ON
RAILWAY AND OTHER JUJRIES
OF THE
NERVOUS SYSTEM.








ON
RAILWAY AND OTHER INJURIES
OF THE
NERVOUS SYSTEM.
BY
A- JOHN ERIC ERICHSEN,
FELLOW OF THE ROYAL COLLEGE OF SURGEONS,
PROFESSOR OF SURGERY AND OF CLINICAL SURGERY IN UNIVERSITY COLLEGE;
SURGEON TO UNIVERSITY COLLEGE HOSPITAL;
EXAMINER IN SURGERY AT THE UNIVERSITY OF LONDON;
AND FORMERLY SO AT THE
UNIVERSITY OF DURHAM, AND THE ROYAL COLLEGE OF PHYSICIANS.
"JE RACONTE, JE NE JUGE PAS."
MONTAIGNE.
s U
PHILADELPHIA:
HENRY C. LEA.
1867.




PHILADELPHIA:
COLLINS, PRINTER, 705 JAYNE STREET.




NOTICE.
THE following Lectures were addressed to the Students
attending the University College Hospital in the Spring
of this year.
They are published as they were delivered; hence their
colloquial style.
My object has been to describe certain forms of Injury
of the Nervous System that commonly result from Accidents on Railways, to which I have reason to believe the
mind of the Profession has not been directed with that
amount of attention which their frequency and the important questions involved in them, appear to demand.
JOHN E. ERICHSEN.
6 CAVENDISH PLACE, LONDON,
June 15, 1866.








CONTENTS.
LECTURE THE FIRST.
INTRODUCTION.
PAGE
Introductory Remarks-Injuries of Spine-Importance of Subject-Conflict of Professional Opinion not confined to Medical ProfessionNecessity of Precision of Statement-The " Railway Spine"-Opinion
of Surgeons-Bacon's Opinion-Case of Count de Lordat-Conclusion......17
LECTURE THE SECOND.
EFFECTS OF SEVERE BLOWS ON THE SPINE.
Concussion of the Spine from Direct and Severe Injury-Opinions of
Authors, Cooper, Mayo, Bell, Boyer, Abercrombie, Ollivier-Case 1,
Recovery-Case 2, Partial Recovery-Case 3, Permanent Paralysis
-Case 4, Death after Concussion of the Spine from Direct Injury to
the Back-Effects of Severe Blows on the Spine-Fatal Result of
Concussion of the Spine-Hemorrhage within Spinal Canal-Laceration of Membranes-Inflammation of Cord and Membranes-CasesComplications of Injury of Cord-Rupture of Ligaments of SpineInflammatory Softening......26
LECTURE THE THIRD.
ON CONCUSSION OF THE SPINE FROM SLIGHT INJURY.
Concussion of Spine from Slight Injuries-Railway Injuries Peculiar but
not Special-Effects of Slight Blows on Spine, Case 5-Concussion
from Railway Injury, Case 6-Concussion from Railway Injury, Case 7
-Concussion from Carriage Accident, Case 8-Concussion from Falls
-Long durations of Symptoms..... 43
LECTURE THE FOURTH.
CONCUSSION OF THE SPINE FROM GENERAL SHOCK. TWISTS AND WRENCHES
OF THE SPINE.
Concussion from General Shock-Case 9. Concussion from Shock to Feet
-Case 10. Concussion from Railway Shock-Case 11. Concussion




Viii                        CONTENTS.
PAGE
from Railway Shock-Case 12. Concussion from Railway ShockTwists, Sprains, and Wrenches of the Spine-Case 13. Wrench of
Spine-Case 14. Twist of the Spine-Effects of Twists and Wrenches
of the Spine...... 55
LECTURE THE FIFTH.
SYMPTOMS AND PATHOLOGY OF CONCUSSION OF THE SPINE.
Period at which Symptoms begin to develop-Length of Time that often
elapses-Concussion not associated with other Injury-Nature of
Changes produced by Concussion-Early Symptoms of Railway Concussion-Detail of Symptoms of Railway Concussion-Symptoms of
Railway Concussion-Interval between Accident and SymptomsPathology of Railway Concussion-Mr. Gore's Case....2
LECTURE THE SIXTH.
DIAGNOSIS, PROGNOSIS, AND TREATMENT.
Diagnosis from Cerebral Concussion-From Rheumatism-From Hysteria
-Prognosis of Concussion of the Spine-What is meant by Recovery
-Probability of Recovery-Period of Fatal Termination-Treatment
-Importance of Rest-Counter Irritation-Medical Treatment. 91




INJURIES OF THE NERVOUS SYSTEM.
LECTURE THE FIRST.
Introductory Remarks-Injuries of Spine-Importance of Subject-Conflict of
Professional Opinion not confined to Medical Profession-Necessity of Precision
of Statement-The " Railway Spine"-Opinion of Surgeons-Bacon's OpinionCase of Count de Lordat-Conclusion.
INTRODUCTORY REMARKS.
GENTLEMEN: It has justly been said by one of the greatest
masters of the Art of Surgery that this or any other country has
ever produced-Robert Liston-that no injury of the head is too
trivial to be despised. The observation, true as it is with regard
to the head, applies with even greater force to the spine; for if the
brain is liable to secondary diseases in the one case, the spinal cord
is at least equally, and probably more so, in the other.
My object in these Lectures will be to direct your attention to
certain injuries and diseases of the spine arising from accidents,
often of a trivial character-from shocks to the body generally,
rather than from blows upon the back itself-and to endeavour to
trace the train of progressive symptoms and ill effects that often
follow such injuries.
These concussions of the spine and of the spinal cord not unfrequently occur in the ordinary accidents of civil life, but from none
more frequently or with greater severity than in those which are
sustained by passengers who have been subjected to the violent
shock of a railway collision; and it is to this particular class of
injuries that I am especially desirous of directing your attention.
For not only have they, in consequence of the extension of railway
traffic, become of late years of very frequent occurrence, but, from
the absence often of evidence of outward and direct physical injury,
the obscurity of their early symptoms, their very insidious cha2




18              INJURIES OF THE SPINE.
racter, the slowly progressive development of the secondary organic
lesions, and functional disarrangements entailed by them, and the
very uncertain nature of the ultimate issue of the case, they constitute a class of injuries that often tax the diagnostic skill of the
surgeon to the very utmost. In his endeavours not only to unravel
the complicated series of phenomena that they present, but also in
the necessity that not unfrequently ensues of separating that which
is real from those symptoms which are the consequences of the
exaggerated importance that the patient attaches to his injuries,
much practical skill and judgment are required.
The secondary effects of slight primary injuries to the nervous
system do not appear, as yet, to have received that amount of con
centrated attention on the part of surgeons that their frequency and
their importance demands; and this is the more extraordinary, not
only on account of the intrinsic interest attending their phenomena,
but also from their having become of late years a most important
branch of medico-legal investigation. There is no class of cases in
which medical men are now so frequently called into the witnessbox to give evidence in courts of law, as in the determination of
the many intricate questions that often arise in actions for damages
against railway companies for injuries alleged to have been sustained
by passengers in collisions on their lines; and there is no class of
cases in which more discrepancy of surgical opinion is elicited than
in those now under consideration.
It is with the view and in the hope of clearing up some of the
more obscure points connected with these injuries, that I bring this
important subject before you; for I believe that, as these cases
come to be more carefully studied, and consequently to be better
understood, by surgeons, much of the obscurity that has hitherto
surrounded them will be removed, and we shall less frequently see
those painful contests of professional opinion which we have of late
been so often constrained to witness in courts of law.
That discrepancy of opinion as to relations between apparent
cause and alleged effect; as to the significance and value of particular symptoms, and as to the probable result in any given case,
must always exist, there can be no doubt, more especially where
the assigned cause of the evil appears to be trivial, where the
secondary phenomena develop themselves so slowly and so insidiously that it is often difficult to establish a connecting link between
them and the accident.




CONFLICT OF PROFESSIONAL OPINION.              19
And for the existence of such discrepancy of opinion, and for
the expression of it, if necessary, on oath-as a matter of opinion,
merely-a very undue amount of blame has been cast on members
of the medical profession.
In well-marked and clearly-defined cases of injury, where the
physical lesion is distinct-as in a fracture-or the general symptoms unmistakable, as in the loss of sight or hearing, or in the
sudden and immediate induction of paralysis-no discrepancy of
opinion can or ever does exist; and I have no hesitation in saying
that in at least nineteen-twentieths of all the railway or other accidents that are referred to surgeons of experience for arbitration or
opinion, there is no serious difference as to the real nature of the
injury sustained, or as to its probable result on the patient, either
locally or constitutionally, immediately or remotely. But in a
certain small percentage of cases, in which, as has already been
said, the relation between alleged cause and apparent effect may
not always be easy to establish, in which the symptoms come on
slowly and gradually, in which they may possibly be referable to
other constitutional states, quite irrespective of and pre-existing to
the alleged injury, and in which the ultimate result is necessarily
most doubtful, being dependent on many modifying circumstances;
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 practitioner
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 occurrence in medical and surgical
practice. We daily witness the same discrepancies of opinion in
the estimate formed by professional men of obscure cases of any
kind. In cases of alleged insanity, in the true nature and probable
cause of many complicated nervous affections, in certain insidious
and obscure forms of cardiac, pulmonary, and abdominal disease;
in such cases as these we constantly find that'guot homines tot
sententice" 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.




20        CONFLICT OF PROFESSIONAL OPINION
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 a something
deficient in the judgment, or wrong in the morale, of its members.
But when we look around us, and inquire into the conduct of
members of other professions, we shall find that in every case in
which the question at issue cannot be referred to the rigid rules of
exact science-whether it be one of engineering, of law, of politics,
or of religion-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 varying aspects to the
minds of different individuals —conflict of opinion being the inevitable result.
Look at any great engineering question. Are engineers of the
highest eminence not ever to be found ranged on opposite sides in
the discussion of any point of practice that has become one of
opinion, and that cannot be decided by a reference to those positive data on which their science is founded? Is there no discrepancy of opinion often manifested amongst gentlemen of unimpeachable integrity in their profession, as to the possible causes of
that very accident, perhaps, which has occasioned the catastrophe
that has led to your presence 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 Commons, amongst the magnates of the legal
profession, on questions that involve points of professional doctrine
and practice?
Is the Church herself free from differences of the widest kind
on questions that we are taught are of the most vital importance?
Have we not for years past heard questions of doctrine, of practice, of ritualism, discussed with an amount of vehemence and zeal
to which we can find no parallel in our own profession? Are not
angry passions roused in quarters where they are little to be expected, and may we not at times be tempted to exclaim, "Tantcene
animis ccelestibus ire?"
These conflicts of opinion, gentlemen, are common to all the
professions and to every walk of life. Religion and politics, law,




NOT CONFINED TO MEDICAL MEN.               21
medicine, and the applied sciences, all contain so much that is, and
ever must be, matter of opinion, that men can never be 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 consequence of the diversity of views that are naturally
entertained, Truth is at last elicited.
Far 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
discrepancies of opinion arising between medical men are often
magnified by the ingenuity of advocates, so as to be made to
assume a very different aspect to that which they were intended to
present, and are exaggerated into proportions which those who
propounded them never meant them to acquire. Medical men deal
habitually with the material rather than the ideal, with facts rather
than with words, and are frequently, perhaps, at times somewhat
inexact in the expressions they use. Mere verbal differences, mere
diversities in modes of expressing the same fact, are thus sometimes
twisted into the semblance of material discrepancies of statement
and opinion. How often have I not 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 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, 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 value
of your evidence. It is your province to give a distinct and clear
description of the facts that you have observed, and an unbiassed
and truthful opinion as to the inferences you draw from them. It
is their business to elicit the Truth, and to place the cause of their
client in the best possible light, by questioning the accuracy of
your facts and by sifting the validity of the opinions you have deduced from them.




22                THE "RAILWAY SPINE."
I purpose illustrating these lectures by cases drawn from my
own practice, and by a reference to a few of the more interesting
published cases that bear upon the subject. In doing so, I shall
confine myself to the detail of a few selected instances. It would
be as useless as it would be tedious to multiply them to any great
extent, as they all present very analogous trains of symptoms and
phenomena. I will not confine my illustrations to cases drawn
from railway accidents only, but will show you that precisely the
same effects may result from other and more ordinary injuries of
civil life. It must, however, be obvious to you all, that in no ordinary accident can the shock be so great as in those that occur on
railways. The rapidity of the movement, the momentum of the
person injured, the suddenness of its arrest, the helplessness of the
sufferers, and the natural perturbation of mind that must disturb
the bravest, are all circumstances that of a necessity greatly increase the severity of the resulting injury to the nervous system,
and that justly cause these cases to be considered as somewhat exceptional from ordinary accidents. This has actually led some
surgeons to designate that peculiar affection of the spine that is
met with in these cases as the "railway spine."
But yet, though the intense shock to the system that results from
these accidents naturally and necessarily gives to them a terrible
interest and importance, do not for a moment suppose that these
injuries are peculiar to and are solely occasioned by accidents that
may occur on railways.
There never was a greater error. It is one of those singular mistakes that has arisen from men trusting too much to their own individual experience, and paying too little heed to the observations
of their predecessors. It is an error begot in egotism and nurtured
by indolence and self-complacency. It is easy for a man to say that
such and such a thing cannot exist, because, "I, in my large experience at our hospital, never saw it," and not to trouble himself to
learn, by the study of their works, that surgeons of equally large,
or perhaps of far greater, experience in their generation, have seen
and have described it.
Sir Astley Cooper, who certainly enjoyed a wider range of experience in surgical practice than has ever before or since fallen to
the lot of any one man in this country, said that his experience,
extensive as it had been, was only as a bucket of water out of the
great ocean of surgical knowledge.




