, 9, 32 Accidents, railway, nature of, 3 Accommodation, of the eye, changes in, 75, 114 Accommodation, failure of, 114 Allbutt, Dr., on optic neuritis, 115 Amblyopia, 115 Anatomy, morbid, 83 — in meningo-myelitis, 84 — in myelitis, 85 — in spinal meningitis, 84, 85 Anaemia, spinal, 82, 88, 89 Anaesthesia, 27, 28, 47 — and hypersesthesia in opposite limbs, 47 Asthenopia, 76, 114 Astigmatism, 115 Attitude in spinal injuries, 76 BELL, Sir Charles, on spinal injury, 9, 34, 35 Bladder, atony of, 30 — contraction of, 30 — irritibUity of, 80 Boyer on spinal injuries, 9, 35 Brachial plexus, injury of, 15 Brown-Sequard on motor and sensory tracts, 29 — on hereditary transmission of effects of injuries, 2 riAEDIAC debility, 101 V Cataract, 110 Central changes after peripheral injury, 106 Cerebral symptoms, 71, 75, 86, 138. Cervical region, injury of, .24, 140 Cilio-spinal axis, 117 (Jarke, Dr. L., on morbid changes in spinal cord, 83 Coccydynia, 98 Coldness of extremities, 80, 90 Colitis, 104 Concussion of spine, 7 — from general shock, 45 — from severe direct injury, 7 — from slight or indirect, 36 — effects of, 74 — nature of, 8? 72, 82 — pathology of, 82 Contraction of muscles, 41, 80, 87 Convulsions, 13, 34 Cooper, Sir A., on spinal injury, 81 Cord, spinal, induration of, 85 — inflammation of, 8, 32, 84 — softening of, 34, 36, 85 ^- consultations, 153 Countenance in gpinal injury, 75 Cramp, 32 Crossing of nerve-fibres in cord, 29 Crystalline lens, dislocation of, 110 Curvature of spine, 8, 28 Cystitis, 30 DEAFNESS, 76 Death after spinal injury, 19, 21, 24, 32, 33, 49, 60 Death, sudden, 22, 24 Diabetes, 106 Diagnosis, 37, 132 Diaphragm, spasm of, 41, 78 Diplopia, 75, 114 — monophthalmica, 114 Dorsal region, injury of, 25, 140 ELECTBICITY, 155 Electric irritability, loss of, 25, 80 Electric tests, 27, 79 Embolism, 106 Epilepsy, 100 Evidence, medical, 146 Extravasation into spinal cord, 34 — meningeal, 46 Eyeball, concussion of, 109 Eyes, affections of, 75, 109, 115 FATAL lesions, 33 Fingers, contraction of, 49 — crush of, 107 Fractures of spine, 23, 24, 35 — union of, 108, 109 GAIT in spinal injury, 77, 88 Genito-urinary organs, affections of, 80 H.a;MATURIA, 104, 106 Haemorrhage, intestinal, 104 — into spinal canal, 33 Hammond, on paraplegia, 34 Hearing, impairment of, 76 Hemicrania, 48 Hemiplegia, 24, 64, 87 Hernia of cord, 33 Hiccough, 102 Hyperajsthesia, 27, 28, 48, 77, 79, 90, 94 Hypermetropia, 115 Hysteria, 91, 139 IMPOSITION, cases of, 134 i. Induration of cord, 85 In flammation of cord, 8, 32, 82 _ of membranes, 8, 32, 34, 38, 82 — of optic nerve, 115, 116, 121 162 INDEX. Injuries of head and spine contrasted, 35 Intellect, impairment of, 75 Intestinal complications, 102 TACCOUB on electric tests, 27 f) Jar in railway accidents, 3, 57 Jones Wharton on failure of sight, 115, 119 — on the sympathetic, 119, 120 LACEEATION of membranes, 33 — of ligamenta interspinalia, 35 intervertebralia, 21 subflava, 35 Liinbs, condition of, 80, 87 Lordat, Count de, case of, 5 Lumbar region, injury of, 25, 140 MATY, Dr., on palsy after fall, 5 Mayes, Dr. , on suppuration of mem- branes, 34 Mayo, Dr., on concussion of spine, 8 Medical evidence, 146 Medico-legal aspects of concussion, 128, 140 Membranes, inflammation of, 8, 32, 34, 38, 82 — laceration of, 33 — suppuration of, 34 Memory, impairment of, 11, 19, 41, 51, 75 Meningitis, cerebral, 8, 32, 86 — cerebro-spinal, 42, 87 — spinal, 8, 32, 34, 38 Meningo-myelitis, 82, 84, 86 — diagnosis of, 137 — morbid anatomy of, 84 Mental condition, 75, 94 Mercury in spinal injury, 156 Molecular changes in cord, 82 Motion, loss of, 25, 78 Movements of limbs in recumbency, 78 — of spine, 77 Miiller on intraspinal hfEmorrhage, 33 Muscles, changes in, 80 — contraction of, 41, 80, 87 — electric irritability of, 80 — rigidity of, 3, 9, 27, 80, 87 Myelitis, 8, 32 Myopia, 115 TTEEVE