those of the vertebral column; often, probably, the pain depends on the nerves of the joints and ligaments of the spine. It is essentially a traumatic spinal neuralgia. The pain may be felt at one or more spots; when severe, it often extends through a considerable length of the spine, and sometimes passes up to the occiput. It is occasionally referred to the sacrum, and may there have the character of a sense of weight or more vague discomfort. The pain is associated with tenderness of the spine, usually deep-seated, chiefly developed at the injured part, but sometimes present also at other spots. It may gradually assume the features of a true neuralgia, may occur in paroxysms, and be induced by mental and other influences which do not act directly on the spine, as well as by exertion, posture, and other agencies that may immediately influence the affected structures. This condition is often called "spinal irritation."

The cause of traumatic lesions of the cord often acts also on the brain. A cerebral lesion may occur from the violence which affects the cord; the cerebral symptoms then coexist with those of the spinal lesion, and may mask the latter during the early stage. More common, however, is functional disturbance of the brain, the result partly, perhaps, of the physical concussion, but chiefly of the mental shock which a serious accident necessarily causes. The resulting condition is favorable to the development and persistence of subjective sensory symptoms. Attention, maintained by concern, has a powerful intensifying influence on all forms of nerve-pain, and certainly aids in keeping up the pain in the back, and even the tenderness which follows injuries to the spine. So marked is the influence of "nervousness" on the subjective symptoms, that it has been even maintained that in a large number of cases of concussion of the spine the symptoms are of hysterical origin.* Well-marked symptoms of hysteria are sometimes manifested by these patients. But, on the other hand, it is necessary to avoid the danger of over-estimating the effect of mental influence, and of regarding, as entirely due to this, symptoms which are real, and are merely intensified by attention. The danger is especially great in cases of railway injuries, concerning which an unbiassed judgment is not easy to secure, and in which, when objective symptoms are absent, it is easy to minimise suffering, and attribute too much to the mental condition. The sinister influence of litigation on the intellect may be traced very widely. I believe that it is rare for symptoms to be purely mental. It is often asserted by those employed for railway companies that subjective symptoms quickly subside when the sufferer's " claims are settled, but it should be remembered that mental anxiety is a potent cause of diseases of

J. J. Putnam, Boston Med. and Surgical Journal,' 1883, Sept. 6th.

Not many years ago it was customary for the "experts" who gave evidence on behalf of railway companies to deny that the spinal cord could be injured if the legs were unwasted. Although the opinion dare not now be expressed, its significance is not without analogies at the present day.

the nervous system, and must be strongly opposed to recovery from genuine disorders. The occurrence of improvement when suspense is at an end, is thus no proof in itself of the nature of the case, and its significance has been unquestionably over-estimated; moreover, in a great many individuals whom I have had an opportunity of observing long after they had received their "damages" (as the expression curiously runs) this subsidence had not occurred, and even the sovereign balm" of substantial compensation has appeared to do very little for the relief of the sufferer.

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These opinions have been formed from a study of cases other than those that involve litigation, in which no elements existed to bias the judgment, and from a comparison of these with many "railway" cases observed apart from forensic proceedings. Those who desire to learn what can be said on the subject of "railway spines," as they have come to be termed, when viewed from the opposite sides, will find abundant material for consideration in the writings of Erichsen (On Concussion of the Spine,' London, 1875) and Clevenger (Spinal Concussion, or Erichsen's Disease,' Philadelphia, 1889) on the one side, and of Page (Injuries of the Spine and Spinal Cord,' London, 2nd ed., 1885) on the other. Scattered papers by J. J. Putnam, Walton, Spitzka, Buzzard, and others, more or less instructive, will be found epitomised in Clevenger's work, where indeed is collected the pith of almost all that has been written on the subject.