OPINIONS OF SURGEONS.                  23
In the writings of Sir A. Cooper himself, in those of his predecessors and contemporaries, especially of Boyer, of Sir C. Bell, and,
at a later period, of Ollivier and Abercrombie, you will find many
cases recorded that prove incontestably that precisely the same
trains of phenomena that of late years have led to the absurd appellation of the "Railway Spine," had arisen from accidents, and
had been described by surgeons of the first rank in this country
and France, a quarter of a century or more before the first railway
was opened, and that they were then generally recognized by surgeons as arising from the common accidents of civil life. The only
difference being, that those accidents having increased in frequency
and intensity since the introduction of railways, these injuries have
become proportionally more frequent and more severe.
Bacon truly said, " They be the best physicians which, being
learned, incline to the traditions of experience, or, being empirics,
incline to the methods of learning." The same remark is applicable to surgeons, and that observation is as true at the present day
as when it was made, nearly three hundred years ago.
Yes, truly, gentlemen, if you are "empirics," incline to the
methods of learning. Do not trust wholly to your empiricism;"
in other words, to your own individual experience; but learn what
has been seen by others of equal, perhaps of greater, experience
than yourselves; as accurate in observing, and as truthful in recording. The study of the works of such men is not a vain and
futile learning, but one replete with valuable results. In reading
their works, you feel that you come into direct communion with
these great men-with the Boyers, the Bells, and the Coopers-and
from them you will learn many a lesson of practical wisdom, the
direct result of their own accurate observations.
But you may go further back than the writings of these great
men, and you will find scattered here and there throughout medical
literature occasional most interesting cases that bear upon this very
point. You will find much in this literature that anticipates what
are often erroneously supposed to be more recent discoveries, and
many a man, thinking that he has struck out a new vein of truth,
and finding that it has already, years ago, been explored and the
ore extracted by his predecessors, may exclaim, " Pereant ante nos
qui nostra dixere."
If you take up the third volume of the "Medical Observations
and Inquiries," you will find that in 1766, exactly one hundred




24          CASE OF THE COUNT DE LORDAT.
years ago, a case is related by Dr. Maty of "a palsy occasioned by
a fall, attended with uncommon symptoms," which is of so interesting a nature, and which bears so closely upon our subject, that
I feel that I need no apology for giving you an abstract of it here,
although, as it occurred between sixty and seventy years before
the first railway was opened in this country, it might at first appear
to have less relation to railway accidents than it really has, for it
is identical in its course and symptoms with many of them.
This case, which is given at length, is briefly as follows:Count de Lordat, a French officer of great rank and merit, whilst
on his way to join his regiment, in April, 1761, had the misfortune
to be overturned in his carriage from a pretty high and steep bank.
His head pitched against the top of the coach; his neck was twisted
from left to right; his left shoulder, arm, and hand much bruised.
As he felt at the time little inconvenience from his fall, he was able
to walk to the next town, which was at a considerable distance.
Thence he pursued his journey, and it was not till the sixth day
that he was let blood on account of the injury to the shoulder and
hand.
The Count went through the fatigues of the campaign, which
was a very trying one. Towards the beginning of the winter (at
least six months after the accident), he began to find an impediment
to the utterance of certain words, and his left arm appeared to be
weaker. He underwent some treatment, but without much advantage; made a second campaign, at the end of which he found the
difficulty in speaking and in moving his left arm considerably increased. He was now obliged to leave the army and return to
Paris, the palsy of the left arm increasing more and more. Many
remedies were employed without effect. Involuntary convulsive
movements took place all over the body. The left arm withered
more and more, and the Count could hardly utter a few words.
This was in December, 1763, two years and a-half after the accident.
He consulted various physicians, and underwent much treatment
without benefit.
In October, 1764, three years and a-half after the fall, Dr. Maty
saw him. "A more melancholy object," he says, "I never beheld.
The patient, naturally a handsome, middle-sized, sanguine man, of
a cheerful disposition and an active mind, appeared much emaciated, stooping, and dejected. He walked with a cane, but with




CONCLUSIONS FROM THIS CASE.               25
much difficulty, and in a tottering manner." His left hand and arm
were wasted and paralyzed; his right was somewhat benumbed,
and he could scarcely lift it up to his head. His saliva dribbled
away; he could only utter monosyllables, "and these came out,
after much struggling, in a violent expiration, and with a low tone,
and indistinct articulation." Digestion was weak, urine natural.
His senses and the powers of his mind were unimpaired. He occupied himself much in reading and writing on abstruse subjects.
No local tumour or disease was discoverable in the neck or anywhere else. From this time his health gradually declined, and he
finally died on the 5th March, 1765, nearly four years after the
accident.
On examination after death, the pia mater of the brain was found
"full of blood and lymph;" and towards the falx some marks of
suppuration. The medulla oblongata is stated to have been greatly
enlarged, being about one-third larger than the natural size. The
membranes of the cord were greatly thickened and very tough.
The cervical portion of the cord was hardened, so as to resist the
pressure of the fingers.
"From these appearances," says Dr. Maty, "we were at no loss to
fix the cause of the general palsy in the alterations of the medulla
spinalis and oblongata." That the twisting of the neck in the fall
had caused the membrane of the cord to be excessively stretched
and irritated; that this cause extended by degrees to the spinal
marrow, which, being thereby compressed, brought on the paralytic
symptoms.
This case is of the utmost interest and importance; and though
it occurred more than a century back, and was published exactly
one hundred years ago, it presents in so marked a manner the ordinary features of a case of "concussion of the spine," arising from
injury, that it may almost be considered a typical case of one of
those accidents.
The points to which I would particularly beg to direct your
attention in this case are these:1st. That there was no evidence of blow upon the spine-merely
a twist of the neck in the fall.
2d. That no immediate inconvenience was felt, except from the
bruise on the shoulder and hand.
3d. That the patient was able to walk a considerable distance,
and to continue his journey after the occurrence of the accident.




26               CONCUSSION OF THE SPINE.
4th. The symptoms of paralysis did not manifest themselves for
several months after the injury.
5th. They were at first confined to the left arm and to the parts
of speech.
6th. They very slowly but progressively increased, extending to
the left leg and slightly to the right arm.
7th. This extension of paralysis was very gradual, occupying two
or three years. The sphincter were not affected, and the urine was
healthy.
8th. The general health gradually but slowly gave way, and death
at last ensued, after a lapse of four years, by a gradual decay of the
powers of life.
9th. After death, evidences of disease were found in the membranes of the cord, and the cord itself. The narrator of the case
stating that the membranes were primarily, and the cord secondarily, affected.
You will find, as we proceed in the investigation of this subject,
that the symptoms, their gradual development, and the after-death
appearances presented by this case, are typical of the whole class of
injuries of the spine grouped together under the one common term
"Concussion," from whatever cause arising,
LECTURE THE SECOND.
EFFECTS OF SEVERE BLOWS ON THE SPINE.
Concussion of the Spine from Direct and Severe injury-Opinions of Authors,
Cooper, Mayo, Bell, Boyer, Abercrombie, Ollivier-Case 1, Recovery-Case 2,
Partial Recovery-Case 3, Permanent Paralysis-Case 4, Death after Concussion of the Spine from Direct Injury to the Back-Effects of Severe Blows on
the Spine-Fatal Result of Concussion of the Spine-Hemorrhage within
Spinal Canal-Laceration of Membranes-Inflammation of Cord and Membranes-Cases-Complications of Injury of Cord-Rupture of Ligaments of
Spine-Inflammatory Softening.
IT is not my intention in these Lectures to occupy your time
with any remarks on those injuries of the spine that are attended
by obvious and immediate signs of lesion to the vertebral column
itself, such as fractures and dislocations of it, or direct wounds of




CONCUSSION OF THE SPINE.                 27
the cord. The nature and the consequences, proximate and remote, of such injuries as these are so obvious and so well understood by all engaged in surgical practice, that their consideration
need not detain us.
My object is to bring under your observation the effects, local
and constitutional, immediate and remote, of certain forms of injury
to which the spinal cord may be exposed without lesion of its protecting column or enveloping membranes. These injuries, from
the obscurity of their primary symptoms, the very slow development of their secondary phenomena, and from the ultimate severity
and long persistence of the evils they occasion, are of the greatest
interest to the practical surgeon.
In considering these injuries, I shall adopt the following arrangement:1. The consideration of the effects of slight and apparently
trivial injuries applied directly to the spine.
2. The effects that injuries of distant parts of the body, or that
shocks of the system, unattended by any direct blow upon the
back, have upon the spinal cord.
3. The effects produced by wrenches or twists of the spine.
Before, however, proceeding to the consideration of these questions, it will, I think, be important to inquire into the effects produced by those forms of concussion of the spinal cord which follow
immediately and directly upon a severe degree of external violence
applied to the vertebral column, as by so doing we shall be able to
understand more clearly the phenomena resulting from the slighter
form of injury.
It is by no means easy to give a clear and comprehensive definition of the term, "Concussion of the Spine."  Without attempting to do so, it may be stated, in explanation of this phrase, that it
is generally adopted by surgeons to indicate a certain state of the
spinal cord occasioned by external violence; a state that is independent of, and usually, but not necessarily, uncomplicated with
any obvious lesion of the vertebral column, such as its fracture or
dislocation-a condition that is supposed to depend upon a shake
or jar received by the cord, in consequence of which its intimate
organic structure may be more or less deranged, and by which its
functions are certainly greatly disturbed, various symptoms indicative of loss or modification of innervation being immediately or
remotely induced.




28               OPINIONS OF SURGEONS.
In fact, it appears to me that surgeons and writers on diseases of
the nervous system have included four distinct pathological conditions under this one term, "Concussion of the Spine," viz., 1. A jar
or shake of the cord, disordering, to a greater or less degree, its
functions, without any obvious lesion cognizable to the unaided
eye. 2. Compression of the cord from extravasated blood. 3.
Compression of the cord from inflammatory exudations within the
spinal canal, whether of serum, lymph, or pus; and, 4. Chronic
alterations of the structure of the cord itself as the result of impairment of nutrition consequent on the occurrence of one or other
of the preceding pathological states, but chiefly of the third.
These various conditions differ remarkably from one another in
symptoms and effects, and have only this in common that they are
not dependent upon an obvious external injury of the spine itself,
as the laceration or compression of the cord by the fracture or
dislocation of a vertebra.
Concussion or commotion of the spinal cord as a consequence
of severe and direct blows upon the back is an injury that has
long been recognized and described by those writers who have
occupied themselves with the consequences of accidents applied to
this part of the body.
Sir A. Cooper' relates two cases of concussion of the spine, one
terminating at the end of ten weeks in complete, the other in
incomplete recovery.
Mayo2 relates two cases. In one at the end of six months there
was no amelioration. In the other at the end of four months
symptoms of inflammatory softening of the cord set in.
Sir Charles Bell3 relates two most interesting cases of concussion
of the spine, both occasioned by falls and blows upon the back, in
one of which the symptoms were immediate, in the other only
developing themselves slowly after an interval of some months.
Boyer4 relates two cases. In one the patient struck his loins by
falling into a deep ditch. He was affected by complex paraplegia,
and speedily died. On examination no morbid appearances could
be detected, neither fracture, dislocation, effusion, or any lesion of
the cord or its membranes. In the other case, a man amusing
1 Dislocations and Fractures of Joints, 8vo. ed., p. 526 et seq.
2 Outlines of Pathology, Lond. 1836.
s Surgical Observations, London, 1816.
4 Maladies Chirurgicales, vol. iii. p, 135,




CASE 1-CONCUSSION, COMPLETE RECOVERY.            29
himself with gymnastic exercises strained his back between the
shoulders. He became paraplegic, and died in a few weeks.
After death no lesion of any kind was found in the spine or cord.
Abercrombie, in his well-known and philosophical treatise on
the Brain and Spinal Cord' has a short chapter on this injury, in
which he relates several cases from his own observations and from
the practice of others, in which the characteristic symptoms of
concussion of the cord followed blows upon the spine.
Ollivier2 has collected, from his own practice and that of others,
thirteen cases of this injury. They are detailed with much minuteness. Several of these proved fatal, and of these the afterdeath appearances are given at length.
Concussion of the spine from a direct and severe injury of the
back may terminate in four ways: 1. In complete recovery after a
longer or shorter time. 2. In incomplete recovery. 3. In permanent
disease of the cord and its membranes; and, 4. In death.
The probability of the termination in recovery does not depend
so much on the actual severity of the immediate symptoms that
may have been occasioned by the accident as on their persistence.
If they continue beyond a certain time, changes will take place in
the cord and its membranes which are incompatible with the proper exercise of its functions.
The following cases will illustrate these forms of spinal concussion from the infliction of severe and direct injury to the spine.
The first case is an instance of complete recovery-after severe
and uncomplicated concussion of the spine. The second case is
one of partial recovery after incomplete paralysis from concussion.
The third case is a remarkable instance of incurable paraplegia
following concussion; and the fourth case is one of death following
a direct blow on the spine.
Case 1.-A man, 42 years of age, a clerk, fell whilst getting
down from the roof of an omnibus, striking his back heavily upon
the ground. He tried to get up, but was unable to do so, and was
carried to University College Hospital where he was admitted in
February, 1857, under my care.
On examination it was found that he had a transverse bruise
upon the back, in the dorso-lumbar region, probably from coming
1 London, 1828, p. 375.
2 Traite des Maladies de la Moelle Epinibre. Paris, 1837.