complications, 99, 139 l\ Nerves, affection of, anterior crural, 26 — auditory, 76 — circumflex, 17, 24, 56, 123 — fifth pair, 100 — interosseous posterior, 127 — musculo-spiral, 17, 24, 56, 79, 123 — obturator, 26 — peripheral, 106 — popliteal external, 26 internal, 26 — seventh pair, 100 — spinal-accessory, 55, 100 — subscapular, 122 — ulnar, 79 Neuralgia, 28, 48 Noises in the head, 75 Numbness, 79 SMI! OCCUEBENCE of concussion, mode of^ 72 OlUvier on Spinal Injury, 9, 33, 31 Ophthalmoscopic changes, 116 Opinion, discrepancy of, 37, 146 Optic nervous apparatus, 119 Optic nerve, atrophy of, 110 inflammation of, 115, 116, 121 Order of symptoms, 81 PAIN, 27, 32, 77, 87 Paralysis after twists, 64 — complete, 17 — motor, 13, 21, 25, 78 — sensory, 11, 13, 21, 27, 79 — spinal anaemia, 90 — varieties of, 24 Paralysis and weakness contrasted, 137 Paraplegia, 9, 15, 21, 25, 46, 79 — after twists, 65, 66 — amputation in, 13 Paresis, 88 Pathology of concussion, 82 Period of onset, 74, 81 Peronation, impairment of, 15 Peronei muscles, paralysis of, 24 Phlebitis, 45, 66, 106 Photophobia, 76, 113 PI euro-pneumonia, 45 Plexus, brachial, injury of, 15 — lumbo-sacral, 26 Position, influence of, 57 — in paraplegia, 79 Pregnancy, 106 Priapism, 31, 80 Prognosis of concussion, 140 — as to life, 140 — as to recovery, 142 — elements of, 37 Psoas muscles, paralysis of, 25 Ptosis, 100 Pulse, state of, 81, 95, 101 Pupils, state of, 76 RAILWAY injuries, mechanism of, 57 nature of, 37 ' Eailway spine, ' 4 Eecovery, complete, 143 — partial, 143 Eest, importance of, 153 Eetina, hyperjemia of, 115, 116 • Eheumatism, 138 Eigidity of muscles, 3, 9, 27, 80, 87 SACEOYDYNIA, 97 Sensation, increased, 77, 79 — paralysis of, 27, 78 — perverted, 29, 78 — subjective, 78, 79, 87, Senses, special, affection of, 75 Sexual power, impairment of, 50, 81 Shock, general, 45, 91 — moral, 91 Sight, impairment of, 12, 19, 75 Signs, objective, 132 Sleep, protective influence of, 57 — in spinal concussion, 75 — therapeutics of, 153 Smell, loss of, 76 INDEX. KJIJ Smell, perverted, 51, 76 Spasm of muscles, 3, 24, 27, 32 Speech, affection of, 76 Sphincters, paralysis of, 30, 79, 80 Spinal anaemia, 82, 88, 89 diagnosis of, 137 Spinal anaemia, treatment, 157 Spinal cord, extravasation into, 33 — hernia of, 33 — induration of, 84 — inflammation of, 8, 32, 84 — softening of, 34, 36, 85 Spinal irritability, 89 Spine, concussion of, 7 — dislocation of, 22 — examination of, 77 — fracture of, 24 — injury of, 7 — rigidity of, 53 — severe direct injury of, 7 — sprains of, 58, 59 — twists of, 58, 59 Sprains of spine, cause of, 59 complications of, 60, 61 — effects of, 61 — prognosis of, 59 Stammering, 52, 76 Strabismus, 75, 100 Struma, effects of, 60 Suppuration of membranes, 34, 35 Sympathetic nerve, distribution of, 120 influence of, 120 injury of, 119 • irritation of, 121 section of, 121 Symptoms, cerebral, 86 — feigned, 135 — nature of, 56, 133 — onset of, 74 — order of, 81 — secondary, 74 Symptoms, spinal, 77 Syphilis, 100 TASTE, impairment of, 76 Teale, J. "W., on high temperature, 35 Temperature, depression of, 31, 80 — elevation of, 31 Termination of concussion, 32 Tetanic spasms after crush of finger, 107 Thrombosis, 106 Touch, sense of, 76 Transmission of effects of injury, 2 Treatment of concussion, 150 Typhoid fever, 139 Twists of spine, 58 UNCONSCIOUSNESS, 96 Urinary organs, complications of, 105 Urine, acidity of, in paraplegia, 10, 11, 80 — alkalinity of, 30, 80, 84 — incontinence of, 30, 80 — retention of, 30, 80, 105 VISION, impairment of, 75, 109 after blows on face, 110 from cerebral meningitis, 118 from injury to fifth pair, 110 to spine, 113 to sympathetic, 119 Vomiting, 101 WEAKNESS after strains, 59, 61 Weakness and paralysis contrasted, 137 Weight of body, 80 Wounds, repair of, 108 Wrenches of spine, 59 yONE, hyperaesthesic, 28 EitiliEiiiJ