DIAGNOSIS.-The chief points in the diagnosis of traumatic lesions to the cord have been already incidentally considered. Immediate symptoms may be due to laceration, hæmorrhage, or to simple concussion, and the diagnosis between these is not always possible at first. If there are immediate symptoms of a partial lesion, these indicate direct injury, while the rapid subsidence of the disturbance of function renders simple concussion probable, and excludes any considerable direct injury. The later development of paralysis indicates myelitis, unless there is evidence of considerable irritation of the nerve-roots at a certain level, which suggests inflammation outside the cord, and perhaps even outside the dura mater. The greatest diagnostic difficulty is presented by the cases just mentioned, in which the symptoms are subjective, and anxious attention has been long given to the local discomfort. The chief elements in the diagnosis of these cases have been, however, already indicated. It is important to search for, and to give due weight to, any symptoms beyond the simple spinal pain. Slight "tingling" or "creeping" sensations may be of cerebral and "functional" origin, but a persistent sensation of "pins and needles" rarely is of that nature. A definite sense of constriction is also strongly suggestive of organic disease, and so is a well-marked difference in the power of the muscles on the two sides. The latter is of least significance if the excess is slight, general, and on the right side-of much greater significance if the diminution is partial, and affects only certain groups of muscles, such as the flexors

of the hip and knee, or the peronei. Any impairment of power over the bladder or rectum is of great diagnostic importance; loss of sexual power, on the other hand, is of little value, since this function is readily depressed by mental anxiety and preoccupation. A slight change in reflex action is most significant when it is partial. A footclonus, or rectus-clonus, is strong presumptive evidence of organic mischief. A slight excess of the knee-jerk is of little value; although it probably always indicates some changes in the nutrition of the spinal cord, it does not indicate structural disease. In all cases it should be remembered that the absence of any common symptom is of far slighter significance, as evidence of integrity of the cord, than is the presence of that symptom as evidence of disease. It may seem superfluous to insist on a consideration so elementary, but it is still possible, as experience proves, for a medical witness to assert in a court of law that a claimant's spinal cord cannot have been injured because some symptom is absent, the presence of which would be important.

PROGNOSIS.-Immediately after an accident a cautious prognosis should be given, even if the symptoms are slight, on account of the possibility that grave disturbance may develop in the course of a few days. In developed cases, the prognosis must in general be guided by the same considerations as those which determine our estimation of the probable course of symptoms of similar character and severity due to spontaneous myelitis. To this there are, however, two general exceptions. First, the danger of death, if any exists, is greater in traumatic cases than in others, as long as the symptoms are increasing. Secondly, if there is no danger to life, or such danger has passed, the prospect of improvement is distinctly greater than in a case of similar features but of non-traumatic origin. If the symptoms are slight or moderate in degree, approximate recovery may be anticipated, although slight symptoms often endure for a very long time. Indeed, in many cases, recovery, although approximate, is not perfect. The patient is never quite as strong, never becomes quite as capable of exertion, as before the injury. A cautious prognosis should also be given whenever there is the late and gradual onset or increase of symptoms that suggests a degenerative process. Such degeneration presents far less tendency to arrest or subsidence than do the earlier lesions. As a rule, the sooner symptoms occur, the better is the prospect of ultimate improvement or recovery, provided they are not so severe as to be incompatible with life.

TREATMENT. The early treatment of these cases, and much of the later treatment of those in which the spinal column is injured, is purely surgical. The points of medical character alone need special mention, and many of these have been anticipated in the preceding pages. In all cases in which spinal symptoms are present immediately after an injury, however slight those symptoms may be, absolute rest should be insisted on for some days or weeks, according