30     CASE 1-CONCUSSION, COMPLETE RECOVERY.
in contact with the step of the vehicle in his fall. He suffered
pain on pressure about the bruised part; but there was no irregularity to be detected in the line of the spinous processes or any
other sign of fracture or of injury to the vertebrae. The ecchymosis extended over the two or three last dorsal and the first lumbar vertebra. His consciousness was in no way disturbed. He
could not stand, his legs giving way under him. He complained
of complete numbness in the left leg, but in the right there was a
certain degree of sensibility associated with tingling, pricking sensations. When laid in bed he could not move the left lower extremity, but he could flex the right thigh upon the abdomen and
draw up the knee, though he could not raise the foot. The catheter
was passed and clear urine drawn off.
He was ordered complete rest in bed; five grains of calomel, to
be followed by a purgative enema, and the use of the catheter, if
necessary, every eighth hour.
Febrile reaction set in, which continued for three or four days.
He was quite unable to empty the bladder; the urine was consequently drawn off by the catheter. There was no incontinence of
flatus or of feces. No change in the state of the lower extremities.
At the end of a week he was decidedly better; he could raise the
right foot from the bed, and the normal sensibility of that limb had
in a great measure returned. He could draw up the left knee, and
there was some sensation in the leg and in the dorsurn of the foot.
The retention of urine continued.
At the end of a fortnight motion and sensation had returned in
the right lower extremity, but the left limb was still weak and
partially numb, with formications and tinglings. He now began
to pass his urine-which was acid-without the use of the catheter.
During the whole of this period the only treatment that had been
adopted was rest in bed, with an occasional aperient. He was
now ordered to sit up, and had dry cupping to the lower part of
the spine.
At the expiration of another week he was able to move about on his
feet with a tottering, straddling gait, by the aid of a chair and stick.
He now steadily improved both in appearance and in power of
moving. At the end of the first month he could walk with but
little assistance; he was still very weak in the left leg, which was
partially numb; it felt as if asleep, and tingled.
Stimulating embrocations were ordered to the spine, and he was




CASE 2-CONCUSSION, INCOMPLETE RECOVERY.          31
put on the bichloride of mercury, gr. y, in tincturse cinchonat co.
3i, thrice a day. Under this treatment he steadily improved, and
was able to leave the hospital at the end of the sixth week, walking
with the aid of a stick. He was treated as an out-patient with
strychnine and iron, and the local application of galvanism, for two
or three weeks longer, and then dismissed cured.
This case is related as an instance of not very uncommon occurrence, in which, after a severe and direct blow upon the spine,
paraplegic symptoms are suddenly developed, which again disappear completely in the course of a few weeks under the influence
of rest and appropriate treatment. The only point of special interest in this case is, that although there was paralysis and complete
retention, the urine continued acid throughout. It is probable that
the pathological lesion in such a case as this, consists of some intravertebral extravasation of blood, the compression exercised by
which occasions the symptoms, which disappear as it gradually becomes absorbed.
Case 2.-A painter, 30 years of age, was admitted into University
College Hospital under my care, in June, 1865, under the following
circumstances. He states that whilst painting a house he overreached himself, and fell with the ladder to the ground, a height of
about thirty feet, striking his back upon a gravel walk. His hand
was cut in the fall but his head was uninjured. On admission he
was found somewhat collapsed, cold, and with a feeble pulse. There
was no evidence of fracture either of spine or pelvis, but the back
was ecchymosed to some extent about the centre of the dorsal region.
He could not stand, but when lying in bed could draw up the
knees nearly to a right angle, although he was unable to raise the
feet. He complained of numbness and tingling in both legs and
feet, but could feel when pinched or pricked. The patient had perfect control over his sphincters, and the urine was acid.
He was treated by rest in bed, dry cupping to the spine, and
occasional aperients. At the end of a month he had not improved,
being as nearly as possible in the same state as on admission. He
was now put on small doses of the bichloride of mercury in bark,
and had counter-irritation applied to the spine. Some little amendment took place under this plan of treatment, and in August he was
able to sit up, but could neither walk nor stand without support,
and continued to complain of the numbness and tingling in his legs.
Towards the end of the month he seemed to have acquired slight




32    CASE 2-CONCUSSION, INCOMPLETE RECOVERY.
power over the legs, and could manage, by dragging them along,
and leaning on a chair and stick or crutch, to move across the
ward. He now very slowly improved, and by the end of September was able to leave the hospital. He was emaciated, cachecticlooking, and could barely manage to walk and drag his leg, by
holding on to the furniture, or by pushing a chair before him. He
continued through the winter mending but slowly. Towards the
early part of the following year he was taken charge of by the
Sisters of Mercy, who sent him to their establishment at Clewer.
There he gradually regained a certain degree of health and strength.
I saw him again on April 20th, exactly ten months after the accident; he was then in the following state: —
He describes himself as being languid, depressed, and as if going
out of his mind. His memory has become very bad-at times all
seems a blank to him. When he goes on an errand he often cannot recollect what it is about; is always obliged to write it down.
His thoughts are confused; he often mixes up one thing with
another. He is very nervous and easily frightened. He dreams
much, and is told that he talks and cries out in his sleep.
He is "not the same man that he was," and thinks he never will
be. He cannot do ordinary work as before the accident-only "odd
jobs."  He cannot walk more than a mile; cannot carry a pail of
water without great exertion.
He is never free from an aching, throbbing pain in the back;
most severe in the middle dorsal region. There the spine is very
tender on pressure, and the tenderness extends to some distance on
either side of it, more especially on the left. This pain is greatly
increased by movement of any kind, especially by bending backwards. He stoops with great difficulty, and is obliged to go upon
one knee in order to pick anything off the floor. He walks in a
shuffling, unsteady manner, and always uses a stick. He complains
of numbness and "pins and needles" in the right leg and foot. There
is no difference in the size of the limbs.
He has suffered since the accident from muscme volitantes and
coloured spectra, "like the rainbow" before his eyes. Light does
not distress him, but loud noises do. His hearing is very acute indeed.
No irritability of bladder; holds and passes his water well; urine
is acid.
This case presents a good example of concussion of the spine followed by partial paralysis of sensation and motion of the lower




CASE 3.-CONCUSSION, PERMANENT PARALYSIS.           33
limbs without affection of the sphincters or alkalinity of urine, terminating in incomplete recovery.
It appears to me doubtful whether intra-vertebral hemorrhage
took place in this case; but there can be little doubt that the spinal
cord had sustained some serious organic lesion which interfered with
complete recovery.
In some cases, however, the result is not so satisfactory even as
in this; the symptoms that are immediately developed continuing
for many years, even for the remainder of the patient's life, without
change.
The following1 is one of the most remarkable cases on record, of
long persistent paralysis after a blow on the spine, the loss of sensation being so complete that the patient submitted to the amputation of both thighs without feeling the slightest pain. As this case
has never, I believe, been published in this country, and is of so
very remarkable a character, I have thought that it might not be
out of place to give an abstract of it here.
Case 3.-A man, 22 years of age, in felling a tree, was struck on
the back part of the head and between the shoulders by a large
bough. This accident occurred in 1845. The force of the blow
expended itself chiefly on the lower cervical spine and the shoulders. A complete paralysis of sensation and motion, of all the
parts below this, was the immediate result. This condition continued without the slightest change. The vital and animal functions
were naturally performed. Respiration, circulation, digestion, secretion, and assimilation were all normal. There was a sensible
increase in the frequency and volume of the circulation, and
respiration was noticed to be slightly increased in frequency above
the normal standard. The weight of the body became greater after
than it had been before the injury, and the lower limbs retained
their natural heat and physical development.
The patient evidenced an unusual share of mental vigour after the
injury, and possessed a resolution and determination that are described as truly surprising in his helpless condition. He threw
himself into the midst of society for excitement, and was fond of
travelling, lying on his back in his carriage.
In 1851, six years after the accident, he presented himself in the
Eve's Surgical Cases, p. 90; and New York Journal of Medicine, 1853. By
Win. D. Purple, M. D., of Greene, New York.
3




34            CASE 4. —CONCUSSION, DEATH.
County Medical Society (Greene, New York), and requested the
amputation of his lower extremities, which he stated were a burdensome appendage to the rest of his body, causing him much labour
in moving them, and stating that he wanted the room they occupied
in his carriage for books and other articles. He insisted on the
operation with his wonted resolution and energy. The surgeon
whom he consulted at first refused to consent to amputation, not
only objecting to so extensive a mutilation for such reasons as he
gave, but fearing lest the vitality of the vegetative existence enjoyed by his limbs might be insufficient for a healthy healing process.
The patient, still determined in his resolve to have the limbs cut
off as a useless burden to the rest of the body, sought other advice,
and at last had his wishes gratified.
Both limbs were amputated near the hip-joints, without the
slightest pain or even the tremor of a muscle. The stumps healed
readily, and no unfavourable symptoms occurred in the progress of
perfect union by the first intention. In this mutilated state he was
perfectly unable to move his pelvis in the slightest degree. He
resumed his wandering life, and travelled over a great part of the
States. He died in May, 1852, of disease of the liver, brought on
by his excesses in drink, to which he had become greatly addicted
since his accident. No post-mortem examination was made.
This case is a most remarkable one in several points of view, and
in none more than in this, that a double amputation of so serious
a character could be successfully practised on a person affected by
complete paraplegia, and yet that the stumps healed by the first
intention. Besides this remarkable fact, there are two special points
of interest in this case which bear upon the subject that we are now
considering, viz., that the weight of the body is stated to have
increased after the accident, and that the limbs which were so completely paralyzed as to admit of amputation without the patient experiencing the slightest sensation of pain, had in no way wasted
during the six years that they had been paralyzed, but retained
"their normal physical development," as is expressly stated in the
report of the case. We can have no stronger evidence than this to
prove that mere disuse of a limb for a lengthened period of years
even, is not necessarily followed by the wasting of it.
Case 4.-J. R., a clerk by occupation, was admitted under my
care into University College Hospital, October 2d, 1862. He had
been knocked down half an hour previously by a Hansom cab, the




CASE 4-CONCUSSION, DEATH.                 35
horse falling partly upon him, and striking him with its knee on
the neck. He never lost consciousness, but being quite unable to
move, was carried to the hospital; on his way he passed his urine
and feces involuntarily.
On examination after admission, it was found that he had an
abrasion and 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-incontinence of feces, retention of urine.
The breathing was wholly diaphragmatic. 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 paralyzed, as he could not move his
legs; but on being 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
difficulty. Pulse 64, strong; passes feces involuntarily.  Urine
drawn off, and is ammoniacal. He was placed on a water mattress,
as his back was becoming excoriated. Ordered quinine and acids.
8th. Is able to move his head and neck from side to side. Has
less pain. Urine more ammoniacal; feces pass involuntarily. Bedsores over sacrum have much extended.
10th. Difficulty of breathing came on, but was relieved by the
11th. On the 12th it returned, with mucous rates, and he died that
night-ten days after the accident.
On examination after death the head and brain were found uninjured and healthy. On exposing the vertebral column, it was
found that the sixth and seventh cervical vertebrae had been separated posteriorly. The vertebrae themselves, and their arches, were
quite sound, but there was a fissure without any displacement,
extending through the articulating processes on the left side. A
large quantity of blood was extravasated into the spinal canal, lying




36        PRIMARY SYMPTOMS OF CONCUSSION.
between the bones and the dura mater. There was a considerable
quantity of reddish serous fluid in the arachnoid. The pia mater
of the cord had some blood-patches upon it on the lower cervical
region. The cord itself was quite healthy.
In this case it will be observed that the paralysis was most extensive, as much so as is compatible with life. The loss of sensation
appeared to be more complete than that of motion, the patient
being able, by an effort of the will, to cross his legs, but he could
not feel when they were pinched or pricked. The fracture of an
articulation without displacement was an accidental and insignificant complication, the real injury consisting in the extravasation
of blood within the vertebral canal, which, by compressing the
cord, induced the paralysis, that ultimately proved fatal. Death
being, doubtless, hastened by the effusion of a large quantity of
serous fluid from the irritated arachnoid.
The primary symptoms of concussion of the cord immediately
and directly produced by a severe blow upon the spine will necessarily vary in severity and extent according to the situation of the
injury, the force with which it has been inflicted, and on the amount
of organic lesion that the delicate structure of the cord has sustained
by the shock or jar to which it has been subjected.
A severe blow upon the upper cervical region may produce instantaneous death.
A severe blow inflicted on the dorsal region may induce more or
less complete paraplegia.
In some cases the paralysis of the lower limbs has been complete
and instantaneous; has affected both sensation and motion, with
loss of power over the sphincters.
In other cases there has only been paralysis of motion, sensation
continuing perfect.
The reverse has been met with, but less frequently and less completely, there being loss of sensation and impairment, though not
complete loss of power over motion.
One leg is frequently more severely affected than the other. Or
the two legs may be unequally affected as to sensation and motion;
both sensation and motion being impaired, but in varying degrees
in the two limbs.
There may be complete loss of power over the sphincters both
of the bladder and anus, with incontinence or retention of urine and
feces; or the loss of power may be confined to the bladder only.




