should always be regarded with grave suspicion, and the grounds for this are not lessened by either an interval of several years since the removal of the tumour, or by the completeness with which this was effected. Especially is this true of cases of mammary cancer. The pains should lead to careful and repeated examination of the spine and a search for any abrupt deviation, in any kind, and in any part of the vertebral column; while the cervical spine should be examined at the sides and from the posterior triangle of the neck, the character of the bony prominences on the two sides being minutely compared. Indications of a growth may often be thus discovered long before they are obtrusive. It is also important to remember the fact that acute transverse myelitis may be an early effect of the disease, and if this lesion, in such a subject, coincides with marked local tenderness, the probability of secondary growth in the bone is very great; it is rendered still greater by preceding pains, and certain by coincident deformity.

It must be remembered that similar root symptoms are sometimes due to an aneurism or to a growth in front of the vertebral column, commencing, for instance, in the glands, irritating the nerves as they emerge from the intervertebral foramina.

From intercostal neuralgia, the influence of movement on the pain is usually a sufficient distinction, even when cord symptoms are absent. The commonly bilateral character of the pain is a further difference. The symptoms of a growth in the lower cervical region are sometimes very closely simulated by symptoms which, from their character and course, are probably due to radicular neuritis. There are severe root-pains, referred to one arm (or less commonly, to both arms), increased by movement and without marked tenderness of the plexus of nerve-trunks. The subjects are also in the later period of life. The distinction rests on the absence of the signs of a growth, on the slighter effect of motion on the pains, on the absence of any progressive tendency, and on the common presence of a history of gout, and especially on the absence of any symptoms of compression of the cord even after the nerve-roots have suffered for some months. Sometimes it is necessary to wait and watch the course of the symptoms. It is necessary to be very careful in assessing the value of slight irregularities; the vertebra prominens is apt to be thought to project too much even for its designation, and a deep bilateral swelling is readily perceived under normal conditions, when the head is bent forward.

The chief difficulty in diagnosis is the distinction from caries when distinct evidence of a growth is absent. In the first half of life caries would alone be thought of in such a case, but in the second half the two diseases are about equally frequent. One distinction, suggestive, not absolute, is the intensity of the pain in tumour, taken in conjunction with its great increase when the patient moves. It is true that the root-pains of caries are said to be

sometimes most severe, but such severity is not frequent enough to destroy the significance of intensity. I have not, for instance, seen a single case of caries (of a large number) in which the pain was comparable to that in most of the cases of growth that have come under my observation. Therefore, while absence of pain is of slighter diag nostic value (in favour of caries), great severity, and agonising increase by movement, are strongly in favour of vertebral growth. In each disease there may be angular curvature, but this, in growths, is usually soon succeeded by other signs of tumour. In caries these signs are absent, and an abscess often develops. A history or indication of tubercle is almost conclusive evidence of caries. These points will, I believe, avail for the distinction in most cases. In a few it is necessary to wait and watch before an opinion can be formed.

Among other diseases with which these growths may be confounded is the dorsal form of tabes, in which severe radiating pains occur in the trunk and not in the legs. But the wide extent of the root symptoms, the slight effect of movement, and the fact that the knee-jerk is lost, suffice for the distinction. The distinction from tumours of the spinal cord and membranes is considered in a later chapter.

PROGNOSIS. The prognosis scarcely requires formulating. The chief differences are in the time that life is likely to last. The pains usually persist, in spite of the progress of the disease, although there is a bare possibility of their subsidence. The chance of any return of power in the paralysed part is small, although not quite absent if the palsy develops in a manner to suggest a secondary myelitis, and the progress of the growth itself is slow.

TREATMENT.-Possibly in a few cases a growth may be so placed as to be removed, and an exploratory operation would be justifiable in any case that might prove suitable; otherwise treatment must necessarily be confined to the relief of pain, and to the avoidance of bedsores and other results of the cord disease. Morphia is alone powerful for the relief of pain, but unhappily the dose has to be quickly increased, and the power of the drug is lessened by custom. It becomes a race between dose and pain, in which, if life lasts long, the pain not uncommonly gets in front of the narcotic. Cocain, however, affords some relief in many cases, and may, with other anodynes, at least prolong the influence of moderate doses of morphia.