to the severity of the early symptoms. This is necessary on account of the secondary inflammation, which, as we have seen, so often occurs. The treatment of developed symptoms must be conducted on the same general principles as in cases of myelitis; the details need not be here repeated. If there is muscular wasting, it is important that the nutrition of the muscles should be maintained by electrical stimulation, since a very considerable amount of ultimate recovery may be anticipated, and it is important to keep the muscular tissue as far as possible in a condition to respond to the nerve-power when this returns. If there is reason to believe that there is inflammation of the membranes, or inflammatory effusion outside the cord, compressing it, mercury may be given, but this condition is probably much more rare than might be anticipated. The influence of mercury on inflammation of the substance of the cord is doubtful. The chief element in treatment is patiently to permit time to do its work, and the tissues to slowly regain such integrity of structure and function as is possible; meanwhile preserving the patient from all influences likely to interfere with the process or to set up other mischief, such as cystitis or bedsores, which would entail fresh danger. There is, however, one therapeutic measure that is of unquestionable value in the treatment of the later stages, especially of the cases in which the recurring symptoms suggest a relapsing myelitis as the sequel of injury ; and that is the repeated application of a mild "actual cautery on each side of the spine opposite the affected region. Several applications should be made, with or without an anesthetic. It is not desirable to lessen the pain by cocaine, because this is likely to interfere with the influence of the proceeding, the beneficial character of which is undoubted. The degenerative sequelae of injuries to the cord need the same treatment as the similar degenerations that occur apart from traumatic influences. Whenever there is evidence of displacement of the bones, or reason to suspect that the cord is compressed by fractured fragments, or even by products of secondary inflammation outside it, the propriety of trephining the spine needs to be considered. The problem is chiefly surgical, but the fact that it will probably not be necessary to open the dura mater increases the desirability of giving the patient this chance of relief. If needed, the sooner the measure is adopted, when improvement has ceased, the better.

The treatment of the neuralgic condition of spinal pain and tenderness, which so often succeeds injury, is frequently difficult. Counterirritation is often useful, either by the actual cautery, blisters, iodine, or repated sinapisms. Of sedatives, Indian hemp is most effective, next to morphia, which should be used as seldom as possible. Hypodermic injections of cocaine may be tried. When all active mischief is over, and the pain has become purely neuralgic, it is often necessary to encourage the patient to neglect it in some degree, and to

For first directing my attention to the fact, and the evidence supporting it in these ca-es, I am indebted to Dr. John Anderson.

exert himself in spite of it, while avoiding whatever increases it in considerable degree and for a considerable time. At the same time, extreme care should be observed by all persons who possess the constitutional states above mentioned, predisposing them to myelitis, &c. This is especially necessary when any symptoms persist, and often difficult to secure, except by uncompromising insistence, in those who have been accustomed to a life of active exertion.

FUNCTIONAL AND NUTRITIONAL DISEASES.
FUNCTIONAL DISEASES.

Very little is known, though much is heard, of functional diseases of the spinal cord. It is, indeed, open to doubt whether there are any morbid states which can accurately be thus designated; as was pointed out in the introduction, most morbid states thus described are either due to disturbance of cerebral functions, or are the result of changes in the nutrition of the elements of the cord. The deranged function may be an expression of altered nutrition, as it is of altered structure, but such cases can only be termed "functional" by a loose misuse of words. We have an example of the transference of our conceptions of functional derangements from the brain to the cord, in the fact that hysterical paraplegia is often regarded as a functional affection of the cord because the symptoms have the same distribution as those of organic diseases of the cord; but a little consideration will show that, in a case of purely hysterical paraplegia, the morbid functional condition is cerebral; the brain-centres which act on the legs are at fault, but the condition of the functions of the cord itself may be absolutely normal. The spinal motor centres are in a state of inactivity because the related cerebral centres are inactive, but this is no more a diseased condition of the cord than is its corresponding functional state during physiological rest. Hysterical paraplegia will be described, with other palsies of like origin, in the chapter on hysteria-a malady for which the term "functional" is often employed in various ways, as a convenient euphemism.

At the same time, it must be remembered that there is no sharp line of demarcation between functional derangement and nutritional changes. As already mentioned, no functional state can exist without leaving behind it some corresponding change in the finer molecular nutrition of the structures; and if functional derangement of lower structures results from that of higher cerebral centres, and is maintained for long, the change in nutrition that results may be considerable, and may be so definite as to persist even after its cause has ceased to act. Moreover the general enfeeblement of defective