FATAL RESULT IN CONCUSSION FROM SEVERE BLOW. 37
This is especially the case when there is paralysis of motion rather
than of sensation in the lower limbs.
The state of the urine will vary. If there is no retention, it will
continue acid. When there is retention the urine usually becomes
alkaline, but sometimes even when there is complete retention it
remains strongly acid; and Ollivier has noted the very remarkable
circumstance in one case of retention that there was an enormous
formation of uric acid, so that the catheter became loaded with it.
Priapism does not occur in concussion, as it does so often in cases
of laceration and irritation of the cord.
The temperature of the paralyzed parts is generally notably lower
than that of the healthy parts of the body, and in some cases an
absence of normal perspiration has been observed.
The secondary symptoms of severe concussion of the spine are
usually those of the development of inflammation in the meninges
and in the cord itself. They consist in pain in some part or parts
of the spine, greatly increased by pressure and on motion, consequent rigidity of the vertebral column, the patient moving it as a
whole. The pain is greatly increased by all movements, but especially by those of rotation.
It frequently extends down the limbs or around the body, giving
the sensation of a cord tied tightly.
If the case goes on to the development of acute inflammatory
action in the cord and its membranes, spasms of a serious character
come on-at first, usually of the nature of trismus-then general
spasms of the body and limbs, usually followed by speedy death
from the exhaustion produced by the repetition of these violent convulsive movements.
If the inflammatory action assume a chronic and subacute character, permanent alterations in the structure of the cord will ensue,
which will lead to paralytic affections of an incurable nature, usually
confined to the lower extremities, but sometimes influencing the
brain, and associated with great and deep-seated derangement of
the general health.
Concussion of the spine from a severe and direct blow upon the
back may prove fatal at very different periods after the injury. The
time at which death occurs will depend partly on the situation of
the blow, and in a great measure on the lesions to which it has given
rise.
Concussion of the spine may, and often has, proved fatal by the




38     HEMORRHAGE WITHIN THE SPINAL CANAL.
sudden induction of paralysis, without there having been found after
death any lesion of the cord that could explain the fatal termination of the case.
Abercrombie says: "Concussion of the cord may be speedily
fatal without producing any morbid appearance that can be detected on dissection." And he refers to the case related by Boyer, and
four by Frank in confirmation of this remark.
But in other cases the fatal result may have been occasioned by
direct and demonstrable lesion of the spine or cord.
There appear to be four forms of lesion that will lead to a fatal
result in cases of spinal concussion.
1. Hemorrhage within the spinal canal.
2. Laceration of the membranes of the cord, and extravasation of
the medullary substance.
3. Disintegration and perhaps inflammatory softening of the cord.
1. Hemorrhage within the spinal canal may occur1st. Between the vertebrae and dura mater;
2d. Between the membranes and the cord;
3d. In both situations.
In these respects intravertebral extravasations resemble closely
those that occur as the result of injury within the cranium. The
three following cases are illustrations of these three forms of hemorachis.
Sir A. Cooper mentions one case, to which I shall have occasion
hereafter to refer, in which, in consequence of a strain of the neck
in a boy of 12 years of age, symptoms of paralysis slowly supervened, which proved fatal at the end of a twelvemonth.
On examination after death, "the theca vertebralis was found
overflowing with blood, which was effused between it and the inclosing canals of bone." This extravasation extended from the first
cervical to the first dorsal vertebra.
Millerl relates the case of a corporal of cuirassiers who fell from
a hay-loft on to his back, striking it against a log of wood. He was
found to be completely paralyzed in his lower limbs, but preserved
his consciousness. He died on the second day. On examination
it was found that there was a large quantity of blood extravasated
between the spinal cord and its membranes. This extTavasation extended from the sixth cervical to the ninth dorsal vertebra.
Bull. des Sc. Medicales, 1826.




INFLAMMATION OF THE CORD AND ITS MEMBRANES. 39
Ollivier1 relates the case of a woman 49 years old, who threw
herself out of a window in the fourth story, alighting on her
back. There was complete paralysis of the lower limbs, with
incontinence of urine. Her mental faculties were unimpaired.
She died on the third day after the injury, and on examination it
was found that there was a fracture, but without any displacement,
of the tenth dorsal vertebra; at this spot blood was extravasated
between the vertebra and the dura mater, and also into the subarachnoid cellular tissue.
2. Death may occur-in that form of severe concussion which
we are at present considering-from laceration of the pia mater,
and hernia of the cord. Of this form of fatal result, Ollivier
records one case, that of a man, 46 years of age, who had fallen
heavily on his back, striking the spine in the middle of the dorsal
region. He had paraplegia, paralysis of the sphincters, violent
pain in the spine at the seat of injury, and much constitutional
disturbance. He died on the seventeenth day. On examination
after death it was found that the pia mater of the cord had been
ruptured at two places opposite to the seat of injury, giving exit
to the medullary substance in two patches, each about the size of
a halfpenny, about two to three lines in thickness, and of a reddish colour. These protrusions had passed out of two longitudinal
slits in the meninges of the cord, each about one inch in length,
situated at the medial and posterior part, and opposite to the fourth
and fifth dorsal vertebra. At the points opposite to these herniary
protrusions, the spinal cord was much contracted, having lost a
great part of its substance; but it preserved its normal consistence.
The dura mater contained a large quantity of bloody serum.
3. The last condition of the cord that leads to a fatal termination
in these cases of concussion arising from direct and severe injury
is an inflammation, with, perhaps, suppuration of the meninges,
with inflammatory softening and disintegration of its substance.
This is, doubtless, of an acute and probably inflammatory character.
The following cases will illustrate the morbid state.
Ollivier relates the case of a man, 28 years of age, who fell from
the second story of a house, striking himself violently on his back,
left hip, and thigh. His lower extremities became paralyzed completely, so far as motion was concerned; incompletely, as to sensa1 Vol. i. p. 492.




40       CASES OF INFLAMMATION OF THE CORD.
tion. The sphincters were paralyzed. He died on the thirtieth
day after the accident. On examination after death, it was found
that the spinous process of the fourth cervical vertebra was detached but not displaced, and the twelfth dorsal vertebra was broken
across but not displaced. The spinal cord was healthy in all parts
except opposite this point, where it was soft, diffluent, of a yellowish-gray colour, and injected with capillary vessels.
A remarkable case is recorded by Sir C. Bell (op. cit., p. 145).
It is that of a wagoner who was pitched off the shafts of his cart
on to the ground, falling on his neck and shoulders. At this part
there was evidence of bruising. He could not stand, and dragged
his legs. He lay for nearly a week without complaint, and had
during this time no sign of paralysis. But on the eighth day he
was suddenly seized with convulsions over the whole of the body
-which were relieved by bleeding. He became maniacal, but in
the course of twelve hours the convulsions ceased and he became
tractable. On the third day after this attack he complained of
difficulty in using his arm, and on the fifth day he had total palsy
of the lower extremities, regaining the use of his arm. He died
about a week after this. On examination after death, it was found
that a considerable space existed between the last cervical and the
first dorsal vertebra. The intervertebral substance was completely
destroyed, and an immense quantity of pus surrounded the bones.
This purulent collection had dropped down through the whole
length of the sheath of the cord to the cauda equina.
The following case offers a remarkable resemblance to the preceding one-being attended by nearly identical post-mortem appearances following the same kind of injury.
Dr. Mayes,' of Sumter District, South Carolina, relates the case
of a negro who, while raccoon-hunting, fell a height of fifteen feet
from a tree, striking his back at the lower cervical and upper
dorsal region against the ground. He instantly became completely
paraplegic, and died on the tenth day. On examination seven
hours after death, it was found that the fifth and sixth cervical
vertebrae were separated from each other posteriorly, but not fractured or dislocated. Here there was manifest injury to the medulla.
As soon as the muscular coverings of the spine were cut through,
the softened and disintegrated medulla gushed out " similar to the
1 Southern Medical and Surgical Journal, 1847.




COMPLICATIONS OF INJURY OF CORD.              41
escape of matter from an abscess when opened by the lancet. The
medulla spinalis was evidently at this point in a state of decomposition."
In this case it is evident that not only the meninges of the cord,
but the ligamenta subflava were torn through, and the arches of
the vertebrae separated to such an extent, that the softened and
disorganized medulla found a ready exit through the gap thus
made at the posterior part of the spinal column.
It is a point of much practical moment to observe that in this,
as in several other of the cases of so-called "concussion of the
spine," there is, in addition to the lesion of the cord, some serious
injury inflicted on the ligamentous and bony structures that enter
into the composition of the vertebral column, which, however,
must be considered as accidental complications, as they do not
occasion, or even aggravate, the mischief done to the medulla itself.
Thus the ligaments, as in the case just related, may be torn through
so as to allow of partial separation of contiguous vertebrae, or, as
in Ollivier's or in Case 4, a vertebra may be fractured-but without any displacement of the broken fragments, or other sign by
which it is possible during life to determine the exact amount of
injury that has been inflicted on the parts external to the cord. In
this respect injuries of the spine again closely resemble those of
the head-their chief importance depending, not on the amount
of injury to the containing, but on that inflicted upon the contained parts. In the spine just as in the head, it will sometimes
be found after death from what appears to be, and in reality is,
simple injury of the nervous centres, that the vertebral column in
the one case, and the skull in the other, have suffered an amount
of injury that was unsuspected during life; and which, though it
may not in any way have determined to the fatality of the result,
yet affords conclusive evidence of the violence to which the parts
have been subjected, and the intensity of the disorganizing shock
that they have suffered.
There is, however, this very essential difference between the
spine and the head in these respects-that a simple fracture of the
cranium may be of no moment except so far as the violence that
has occasioned it may have influenced the brain. Whilst in the
spine the case is not parallel; for as the vertebral column is the
centre of support to the body, its influence in this respect will be
lost when broken; even though the spinal cord may not have been




42          RUPTURE OF LIGAMENTS OF SPINE.
injured by the edges of the fractured vertebrae, but simply violently and fatally concussed by the same force that broke the spine
itself.
Boyer had previously noticed the very interesting practical fact,
that when the interspinous ligaments were ruptured in consequence
of forcible flexion of the spine forwards, no fatal consequences
usually ensue, the integrity of the parts being restored by rest.
But that when the ligarenta subflava are torn through, and the
arches separated, paraplegia and death ensue. This he attributes
to stretching of the spinal cord. Sir C. Bell, however, with great
acuteness, has pointed out the error of this explanation, and states
that " it is the progress of inflammation to the spinal marrow, and
not the pressure or the extension of it, which makes these cases of
subluxation and breach of the tube fatal" (p. 149). There can be
no doubt that this explanation is the correct one, and that when
once the spinal canal is forcibly torn open, fatal inflammation will
spread to the meninges and to the medulla itself.
Perhaps the most marked case on record of inflammatory softening of the cord consequent upon concussion of it, unattended with
any injury to the osseous or ligamentous structures of the spine, is
that which occurred in the practice of Dr. Hunter, of Edinburgh,
and is related by Abercrombie. It is that of a man thirty-six years
of age, who fell from the top of a wagon, a height of ten feet,
into a pile of small stones, striking his back between the shoulders.
He was immediately rendered paraplegic. When admitted into
the Edinburgh Infirmary at the end of a month he was greatly
emaciated: there was paralysis of motion, but not of sensation, in
the lower extremities, retention of urine, involuntary liquid
motions, deep-seated pain on pressure in the region of the third,
fourth, and fifth dorsal vertebrae. Three days after admission
tetanic symptoms came on; then more general spasms of the limbs
and body, of which he died in forty-eight hours. On examination
after death there was no injury found to the spine itself. There
was a high degree of vascularity of the pia mater of the cord in
the dorsal region. There was most extensive softening of the body
of the cord, affecting chiefly the anterior columns. "These were
most remarkably softened throughout almost the whole course of
the cord; in many places entirely diffluent; the posterior columns
were also softened in many places, though in a much smaller
degree" (p. 348).




CONCUSSION OF SPINE FROM SLIGHT INJURIES.            43
This case epitomizes so succinctly and clearly the symptoms and
after-death appearances occurring in cases of inflammatory softening after uncomplicated concussion of the cord from severe and
direct violence, that it needs neither comment nor addition.
The consideration of these subjects in connection with concussion
of the spine, as the result of severe and direct violence, will pave
the way for what I shall have to say in the next lecture about concussion of the spine as the result of slight, indirect, and less obvious
injuries.
LECTURE THE THIRD.
ON CONCUSSION OF THE SPINE FROM SLIGHT INJURY.
Concussion of the Spine from Slight Injuries-Railway Injuries Peculiar but not
Special-Effects of Slight Blows on Spine, Case 5-Concussion from Railway
Injury, Case 6-Concussion from Railway Injury, Case 7-Concussion from
Carriage Accident, Case 8-Concussion from Falls-Long durations of Symptoms.
IN the last lecture I directed your attention to the symptoms,
effects, and pathological condition presented by cases of concussion
of the spine, proceeding from the infliction of severe injury directly
upon the vertebral column so as immediately and injuriously to
influence the organization and the action of the delicate nervous
structures included between it.
My object in the present lectures is to direct your attention to a
class of cases in which the injury inflicted upon the back is either
very slight in degree, or in which the blow, if more severe, has
fallen upon some other part of the body than the spine, and in
which, consequently, its influence upon the cord has been of a less
direct and often of a less instantaneous character.
These cases are extremely interesting to the surgeon, for not
only is the relation between the injury sustained and the symptoms developed less obvious than in the former case, but in consequence of the length of time that often intervenes between the
occurrence of the accident and the production of the more serious
symptoms, it becomes no easy matter to connect the two in the
relation of cause and effect.