VERTEBRAL EXOSTOSES.

Exostoses sometimes grow from the bodies of the vertebræ into the spinal canal, and may compress the cord or nerves. They are, however, exceedingly rare. The symptoms may be those of slow compres sion of the cord, or of irritation, expressed chiefly by pain. They usually resemble those of a tumour of the cord or membranes rather than of the bones, but the pain is occasionally much increased by movement. Their chief characteristic is extreme chronicity. In one case

the patient suffered frequent intense paroxysms of pain in the right groin, which had occurred for two years, with occasional intervals of freedom. There was some weakness of the legs, but no considerable paralysis. Ten years before, he had had some loss of sensibility in each thigh, which had passed away. An intra-spinal tumour was diagnosed; the post-mortem examination revealed exostoses from the bodies of the ninth and tenth dorsal vertebræ, slightly compressing the cord. Although extreme chronicity may raise a suspicion of exostosis, it is doubtful whether a confident diagnosis is ever justified except in the cases in which there are similar exostoses elsewhere. This rare indication existed in a patient, under the care of my colleague Dr. Barlow, who presented multiple exostoses, and paraplegia of gradual onset, which was supposed during life, and found after death, to be due to a similar exostosis within the spinal canal. It had sprung from one of the lumbar vertebræ, and had compressed the nerves of the cauda equina.

Exostoses constitute a more promising field for the surgeon than other kinds of vertebral tumour. Many of them are so placed that their removal is feasible. If situated in front of the cord, the division of some nerve-roots, at least in the dorsal region, might permit access to the growth.

SYPHILITIC DISEASE.

Syphilitic caries of the bodies of the vertebra is a rare variety, the symptoms of which do not differ from those of the scrofulous form. It has been observed in the cervical region, secondary to deep syphilitic ulceration of the pharynx. Nodes of the vertebræ, within the canal, are occasionally presumed to exist and to compress the cord, but I do. not know of any pathological observation confirming the assumption, and it is probable that most of the supposed instances have been cases of syphilitic gummata in the meninges. Deep-seated thickening of the tissues about the cervical vertebræ sometimes occurs in syphilitic subjects. It may develop on one side or both, and is apparently due to a syphilitic cellulitis. The swelling may be felt either on each side and behind the upper cervical spine, or deep in the posterior triangle of the neck. It may damage the nerves before they enter the brachial plexus, causing a defined palsy, as in one case of the lower arm muscles. Movements of the neck may be interfered with, and irritation of the nerves may cause neuralgia-like pain, generally felt down the arm, and often very severe. Except by the absence of nodulation, it is scarcely to be distinguished from a deep-seated growth. The spinal cord does not usually suffer. All the symptoms pass away under antisyphilitic treatment. In one case, however, iodide had no duence, although mercury quickly cured.

EROSION BY ANEURISM.

Bones, like other structures, may atrophy and waste before the pressure of an aneurism, and the bodies of the dorsal, or rarely of the lumbar vertebræ may be thus eroded by aneurisms of the aorta. The pressure and absorption take place from the left side. Two or three vertebræ usually suffer, and the bodies more than the intervertebral cartilages. The periosteum becomes thickened, and may resist the pressure and to some extent protect the cord. Sometimes, however, the cord becomes compressed, or the periosteum may come to form part of the wall of the aneurism, and may give way before the blood-pressure, so that rupture occurs into the spinal canal.

The symptoms vary much. Pain along the nerve-roots is usually severe, but this may attend aneurisms that merely compress the nerves after their emergence, and do not damage the bone. The process of

erosion is usually attended by severe pain in the spine. When the cord is reached, compression causes the usual paraplegic symptoms, of slow or rapid onset. Rupture into the canal is attended by sudden complete paraplegia and death, either immediate, or in the course of a few hours, from ascending paralysis, due to the hæmorrhage around the spinal cord.