44  RAILWAY INJURIES PECULIAR, BUT NOT SPECIAL.
Symptoms indicative of concussion of the spine have of late
years not unfrequently occurred, in consequence of injuries sustained in railway collisions, and have been very forcibly brought
under the observation of surgeons in consequence of their having
been the fertile sources of litigation; actions for damages for injuries
alleged to have been sustained in railway collisions having become
of such very frequent occurrence as now to constitute a very
important part of medico-legal inquiry.
The symptoms arising from these accidents have been very
variously interpreted by surgeons, some practitioners ignoring
them entirely, believing that they exist only in the imagination of
the patient, or, if admitting their existence, attributing them to
other conditions of the nervous system than any that could arise
from the alleged accident. And when their connection with, and
dependence upon, an injury have been incontestably proved, no
little discrepancy of opinion has arisen as to the ultimate result of
the case, the permanence of the symptoms, and the curability or
not of the patient.
I will endeavour in these Lectures to clear up these important
and very intricate questions; and in doing so I shall direct your
attention most particularly to the following points:1. The effect that may be produced on the spinal cord by slight
blows when inflicted on the back or distant part of the body.
2. The length of time that may intervene between the alleged
injury and the development of the symptoms.
3. The diagnosis of the symptoms of " Concussion of the Spine,"
from those arising from other morbid states of the nervous system.
4. The grounds on which to form a prognosis as to the probable
result.
I shall illustrate these various points by selected cases, not only
of persons who have been injured on railways, but in the ordinary
accidents of civil life.
I wish particularly to direct your attention to the fact that there
is in reality no difference whatever between the symptoms arising
from a concussion of the spine received in a railway collision
and those from a fall or ordinary accident-except perhaps in
severity-and that it is consequently an error to look upon a certain class of symptoms as special to railway accidents. I cannot,
indeed, too strongly impress upon you the fact that there is in
reality nothing special in railway injuries, except in the severity




EFFECTS OF SLIGHT BLOWS ON SPINE.             45
of the accident by which they are occasioned. They are peculiar
in their severity, not different in their nature from injuries received
in the other accidents of civil life. There is no more real difference
between that concussion of the spine which results from a railway collision and that which is the consequence of a fall from a
horse or a scaffold, than there is between a compound and comminuted fracture of the leg occasioned by the grinding of a railway
carriage over the limb and that resulting from the passage of the
wheel of a street cab across it. In either case the injury arising
from the railway accident will be essentially of the same nature as
that which is otherwise occasioned, but it will probably be infinitely
more severe and destructive in its effects, owing to the greater
violence by which it has been occasioned. I intend to draw my
illustrations, to some extent at least, from ordinary accidents, as in
these the question of compensation in money for injury sustained
is not mooted, and hence an element which is usually alleged to
have a disquieting effect on the nervous system of the sufferer is
eliminated from our consideration.
The consideration of the effects that may be produced on the
spinal cord by slight blows, whether applied to the back or to a
distant part of the body, is not altogether a matter of modern surgical study arising from the prevalence of railway accidents, but
had, long antecedent to the introduction of modern means of locomotion, arrested the attention of observant practitioners.
Abercrombie, writing in 1829, says that chronic inflammations
of the cord and its membranes "may supervene upon very slight
injuries of the spine;" and further on he says, "Every injury of the
spine should be considered as deserving of minute attention. The
more immediate effect of anxiety in such cases is inflammatory
action, which may be of an acute or chronic kind; and we have
seen that it may advance in a very insidious manner even after
injuries that were of so slight a kind that they attracted at the time
little or no attention" (p. 381).
Nothing can be clearer and more positive than this statement.
These remarks of Abercrombie's are confirmed by Ollivier, by Bell,
and by other writers on such injuries.
The following cases will illustrate this point.
The first two are cases of concussion of the spine resulting from
railway accidents, in which there were at the time slight marks of




46    CASE 5.-CONCUSSION FROM SLIGHT INJURY.
external injury. The others are very similar cases occurring from
other accidents than those received on railways.
Case 5.-Mr. R., 35 years of age, a farmer and miller, of very
active habits, accustomed to field sports, and much engaged in
business, habitually in the enjoyment of good health, was in a railway collision that took place on Nov. 4, 1864. He received a blow
upon his face which cut his upper lip on the left side, and was
much and severely shaken. He did not lose consciousness, and
was able shortly to proceed on his journey. On leaving the station
to proceed to his own home, it was observed by a friend who
drove him that he did not appear to recollect the road, with which
he was familiar, having been in the daily habit of driving over it
for years.
On reaching home, feeling bruised, shaken, and confused, he took
to his bed, but did not feel sufficiently ill to seek medical advice
until November 9, five days after the accident, when he sent to Mr.
Yorke, of Staunton, who continued to attend him. But notwithstanding every attention from that gentleman, he progressively, but
slowly got worse.
I saw Mr. R. for the first time on the 18th February, 1866, fifteen
months after the occurrence of the accident, when I found him in
the following state. His face was pallid, much lined, indicative of
habitual suffering. He looked much older than his alleged age
(36 years). He was sitting with his back to the light, and had the
venetian blinds drawn down so as to shade the room, the light
being peculiarly distressing to him. His skin was cool. Tongue
slightly furred, appetite moderate, digestion impaired. Pulse 104
to 106, weak and compressible. I understand from Mr. Yorke
that it rarely fell below this, and often rose above it. He has not
lost flesh, but all his friends say that he is quite an altered man.
He states that since the accident his memory has been bad-that
he cannot recollect numbers-does not know the ages of his children, for instance-he cannot add up an ordinary sum correctly-he
will add up the same set of figures if transposed differently. Before
the accident he was considered to be a peculiarly good judge of
the weights of beasts-since its occurrence he has lost all power of
forming an opinion on this point. He has been quite unable to
transact any business since the injury. Is troubled with frightful
dreams. Starts and wakes up in terror, not knowing where he is.
Has become irritable, and can neither bear light nor noise. He




CASE 5.-RAILWAY INJURY.                  47
frowns habitually, so as to exclude the light from his eyes. He
complains of stars, sparks, flashes of light and coloured spectra
flaming and flashing before the eyes. He cannot read for more
than two or three minutes at a time, the letters becoming confused,
and the effort being painful to bear. On examining the state of
the eyes, I find that vision is good in the right eye, but that this
organ is over sensitive to light. Vision is nearly lost in the left
eye, so much so that he cannot read large print with it.
His hearing is over sensitive with the right ear, dull on the left
side. He cannot bear noises of any kind, more particularly if sudden; they are peculiarly distressing to him. Even that of his
children at play-annoys him.
He complains of a numb sensation accompanied by tingling,
burning sensations on the right side, in the right arm and leg, more
particularly in the little and ring-fingers, and along the course of
the ulnar nerve. The rest of the right hand feels numb. He makes
no complaint of the left arm or leg. These sensations are worst in
the morning.
He cannot stand or walk without the support of a stick, or by
resting his hand on a piece of furniture. He can do so in this way
on the left leg, but if he attempts to do so on the right foot the
limb immediatly bends, and sinks as it were under him. His gait
is very peculiar. He separates the feet so as to make a straddling
movement, and brings one foot very slowly before the other. He
advances the right foot less than the left, and does not raise the
sole as far from the ground. The foot seems to come down too
quickly. He does not drag with the toes, but does not raise the
heel sufficiently, and is apt to catch it in walking in inequalities on
the ground. Flexion and extension are more perfectly and rapidly
performed with the left than the right foot.
The attitude of his body in walking is very peculiar: the back
is stiff, the head fixed, and he looks straight forward without turning it to the one side or the other.
He has great difficulty in going up or down stairs, cannot do
so without holding on by the banisters. The difficulty is greatest
in going down stairs, and if he attempts this without support he
falls or rolls over to the right side.
There is no appreciable difference in the size of the two legs,
but the right feels colder than the left. The patient complains of
the coldness of both legs and feet.




48             CASE 5.-RAILWAY INJURY.
The spine had lost its natural flexibility, so that the patient kept
the body perfectly straight, fixed, and immovable. He could not
bend the body in any direction without suffering severe pain.
This was complained of equally whether the patient bent forwards,
backwards, or sideways. It was most severe on any attempt being
made to twist the spine. He sits in a rigid and upright attitude.
There was considerable pain at the occipito atloid articulation,
as also at that between the axis and atlas. If an attempt was made
to bend the head forcibly forwards, or to rotate it, the patient
suffered so severely that it became necessary to desist. When
directed to look round, the patient turned the whole body.
Owing to the rigidity of his spine he could not stoop so as to
pick anything off the floor without going down on one knee.
On examining the spine by pressure and percussion, three
tender spots were found; one in the upper cervical, the other in
the middle dorsal, and the third in the lumbo-sacral region. There
is pain both on superficial and on deep pressure at these spots.
The pain is limited to the spine, and does not extend to the muscular structures on either side of it.
The power of retaining the urine is very materially diminished.
He passes water four or five times in the night, and every second
hour during the day. The urine is sub-acid.
The generative power, though impaired, is not lost. A remarkable circumstance has been noticed in this case by Mr. R.'s
wife and his friends. It is that since the accident he is unable to
judge correctly of the distance of objects in a lateral direction,
though he appears to be able to do so when looking straight forward. Thus, when driving in the middle of a straight road he
always imagines that the carriage is in danger of running into the
ditch or hedge on the near side.
The opinion I gave was, that the patient had sustained an injury
of the spinal cord, and that the base of the brain was also, to some
extent, though probably secondarily, involved. That chronic
subacute meningitis of the spine and base of the cranium had
taken place. That it was not probable that he would ever completely recover, and that it was even doubtful whether, as the disease had up to the present time been progressive, it might not
continue to be so, and terminate in incurable disorganization of
the nervous centres. The patient was seen by Sir Charles Hard



CASE 6.-RAILWAY INJURY.                  49
ings and Mr. Carden, who took a similarly unfavourable view of
his present state and probable future.
An action was brought at the spring assizes at Worcester, in
1866, against the company on whose line the patient had been
injured. No surgical evidence was called for the company, the
statement made by the plaintiff's medical advisers being accepted.
The question of damages resolved itself, to a great extent, into
one of loss of income and expense incurred. The jury awarded
~5775.
Case 6.-Mr. J., 43 years of age, a wine-merchant, healthy and
of active business habits, was in a railway collision on the 23d of
August, 1864. He was suddenly dashed forwards and then rebounded violently backwards.
When he extricated himself from the ruins of the carriage in
which he had been travelling (a third-class one), he believed himself to be unhurt-suffering from no immediate effect of the shock
he had sustained. He assisted his fellow-passengers, many of whom
were much injured, and was thus actively engaged for two hours.
On his return home the same evening, he was greatly excited
and very restless; he felt chilly, and his arms and legs tingled.
He could not sleep that night.
On the following day he felt ill and shaken; could not attend to
his business, and was lame from some slight contusions on his legs.
He continued much in this state for several days, and was seen by
Mr. Everett, of Worcester (to whom I am indebted for the early
history of this case), on the 1st of September, eight or nine days
after the accident. He was then much disturbed in health; his
pulse was feeble, he looked anxious and depressed; he complained
of violent pains in the head, confusion of thought, and loud noises
in the ears and head. He also complained, but slightly, of pain in
the back.
These symptoms continued for some time without improvement.
He found more and more difficulty in walking, and his right ankle
often gave way. This appeared to Mr. Everett to be owing to some
spasmodic action of the muscles of the leg rather than to any weakness of the joint itself.
He now began to show more serious symptoms in connection
with the nervous system. His memory became worse and confusion of ideas greater; he often called people and things by wrong
names; addressed his wife as "sir."
4




50             CASE 6.-RAILWAY INJURY.
The pains in the head became more violent, and assumed a
paroxysmal character. There was acute sensibility to sound in
the right ear, deafness of the left. Vision of the right eye was
rather dim.
This was his condition at the end of twelve weeks after the
occurrence of the accident. The symptoms, though progressively
assuming a more and more serious character, did not do so uninterruptedly, but, as Mr. Everett expresses it, were "undulatory,"sometimes better, sometimes worse; but yet at the expiration of
any given time of a few weeks' duration, decidedly and persistently
worse than at an earlier period.
Three months after the accident he began to complain, for the
first time, of contractions of the muscles of the right arm and hand.
His fingers became flexed, so that force was required to straighten
them. Shortly afterwards the left arm became similarly affected.
These contractions assumed an intermitting and spasmodic character, and occurred several times daily.
The pain in the back, which was but slightly complained of at
first, now became more and more severe. It was more acute over
the sixth to the tenth dorsal vertebra, both inclusive. Spasms of
the diaphragm now came on occasionally, and distressed him much.
His gait was peculiar; he seemed to be uncertain where to set
his feet, and he kept his head steadily fixed.
On February 1, 1865, five months after the accident, he complained, for the first time, of pain in the neck, greatly increased on
moving the head.
During the whole of this period his digestion had been fairly
good. He had gained flesh since the accident. There had been
no loss of power over the sphincters, and his urine was normal and
acid.
I saw this patient, in consultation with Mr. Carden and Mr.
Everett, of Worcester, on March 8th, 1865, and found that the
symptoms above detailed continued, and had somewhat increased
in intensity since the last report.
Loss of memory, confusion of thought and ideas, utter incapacity
for business, disturbed sleep, pains and noises in the head, partial
deafness of the left, morbid sensibility of the right ear, irritability
of the eyes, rendering light very painful-though vision had become imperfect in the right eye. Numbness, tingling sensation,




CASE 7.-CARRIAGE ACCIDENT.                51
and formication in the right arm and leg, were the most prominent
subjective symptoms.
He walked with a peculiar unsteady straddling gait; was obliged
to feel with his right foot before planting it on the ground; did not
raise the heel, but carried the foot flat, and let it fall suddenly;
instead of putting it on the ground in the usual way; used a stick,
or supported himself by the furniture.
He could stand for a moment on the left leg, but immediately
fell over if he attempted to do so on the right.
His right arm and hand were numb; the little and ring-fingers
contracted. He could not pick up a small object, as a pin, between
his finger and thumb, nor could he write easily or legibly.
The spine was very tender at three points-in the upper cervical, in the middle dorsal, and in the lower lumbar regions. There
was constant fixed aching pain in it in these situations. This pain
was greatly increased on pressure; it was limited to the vertebral
column, and did not extend beyond it.
Movement of any kind greatly increased the pain. If the head
was raised by the hands and bent forward, or rotated, so as to influence the articulations between the occipital bone, the atlas, and the
axis, the patient shrieked with the agony that was occasioned.
He could not bend the body either forwards, backwards, or
sideways, the pain being so greatly increased in the dorsal and
lumber regions by these movements. He consequently could not
stoop.
The spine had entirely lost its normal flexibility. It was perfectly rigid, moved as a whole as if made of one bone. The
patient could neither bend nor turn his head. Hence he could not
look on the ground in walking to see where to place his feet; and
when he wished to look round, he had to turn the whole body.
The pulse was feeble, about 98. Countenance pale, anxious,
haggard. Tongue slightly coated. Digestive and other functions
well performed. Urine clear and acid.
The case was tried at the spring Assizes at Worcester in 1865.
The opinion expressed by Mr. Carden, Mr. Everett, and myself,
amounted to this, that the patient was suffering from concussion
of the spine, which had developed irritation or chronic inflammation of its membranes and of the cord, and that his recovery was
very doubtful. The plaintiff recovered ~6000 damages.
At this time (May, 1866), a year and nine months after the




52            CASE 7.-CARRIAGE ACCIDENT.
accident, he is still an invalid, being so completely shattered in
health that he has been obliged to winter in the southwest of England, and is quite unequal to attend to business of any kind.
Case 7.-The following case illustrates the fact that a train of
symptoms of a most persistent nature, closely resembling those
detailed in the preceding cases, may occur from other causes than
railway accidents.
Captain N., 38 years of age, consulted me on October 27th,
1862. Looks careworn, pale, lined, and at least ten years older
than his real age. He states that in November, 1854-eight years
previously, he had been thrown out of a pony-chaise, which was
accidentally upset. At the time he hurt his right knee and bruised
the right arm, but sustained no blow or evidence of injury on the
head or back. He was much bruised and shaken at the time, but
did not suffer any serious ill effects for several months. after the
accident, although during the whole of this period he felt ailing,
and that he was in some way suffering from the injury he had sustained.
About six months after the accident he began to be troubled
with the following train of symptoms, which have continued ever
since: Confusion of thought; his memory was impaired; he had
giddiness, especially on moving the head suddenly; his sight became impaired; he suffered from muscse volitantes; sparks and
flashes of light; he could not continue to read beyond a few
minutes, partly because the letters ran into each other, partly
because he could not concentrate his thoughts so as to fix his
attention.
He now began to suffer from a feeling of numbness and a sensation of " pins and needles" in both hands, but more particularly
the left, and chiefly in those parts supplied by the ulnar nerve.
He complained of the same sensations in the left leg and foot.
He walked with difficulty, and with the legs somewhat apart, using
a stick, or else supporting himself by holding on to pieces of furniture in the room as he passed them. He can stand on the right
leg, but the left one immediately gives way under him. He walks
with great difficulty up and down stairs, obliged to put both feet
on the same step. The spine is tender on pressure and percussion
in the lower cervical region and between the shoulders. It is stiff;
he cannot bend the back without pain, and cannot stoop without
falling forward.




CASE 8.-LONG DURATION OF SYMPTOMS.               53
He has irritability of the bladder, passing water every second or
third hour, and can only do so in a sitting position. He has completely lost all sexual power and desire. The urine is slightly
acid. These symptoms have continued with varying intensity,
since their commencement, about six months after the accident.
He thinks they were most severe about a year after they began,
and have somewhat improved since then. But he has never been
free from them, or enjoyed a day's health, for the last seven and a
half years, and never expects to do so.
This case closely resembles, in all its general features, and in many
of its details, those that have just been related. It only differs in
the symptoms being less intense, as would naturally be expected,
from the accident that occasioned them being less severe than those
which occur from railway collisions. The persistence of the symptoms for so lengthened a period as nearly eight years is significant
of the long duration of the pernicious effects of these insidious
injuries to the nervous system.
But the interminable duration of the most serious nervous phenomena, from comparatively slight injuries of the spine, receives
additional illustration from the following case.
Case 8.-Miss B., 26 years of age, was brought to my house on
the 11th April, 1866, by my friend Dr. Gibb. She looked moderately healthy, was of good constitution, with no discernible hereditary tendency to disease of any kind-was not anemic.   The
digestive and uterine functions were well performed. She has had
no disease except that from which she now suffers, no convulsions
or fits in childhood.
When about eighteen months old, she fell out of her cot and
injured her cervical spine. From that time to the present she has
suffered from a continuous and remarkable train of nervous phenomena. These were aggravated about the period of puberty, and
at the age of 17 were still further increased in consequence of her
falling over a stile backwards. She has never had hysteria in any
of its ordinary forms, paralysis, epilepsy, or convulsive attacks of
any kind.
On examining the spine, I find it straight and the body well
formed. There is a distinct projection backwards of the spinous
processes of the fifth and sixth cervical vertebra. She complains
of a constant pressure and pain of a grating or grinding character
in this region, as if the bones were in contact with one another.




54      CASE 8.-LONG DURATION OF SYMPTOMS.
There is no evidence of abscess or of any distinct mischief in or
around the tender vertebrae, and nothing is to be observed with
the laryngoscope at the anterior part of the cervical vertebrae or
pharynx. From this point a peculiar sense of uneasiness spreads
itself over the whole of the body and limbs, producing nervous
sensations of the most distressing character. These sensations,
which consist of tingling and painful feelings, prevent her sitting
still or lying down quietly for any length of time. She is better
when in movement. She cannot sleep for more than an hour or
two at a time, and is conscious of her sufferings through her sleep.
Her power of movement has never been impaired, the distress
being confined to sensation, and not producing any disturbance of
motion.
She can walk well under certain circumstances, can stand, and
in fact scarcely ever sits; but cannot turn suddenly without becoming giddy, with the fear of falling.
She can walk well so long as there is anything near her. Thus
she can walk along a street guided by the area railings; but when
she comes to an open space, as a square or crossing, she is lost, and
requires to be guided or she would fall. She cannot bear the
sensation of having a space around her, and would then fall unless
supported.
She has unceasing loud noises in her head, which she compares
to "gravel-stones" rolling through it. They are so loud that she
thinks that other people must hear them.
Her hearing is good.
Her sight is strong, but she sees the circulation of the blood in
her own eyes, the corpuscles spinning round in convolutions, and
often coloured. No perversion of smell or taste. The hands and
feet always cold, even in summer.
She has been from first to last under the care of at least thirty
medical men. Has had every variety of treatment adopted-a
seton kept open in the neck and the clitoris excised; but so far
from benefiting has slowly but steadily become worse, and her
general health is now beginning to give way.
This lady, who is 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 excurvation in
the cervical vertebrae. At this point there had evidently existed
disease leading to organic changes to which the remarkable train




CASE 9.-CONCUSSION FROM GENERAL SHOCK.               55
of general phenomena presented by this case were doubtless
referable. If I were to hazard an opinion, it would be that some
thickening of the meninges of the cord had probably taken place,
the effect of which was to interfere with the sensory portions of the
cord, rather than with the motor.
LECTURE THE FOURTH.
CONCUSSION OF THE SPINE FROM GENERAL SHOCK.
Concussion from General Shock-Case 9. Concussion from Shock to Feet-Case
10. Concussion from Railway Shock-Case 11. Concussion from Railway Shock
-Case 12. Concussion from Railway Shock-Twists, Sprains, and Wrenches of
the Spine-Case 13. Wrench of Spine-Case 14. Twist of the Spine-Effects of
Twists and Wrenches of the Spine.
THERE is another class of cases of an extremely insidious and
protracted character to which I wish to direct your attention, viz.,
those cases in which the patient has received no blow or injury
upon the head or spine, but in which the whole system has received a severe shake or shock, in consequence of which disease
is developed in the spinal cord, perhaps eventually extending to
the membranes of the brain. These cases, although necessarily
more frequent in railway than in other injuries, yet occasionally
occur as a consequence of ordinary accidents. I will first relate a
case of this kind, and then direct your attention to the details
of several instances that have fallen under my notice of similar
phenomena occurring after railway accidents.
Case 9.-On the 17th November, 1861, I saw, in consultation
with Dr. Strong, of Croydon, Mrs. B., 32 years of age. She states
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 is quite certain. She felt nervous, faint, and
skaken 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




56         CONCUSSION FROM SHOCK TO FEET.
the mother of two children. She had never suffered 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
-apparently 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 previously 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 is this numb sensation in the hands, and in the
right leg, she has no impairment of motion. She can pick up a
pin, untie a knot, and otherwise use the right hand, which is the
one most affected, in ordinary small occupations. She can stand;
walk fairly well.
I saw the patient again on the 13th April, four months after the
accident. Notwithstanding the treatment that had been adopted
(iron and strychnine), she was weaker, looked anaemic, and was
rather worse, so far as the paralytic symptoms were concerned.
She could no longer pick up so small an object as a pin, but can
pick up a piece of money-a shilling for instance. The right hand
and leg are still the worst, but the left limbs are more affected than
they were. In the left hand the numbness has now affected the
little, ring, and middle fingers, with the tip of the forefinger.
From this time to the present there has been a very slow increase
in the symptoms, notwithstanding a great variety of treatment to
which the patient has been subjected by the many different medical men whom she has 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 tells me that she feels that she is
gradually, though very slowly, getting worse. She has an anxious,
anaemic look. She totters in walking, so that in going about the
room she supports herself by the chairs and tables. She could not
in any way walk a quarter of a mile. She can stand unsupported
on the left leg, but she immediately falls over if she attempts to do
so on the right. The right hand and foot are much colder than




CASE 10.-CONCUSSION FROM RAILWAY SHOCK.           57
the left. The paralysis of the hands continues much the same, but
a marked change has taken place in the right hand in consequence
of the contraction of all the fingers, but more especially of the little
and ring-fingers. They have become rigid, and the flexor tendons
stand out strongly. She can, consequently, scarcely use this hand.
On testing the irritability of the muscles in the opposite limbs by
galvanism, the contraction was almost nil in those of the right arm
and hand. Much stronger, though not normally strong, on the left
side.
She complains of confusion of thought and loss of memory; the
senses are unimpaired. Appetite is bad, and digestion imperfect.
Urine is acid. Can hold her water well.
In this case a very trivial accident occasioned a jar communicated
to the feet, and evidently transmitted to the nervous centres, leading to impairment of innervation, and eventually to progressive
and incurable paralysis.
Case 10.-M. H. I., a surgeon, 43 years of age, naturally a stout
healthy man, of active professional habits, consulted me on February 22d, 1865. He states that on 9th October, 1864, he was in
a railway collision, by which he was thrown forwards, but without
any 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 sufficiently
for the purpose.
About a month after the accident he began to suffer from pain
across the loins. He could not walk without great fatigue. He
lost strength and flesh, and his pulse became habitually much more
frequent than natural, being about 98 to 100.
At the present time, four and a half months after the accident, he
continues much in the same state; is quite unfit for business, and
has been obliged to relinquish practice; not owing to any mental
incapacity, but entirely owing to his bodily infirmities. His mind
is quite clear, and his senses perfect, though over-sensitive; loud
and sudden noises and bright light being peculiarly distressing to
him.
He complains chiefly of the spine. He suffers constant pain in
the lower part of it, in the lower dorsal, and the lumbar regions.




58   CASE 11.-CONCUSSION FROM RAILWAY SHOCK.
He compares the sensation there experienced to that of a wedge or
plug of wood driven into the spinal canal. It is a mixed sensation
of pain and distension. The spine generally is tender, and the
pain in it is greatly increased by manipulation, pressure, and purcussion. It has lost its normal flexibility, moves as a whole, so
that he cannot bend forwards or stoop. There is no pain in the
cervical region, or on moving the head.
He complains of painful numbness and formications in the right,
and occasionally down the left leg. The legs are stiff and weak,
especially the right one. He cannot stand unsupported on this for
a moment. He walks in a slow and awkward manner-straddling
-not able to place the feet together. If told to stand on his toes,
he immediately falls forwards. He has lost control over the limbs,
and does not know exactly where to place the feet. He has a
frequent desire to pass water, suffers greatly from flatus, and has
completely lost all sexual 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; indeed, that
in some respects, so far especially as power of movement was concerned, it had progressively become worse.
In this case the injury produced by the shock had evidently
occasioned mischief within the lower portion of the spinal canal,
leading to partial paraplegia. I believe this mischief to have been
of a chronic inflammatory nature; the tenderness of the spine, the
feeling of distension, the pain in movement, and the habitually
high pulse, point in this direction. This case was settled out of
court for ~2500.
Case 11.-Mr. C. W. E., about 50 years of age, naturally a stout,
very healthy man, weighing nearly seventeen stone, a widower, of
very active habits, mentally and bodily, was in a railway collision
on February 3d, 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




CASE 11.-CONCUSSION FROM RAILWAY SHOCK.           59
health. Was obliged to have change of air and scene, and gradually,
but not uninterruptedly, continued to get worse, until I saw him
on the 26th March, 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. Elkington, of Birmingham, and by several others, as Dr. Bell Fletcher, Dr. Gilchrist, Mr.
Gamgee, Mr. Martin, &c. He had been most anxious to resume
his business, which was of an important official character, and had
made many attempts to do so, but invariably found himself quite
unfit for it, and was most reluctantly constrained to relinquish it.
When I saw him at this time, he was in the following state:He has lost about twenty pounds in weight, is weak, unable to
walk a quarter of a mile, or to attend to any business. His friends
and family stated that he is, in all respects, "an altered man." His
digestion is impaired, and his pulse is never below 96.
He complains of loss of memory, so that he is often obliged to
break off in the midst of a sentence, not being able to complete it,
or to recollect what he has commenced saying. His thoughts are
confused, and he cannot concentrate his attention beyond a few
minutes upon any one subject. If he attempts to read, he is
obliged to lay aside the paper or book in a few minutes, as the letters become blurred and confused. If he tries to write, he often
mis-spells the commonest words; but he has no difficulty about
figures. He is troubled with horrible dreams, and wakes up
frightened and confused.
His head is habitually hot, and often flushed. He complains of
a dull confused sensation within it, and of loud noises which are
constant.
The hearing of the right ear is very dull. He cannot hear the
tick of an ordinary watch at a distance of six inches from it. The
hearing of the left ear is normal, he can hear the tick at a distance
of about twenty inches. Noises, especially of a loud, sudden, or
clattering character, distress him greatly. He cannot bear the
noise of his own children at play.
The vision of the left eye has been weak from childhood. That
of the right, which has always been good, has become seriously
impaired since the accident. He suffers from muscae volitantes,
and sees a fixed line or bar, vertical in direction, across the field
of vision. He complains also of flashes, stars, and coloured rings.