The diagnosis is scarcely possible unless other indications of aneurism are detected, since the symptoms closely resemble those of a growth in the bone. The nature of the disease may, however, be suspected if such symptoms as bave been described are succeeded by sudden paraplegia followed quickly by ascending paralysis.

HYDATID DISEASE.

Hydatid cysts sometimes develop in the loose adipose tissue between the dura mater and the bone, and it is believed that they sometimes form in the substance of the bones themselves. About a dozen cases have been collected by Leyden.* As the cyst grows, the bone of the arches sometimes becomes atrophied by pressure, and the cyst may develop outside the canal, so that there is a double cyst, outside and inside, connected by a narrower part. Occasionally the cyst develops also in front of the spine, in the thorax or abdomen. The internal cyst necessarily compresses the spinal cord, which often also becomes inflamed. The usual paraplegic symptoms develop, both motion and sensation being usually lost. Radiating pains along the nerve-roots are frequent. The symptoms, in themselves, resemble too closely those caused by other diseases of the spinal column to permit a diagnosis to be made, unless similar disease elsewhere suggests the nature of the spinal lesion, or unless the cyst can be felt in the back, when a puncture may prove its nature. All the cases hitherto recorded have terminated fatally, but it has been conjectured that, if puncture

Klinik der Rückenm. Krankh.,' Band i.

can be effected, a cure may sometimes be possible. In one such case, however, a girl, aged twenty-two, in which a small tumour beside the last dorsal and first lumbar spines was opened (on account of complete palsy of legs, bladder, and rectum), a continuous discharge of echinococcus cysts occurred, more than a hundred escaping in the course of four months, when the patient died in consequence of ascending damage to the cord. The tumour has been noticed for eight years before death, during four of which it produced symptoms of irritation of the nerves, and finally prominence of the vertebral spines developed.*

Numerous small cysticercal vesicles have also been occasionally found within the dura-matral sheath. In one case, several such vesicles were attached to nerve-roots, one to each, in the lumbar region, while a considerable number on the cervical enlargement were beneath the pia arachnoid.+ Such cysts may compress the cord, producing paraplegia, and even death. As in other forms of compression, the paraplegia may come on suddenly.‡

DISEASES OF THE ARTICULATIONS.

LATERAL CURVATURE OF THE SPINE seldom affects the functions of the cord. Even when slight compression has occurred, the slowness of its production has apparently prevented interference with function. In very rare cases some weakness of the legs has been present, possibly, but not certainly, the result of the curvature. Occasionally the intervertebral foramina have been narrowed, and the pressure on the nerves has caused radiating neuralgic pains.

VERTEBRAL ARTHRITIS.-In chronic rheumatoid arthritis the intervertebral articulations are sometimes involved. The symptoms are local pain, tenderness, and limitation of movement, which may go on to absolute fixation, especially in the cervical region, if anchylosis occurs. I have known the whole neck to be rigid from this cause, in a case in which also the movement of the lower jaw was much reduced. More frequently, movement is restricted by pain before the mechanical limit is reached. Sometimes an occasional clicking sound occurs. Enlargement of the ends of the bones may occur, and, in thin persons, may even be felt. The pain is increased by movement, and often by changes in the weather, and by fatigue. It is often felt through a considerable extent of the spine, and may extend to the back of the head. The cord is scarcely ever compressed, but the narrowing of the foramina may damage the nerve-roots. The articular processes, it will be remembered, form one side of the inter• Pedjkow, Med. Obos.' (Russ.), xxviii; and 'Cent. f. Nerv.,' xii, 271. ✦ Hirt, Berl. kl. Wochenschr.,' 1887, No. 3. The relation of the symptoms to the parasitic disease is doubtful in a degree that makes it useless to mention them. I As in a case recorded by Wiegand (Warsaw Med. Ob.;' and 'Cent. f. Nerv.,' 1853, 665).