60   CASE 11.-CONCUSSION FROM RAILWAY SHOCK.
Light, even of ordinary day, is especially distressing to him.
In fact, the eye is so irritable that he has an abhorrence of
light. He habitually sits in a darkened room, and cannot bear
to look at artificial light-as of gas, candles, or fire. This intolerance of light gives a peculiarly frowning expression to his countenance. He knits and depresses his brows in order to shade his
eyes.
The senses of smell and taste seem to be somewhat perverted. He
often thinks that he smells fetid odours which are not appreciable
to others, and has lost his sense of taste to a great degree. He
complains of a degree of numbness, and of "pins and needles" in
the left arm and leg, also of pains in the left leg, and a feeling of
tightness or constriction. All these symptoms are worst on first
rising in the morning.
He walks with great difficulty, and seldom without the aid of a
stick; whilst going about a room he supports himself by taking
hold of the articles of furniture that come in his way. He does
not bring his feet together-straddles in his gait-draws the left
leg slowly behind the right-moves it stiffly and keeps the foot flat
in walking, so that the heel catches the ground and the limb appears to drag. He has much difficulty in going up and down
stairs, cannot do so without support.
He can stand on the right leg, but if he attempts to do so on the
left, it immediately bends and gives way under him, so that he
would fall.
The spine is tender on pressure and on percussion of these points,
viz., at lower cervical, in middle dorsal, and in lumbar regions.
The pain in these situations is increased on moving the body in
any direction, but especially the antero-posterior. There is a degree of unnatural rigidity, of want of flexibility, about the spine,
so that he cannot bend the body-he cannot stoop without falling
forwards.
On testing the irritability of the muscles by galvanism, it was
found to be very markedly less in the left than in the right leg.
The genito-urinary organs are not affected. The urine is acid,
and the bladder neither atonic nor unduly irritable.
The opinion that I gave in this case was to the effect that the
patient 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




CASE 12.-CONCUSSION FROM RAILWAY SHOCK.           61
left leg, probably dependent 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. The
patient brought an action for damages at the Gloucester Spring
Assizes, April, 1866, against the company on whose line he had
been injured, and, notwithstanding powerful adverse medical testimony, recovered ~3500 damages.
Case 12.-The following case presents some very remarkable and
unusual nervous phenomena, resulting from railway shock, which
I will briefly relate to you.
"Mfarch 1, 1865. Mr. D. is a man of healthy constitution and
active habits, aged 33. He 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
arriving 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 lameness, 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 to move more between the shoulders after these applications.
"28th. 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
Lancashire, greatly fatigued by journey. A discharge came on
from the urethra, lameness much increased, could not advance the
left leg in front of the right, and great prostration."
I saw him, in consultation with Mr. Hewer, May 1, 1865, when
I received 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.




62   CASE 12.-CONCUSSION FROM RAILWAY SHOCK.
But in addition to these, he presented the following somewhat
peculiar and exceptional symptoms:1. An extreme difficulty in articulation, in 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 has been aggravated to the degree that has just
been mentioned, so as to constitute the most intense stutter that I
have ever heard in an adult.
2. A very peculiar condition of the spine and the muscles of
the back.
The spine is rigid-has lost its natural flexibility to anteroposterior as well as to lateral movement.
There is an extreme degree of sensibility of the skin of the
back, from the nape of the neck down to the loins. This sensibility extends for about four inches on either side of the spine.
It is most intense between the shoulders.
This sensibility is both superficial and deep. The superficial
or cutaneous sensibility is so marked, that on touching the skin
lightly or on drawing the finger down it, the patient starts forwards as if he had been touched with a red-hot iron. There is
also deep pain on pressure along the whole length of the spine,
and on twisting or bending it in any direction.
Whenever the back is touched at these sensitive parts, the
muscles are 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 is most peculiar. He does not carry one
leg before the other alternately in the ordinary manner of walking, but shuffles sideways, carrying the right leg in advance, and
bringing up the left one after it by a series of short steps. He
can alternate the action of the legs, but he cannot bring one leg
in front of the other without twisting the whole body and turning,
as on a pivot, on the leg that supports him. He cannot 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




TWISTS AND STRAINS OF THE SPINE.             63
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
different times by Sir W. Fergusson, Drs. Reynolds and Walshe.
We all agreed that the patient was suffering from "concussion of
the spine," and that his ultimate recovery was uncertain. Mr. D.
brought an action against the railway company, which was tried
at Guildhall, in December, 1865, and recovered ~4750 damages.
Since the trial he has been continuously under my care, and I
have seen him at intervals of about a month. He has been treated
by perfect rest, lying on a Prone couch; by warm salt-water
douches to the spine, for which purpose he has resided at Brighton,
and by full doses of the bromide of potassium. Under this treatment he has considerably improved (May, 1866). The extreme
sensibility of the back is materially lessened, and he can walk
much better than he did. He also stammers less vehemently, but
he still has considerable rigidity about the spine, can only walk
with the aid of a stick, and retains that peculiar careworn, anxious,
and aged look that is so very characteristic of those who have
suffered from these injuries.
I shall now direct your attention to another very peculiar and
interesting class of cases, those in which the spine has been violently twisted or strained, but not concussed or jarred.
TWISTS, SPRAINS, or WRENCHES OF THE SPINE, without fracture
or dislocation of the vertebra, may occur in a variety of ways.
Boyer relates a fatal case of this kind, occurring from an injury
received in practising gymnastics. Sir A. 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 other, the head is frequently forcibly 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




64         TWISTS AND STRAINS OF THE SPINE.
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 met with 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 motion of any kind, and however slight, to and fro, and
especially by rotation. The pains are greatly increased on pressure
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 off a pillow without
the assistance of his hand, or that of another person.
The lumbar spine is often strained in railway collisions, with or
without similar injury to the cervical portion of the column, in
consequence of the body being forcibly swayed backwards and
forwards 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 external pressure, and great aggravation
of suffering on any movement being impressed upon it, 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 consequence of injury.
They may of themselves prove most serious, or even fatal.
Thus, in Case 13, 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 14, 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




CASE 13.-WRENCH OF THE SPINE.               65
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
structures 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, continues to be weak and preternaturally mobile,
in consequence of elongation of the ligaments, or. weakness or
atrophy of the muscles, beyond this period, it will, in all probability, never be so strong as it was before the accident.
The same holds good with the spine; and a vertebral column,
which, as in Case 13, 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.
One great prospective danger in strains 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 in Cases 6 and 11 this
happened. We see that this is particularly apt to happen when
the strain or twist occurs between the occiput and the atlas or
axis. In these cases a rigid tenderness is gradually developed,
which is most distressing and persisting and evidently of an inflammatory character.
Or, as in Case 13, the paralysis may remain incomplete, being
confined to the nerves which 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 nervous cord itself having been
injured in its passage through the intervertebral foramen.
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 eventually by death from extravasation of blood
into the vertebral canal.
Case 13.-Miss —, a lady, 28 years of age, was involved in
the terrible catastrophe that occurred on the South Eastern Railway, at Staplehurst, 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, another lady, a
fellow-passenger, who had been killed, being stretched across her.
5




66         CASE 13.-WRENCH OF THE SPINE.
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 says felt loose. It used to fall on any side, as if the
neck was broken, usually hanging with the chin resting on the
breast.
Without going into an unnecessarily minute detail of all the distressing symptoms with which this young lady was affected, it
suffices 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
ligamentous 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 backward direction. When lying on her back she
had no power whatever to raise her head, and was obliged to do so
with her right hand put under it so as to support it. If she
wished to get up when in bed, for instance, she was obliged to
assume a most distressing action, being compelled to roll over on
to her face, and then, pressing the forelead against the pillow, get
upon her knees.
There was no pain in the cervical spine, nor could any irregularity of 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 appeared to be in the lower part of the cervical
spine.
The left arm had at first and for many weeks been 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 partially
paralyzed, so far as motor influence was concerned. The circumflex, the musculo-spiral, the median and the ulnar were all affected




CASE 13.-WRENCH OF THE SPINE.               67
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 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 paralyzed state of the left arm was a'most serious and distressing inconvenience to the patient. Before
the accident she had been an intrepid rider, a skilful driver, and an
accomplished musician, playing much on the harp and piano. All
these pursuits were necessarily completely put a stop to, and frot
being remarkable for her courage she had become so nervous as
scarcely to be able to drive in a carriage.
Mr. Tapson had most skilfully and assiduously attended this
very distressing 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 condition 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 vertebrae 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.




68           CASE 14.-TWIST OF THE SPINE.
This loosening was most 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 having 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 improvement had taken place in this respect for
several months. As the nerves of the whole of the brachial plexus
were implicated, and apparently to 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 on their exit through
the vertebral column. I think it most probable that 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 localized 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.
This lady brought an action for damages against the railway
company at Guildhall in the spring of 1866. But as she had sustained no pecuniary loss by the accident, she was only awarded the
wretched "compensation" of ~1350. Mental sufferings, bodily
pain, and disability, and complete annihilation of the prospects of
a life, weigh lightly in the scales of justice, which are only made
to kick the beam by the burden of the actual money loss entailed
by the accident.
Case 14.-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, thrown from his horse on December 12, 1865. He
fell on the back of his head, on soft ground, and rolled over. He
got up immediately after the fall and walked to his house, a dis



CASE 14.-TWIST OF THE SPINE.               69
tance of about one hundred yards. He had no cerebral disturbance
whatever, being neither 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 consequence 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 difficulty in controlling his right
arm. He managed, however, to do so, and did write a letter. He
was under surgical treatment in the country, and was not considered to have paralysis, as he could use his arms well for all
ordinary purposes, and could walk without difficulty.
Towards the end of January, nearly six weeks after the accident,
symptoms of paralysis very gradually and slowly began to develop
themselves. The right arm became cold, numb, and was affected
by creeping 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, and 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,
struggled much, and was unable to rise. He was found, after a
time, lying partly under his bed. On the following day it was
found that the left side was partially paralyzed, the right side continuing in the condition already described. There was now considerable swelling and tenderness on the left side of the neck and
about the third and fourth cervical vertebrae. He was seen shortly
after this by Dr. Jenner, in consultation with Dr. Reynolds, and was
ordered complete rest, with large doses of iodide of potass.
I saw him on March 3d, 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
complete paralysis of the right arm, partial of the right leg. The
left arm was also partially paralyzed, and the left leg slightly so.




70          CASE 14.-TWIST OF THE SPINE.
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
quick; 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 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 vertebra 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 potass; and
a gutta-percha case, extending from the top of his head' to the
pelvis, and embracing 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
gratified to find that a steady improvement was taking place. On
March 27th 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, grasp 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 rather owing 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 of its points. In the first
place, the fact that the paralysis did not begin to show itself until
several weeks-nearly six —had elapsed from the time of the accident is a matter 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 gradual subsidence of the very threatening symptoms with which the patient was affected, and the dis



CASE.14.-TWIST OF THE SPINE.               71
appearance 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 illustrated by a case recorded by Sir Astley Cooper as occurring in the practice of Mr. Heaviside. It is briefly.as follows:
A lad, 12 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 vertebroe were violently strained. As the line immediately slipped 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 occurrence. He suffered from pains
in the head and in the back of the neck, the muscles of which 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.
Eleven months after the accident the complaint and the paralytic
affection of the limbs were gradually getting much worse, added
to which he felt a most vehement 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
overflowing 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 progressive 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
I Sir A. Cooper, Fractures and Dislocations, 8vo. ed., p. 530.




72  PERIOD AT WHICH SYMPTOMS BEGIN TO DEVELOP.
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. 38) to be the common
accompaniment of many fatal cases of so-called " concussion of the
spine."
Each of these three cases of twist of the spine is typical of a
special group of these injuries. In the first case 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 case 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
hemorrhage into the spinal canal.
LECTURE THE FIFTH.
Period at which Symptoms begin to develop-Length of Time that often elapses
-Concussion not associated with other Injury-Nature of Changes produced
by Concussion-Early Symptoms of Railway Concussion-Detail of Symptoms
of Railway Concussion-Symptoms of Railway Concussion-Interval between
Accident and Symptoms-Pathology of Railway Concussion-Mr. Gore's Case.
ONE of the most remarkable circumstances connected with
injuries of the spine is, the disproportion that exists between the
apparently trifling accident that the patient has sustained, and the
real and serious mischief that has occurred. Not only do symptoms
of concussion of the spine of the most serious, progressive, and persistent character, often develop themselves after what are apparently
slight injuries, but frequently when there is no sign whatever of
external injury. This is well exemplified in Case 9, the patient
having been partially paralyzed simply by slipping down a few
stairs on her heels. The shake or jar that is inflicted on the spine
when a person jumping from a height of a few feet comes to the




CONCUSSION NOT ASSOCIATED WITH OTHER INJURY. 73
ground suddenly and heavily on his heels or in 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 in them being often
followed by a train of slowly-progressive symptoms indicative
of concussion and subsequent irritation and inflammation of the
cord and its membranes.
But I may not only say that sudden shocks applied to the body
are liable to be followed by the train of evil consequences that we'
are now discussing. I may even go further, and say that these
symptoms of spinal concussion 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 the rarest thing
possible to find that the spinal cord or the brain has been
injuriously 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 an 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 concussed 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 nervous power. What immediate change, if any, has taken
place in the nervous structure to occasion that 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 action of the




74     EARLY SYMPTOMS OF RAILWAY CONCUSSION.
nervous system just as we do in the action of the iron by the
change that is induced in the loss of its magnetic force.
But whatever may be the nature of the primary change that is
produced in the spinal cord by a concussion, the secondary effects
are clearly of an inflammatory character, and are identical with
those phenomena that have been described by Ollivier, Abercrombie, and others, as dependent on chronic meningitis of the
cord, and subacute 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 sufferer is usually quite unconscious that any serious accident
has happened to him. He feels that he has been violently jolted
and shaken, he 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 congratulates 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
feeling 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 differentcases, from a
day or two to a week or more, he finds that he is unftt for exeition
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 necessarily vary much in different cases.
There is great variation in the period at which the more serious,
persistent, and positive symptoms of spinal lesion begin to develop
themselves. In some cases they do so immediately after the occurrence of the injury, in others not until several weeks, I might




DETAIL OF SYMPTOMS OF RAILWAY CONCUSSION. 75
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. His friends remark, and he feels, that "he
is not the man he was." He has lost bodily energy, mental 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, undergoes, 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, 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, especially in Cases 5 and 6.
It may, however, throw additional light on this subject, if we
analyze 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 every one of these symptoms may present thernselves 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.
The countenance is usually pallid, lined, and has a peculiarly careworn, anxious expression; the patient generally looking much
older than he really is or than he did before the accident. I have
seen one instance of flushing of face. This was marked in Case 11.
The memory is defective. This defect of memory shows itself in
vaious ways; thus, Case 2 said that he could not recollect a message unless he wrote it down;-Case 6 forgot some common words
and misspelt others; Case 5 lost command over figures; he could
not add up a few figures, and had also lost, in a great degree, the




76         SYMPTOMS OF RAILWAY CONCUSSION.
faculty of judging of weight, and of distance in a lateral direction;
he forgot dates, the ages of his children, &c.
The thoughts are confused. The patient will sometimes, as in
Case 11, break off in the middle of a sentence, unable to finish it;
he cannot concentrate his ideas so as to carry out a connected line
of argument; he attempts to read, but is obliged to lay aside the
book or paper after a few minutes' attempt at perusal.
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 temper often becomes changed for the worse, the patient
being 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 in
sudden alarm; dreams much; the dreams are distressing and
horrible.
The head is usually of its natural temperature, but sometimes
hot, as in Case 11. The patient complains of various uneasy sensations in it; of pain, tension, weight, or throbbing; of giddiness; of
a confused or strained feeling in it. Frequently loud and incessant
noises, described as roaring, rushing, ringing, singing, sawing,
rumbling, or thundering. 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 special sense usually become more or less seriously
affected. They become sometimes over sensitive and irritable, or
are impaired in their perceptions, and at others perverted in their
sensations. In many cases we find a combination of all those conditions in the same organ.
Vision is usually affected in various ways and in very different
degrees. In some cases, though rarely, there is double vision and
perhaps slight strabismus. In others an alteration in the focal
length, so that the patient has to use glasses, or to change those he
has previously worn. The patient cannot read for more than a
few minutes, the letters running into one another. -More commonly, muscle volitantes and spectra, rings, stars, flashes, sparkswhite, coloured, or flame-like-are complained of. This happened
in Cases 5, 6, and 11. The eyes often become over sensitive to
light, so that the patient habitually sits in a shaded or darkened




SYMPTOMS OF RAILWAY CONCUSSION.               77
room, turns his back to the window, and cannot bear unshaded
gas- or lamp-light. 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
in the bottom of the eye is visible to some patients.
The hearing may be variously affected. Not only does the
patient commonly complain of the noises in the head and ears that
have 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.
Taste and smell are sometimes, but more rarely, perverted. Case
11 complained of occasional fetid smells, which were not perceptible to any one else.
The sense of touch is impaired. The patient 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 weight, cannot
tell whether a sovereign or a shilling is balanced on his finger.
Speech is rarely affected. Case 12 stammered somewhat before
the accident, but after it his speech became a most painful and an
indescribably confused stutter that it was almost impossible to
comprehend. The same phenomenon was observed in the Count
de Lordat's case, p. 24. But it is certainly rare.
The attitude of these patients is usually peculiar. It is stiff and
unbending. They hold themselves very erect, usually walk straight
forwards, as 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 pain and difficulty that the patient is
afraid to attempt them, and hence keeps the head in its attitude of
immobility.




78        SYMPTOMS OF RAILWAY CONCUSSION.
The movements of the trunk are often equally restrained,
especially in the lumbar region. Flexion forwards, backwards, or
sideways, is painful, difficult, and may be impossible; flexion backwards is usually most complained of.
If the patient is desired to stoop and pick anything off the ground,
he will not be able to do so in the usual way, but bends 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 it.
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 the upper cervical, the middle dorsal, and the lumbar
regions. The exact 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 in consequence of the
pain that is occasioned by any movement of the trunk in the 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 impress upon its motions.
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 vertebra. 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 5 and 6; and in both
these it is interesting to observe that distinct evidences of cerebral
irritation had been superadded 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 12, the 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




SYMPTOMS OF RAILWAY CONCUSSION.               79
these cases, from 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 12, they may be found to be very irritable and spasmodically
contracted, so that their outlines are very distinct and marked.
The gait of the patient is remarkable and characteristic. He
walks more or less unsteadily, generally uses a stick, or, if deprived
of that, is apt to lay his hand on any article of furniture that is
near to him, with the view of steadying himself.
He keeps his feet somewhat apart, so as to increase the basis of
support, and consequently walks in a straddling manner.
As one leg is often weaker than the other, he totters somewhat,
raises one foot but slightly off the ground, so that the heel is apt to
touch. He seldom drags the toe, but walking flat-footed as it were
on one side, the heel drags. This peculiar straddling, tottering,
unsteady gait, with the spine rigid, the head erect, and looking
straight forwards, gives the patient the aspect of a man who walks
blindfolded.
The patient cannot generally stand equally well on either foot.
One leg usually immediately gives way under him if he attempts
to stand on it.
He often cannot raise himself on his toes, or stand on them, without 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.
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 banisters, and often
brings both feet together on the same step.
A sensation as of a cord tied round the waist, with occasional
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 nervous power of the limbs will be found to be variously modified, and will generally be so to very different degrees in the different limbs. Sometimes one limb only is affected, at others the arm




80         SYMPTOMS OF RAILWAY CONCUSSION.
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 respects, 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 impaired in one limb, or sensation in one and motion in
another. The paralysis is seldom complete. It may become so in
the more advanced 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 especially marked in the legs, and
more often 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 seat 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.
The loss of motor power in the foot and leg is best tested by the
application 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 an 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. 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 retention of
urine or cases requiring the continued use of the catheter; nor




SYMPTOMS OF RAILWAY CONCUSSION.                 81
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 of feces.
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,
especially in the earlier stages. The patient complains of shooting
pains down the limbs, like stabs, darts, or electrical shocks. The
surface of the skin is sometimes over-sensitive in places on the
back (as in Case 12), or in various parts of the limbs, hot, burning
sensations are experienced 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.
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 extend to several; its degree and extent are
best tested by Brown-S6quard's instrument.
Coldness of one of the extremities, dependent upon actual loss of
nervous power, and defective nutrition, is often perceptible to the
touch, and may actually be established by the 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 appreciable 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 case of complete paraplegia, which has lasted for years,
as in Case 3, 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 that is more or less completely paralyzed is not the simple consequence of the disuse of the muscles,
6




82        SYMPTOMS OF RAILWAY CONCUSSION.
or it would always occur. But it must arise from some modification of innervation, influencing the nutrition of the limb, independently of the loss of its muscular activity.
In most cases, however, where the paralytic condition has been
of some duration, the size of the limb dwindles; and on accurate
measurement it will be found to be somewhat smaller in circumference than its fellow on the opposite side.
The 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 contractions.
The body itself generally loses weight; and a loss of weight,
when the patient is rendered inactive by a semi-paralyzed 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 paralyzed, we often see a considerable
increase of size and weight take place. 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-urziary organs is seldom  much
deranged in the cases under consideration, as there is usually no
paralysis of the sphincters. Neither retention of urine nor incontinence of flatus and feces occurs. Sometimes, as in Case 5, 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.
The sexual desire and power are usually greatly impaired, and
often entirely lost. Not invariably so, however. The wife of Case
5 miscarried twice during the twelvemonth succeeding her husband's accident. I have never heard priapism complained of.
The pulse varies in frequency at different periods. In the early




INTERVAL BETWEEN ACCIDENT AND SYMPTOMS.             83
stages it is usually slow; in the more advanced it is quick, near to
or above 100. It is always feeble.
The order of the progressive development of the various symptoms
that have just been detailed is a matter of great interest in these
cases, and 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 cerebral disturbance, and the affection of the organs
of sense; the loss of motor power, and the peculiarity of gait.
The period of the supervention of these symptoms after the occurrence of the injury will greatly vary. Most 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,
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 state. 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 feelings or indications of nervous
prostration and irritation so characteristic 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
inquiry, that there has never been an interval 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




84       PATHOLOGY OF RAILWAY CONCUSSION.
immediately relapsed to a worse state than before when he has
attempted to do.work of any kind.
It i's 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.
Having thus described the various symptoms that may arise
from these shocks to and concussions of the spine, let us now
briefly inquire into the pathological conditions that lead to and
that are the direct causes of these phenomena.
I have already pointed out and discussed at some length, at p.
37 et seq., the pathological conditions that are found within the
spinal canal in those cases of paralysis, more or less complete, 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, and 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 disorganization
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 where the symptoms,
as just detailed, are less those of paralysis than of disordered
nervous action, the pathdlogical states on which these symptoms
are dependent are of a more chronic and less directly obvious
character than those above mentioned.  They doubtless consist
mainly of chronic and subacute inflammatory action in the
spinal membranes, and in chronic myelitis, with those changes
in the structure of the cord that are the inevitable consequences
of a long-continued chronic inflammatory condition developed
by it.
The only case on record with which I am acquainted, in which
a post-mortem examination has been made of the spinal cord of a
person who had actually died from the remote effects of concussion
of the spine from a railway collision, is one that has very recently
been related, and the parts exhibited to the Pathological Society
by Dr. Lockhart Clarke. The patient, who had been under the
care of Mr. Gore, of Bath, by whom the preparation was furnished,
was a middle-aged man of active business habits. He had been in




PATHOLOGY.-MR. GORE'S CASE.                85
a railway collision, and, without any sign of external injury, fracture, dislocation, wound, or bruise, began to manifest the usual
nervous symptoms. He gradually, but very slowly, became partially paralyzed in the lower extremities, and died three years and
a half after the accident.
Mr. Gore has most kindly furnished me with the following
particulars of the case. On the occurrence of 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 with much distress. Numbness and a want of power in the muscles of the lower limbs gradually but steadily increasing, he soon became disabled. 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 certainly within less than a year of the time of
the occurrence of the accident. In the latter part of his illness
some weakness of the upper extremities became apparent, so that
if the patient was off his guard a cup or glass would slip fiom his
fingers. 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 not so severe as usual, there was no very
marked tenderness or rigidity of the spine, nor were there any convulsive movements.
On examination after death, 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 anterior-posterior diameter in the cervicodorsal region. The narrowing was owing to absorption of the posterior columns. These had not only to a great extent disappeared,
but the remains were of a dark brownish colour, and had undergone
important structural changes.  This case is of remarkable interest
and practical value, as affording evidence of the changes that take




86        PATHOLOGY OF RAILWAY CONCUSSION.
place in the cord under the influence of " concussion of the spine'
from a railway 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.
It is well known to pathologists that two distinct forms of
chronic subacute inflammation 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 vascularization of the membranes is met with. The
meningo-rachidian veins are turgid with blood, and the vessels of
the pia-mater will be 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.
Ollivierl 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 piamater. 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 vertebrae. He has also seen rough cartilaginous (fibroid?)
laminae developed in the arachnoid. Lymph also of a puriform
appearance has often been 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'1iportant practical remark-the truth of which is fully carried
out by a consideration of the cases related in Lectures 2 and 3ht'if spinal meningitis rarely exists without there being at the same'ife a more or less extensive inflammation of the cerebral meninges,
hi'~ence, he says, arises the difficulty of determining with preiotiDothe symptoms that are special to inflammation of the mem-'Afi6''s"bof the spinal cord.
/"l'~n'ntnyelitis occurs, the inflammation attacking the substance
tP,'trli:itt l itself, the most usual pathological condition met with
l^  fter~iiA~ of its substance, with more or less disorganization of
u:!i^ Jj: [  ao:2i:,;  1 Vol. ii. p. 237.




PATHOLOGY: MENINGO- MYELITIS.               87
its tissue. This softening of the cord as a consequence of its inflammation may, according to Ollivier, occupy very varying extents of its tissue. Sometimes the whole thickness of the cord is
affected at one point, sometimes 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
gray 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 lumbar. 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 nothing but connective tissue is left behind at the part affected.
Ollivier makes the important observation, that when myelitis is
consecutive 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 congestion, and increased vascularization
of the membranes. The case of the Count de Lordat (p. 24) 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 coexist. 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 meningitis, in others those of myelitis,
being most marked, and after death the characteristic appearances
presenting a prominence 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




88                 CEREBRAL SYMPTOMS.
attention with an elaborate inquiry into the pathology of these
affections, but rather to consider them in their surgical relations.
I wish now to direct your attention to the symptoms that are
admitted by all writers on diseases of the nervous system to be
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
to the body.
The symptoms that I have detailed at pp. 74 to 83, arrange
themselves in three groups:1st. The cerebral symptoms.
2d. The spinal symptoms.
3d. 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 to you, 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.
1. 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 posi-.
tive. He says that it is rare to find inflammation of the spinal
membranes limited to the vertebral canal. 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




SPINAL AND GENERAL SYMPTOMS.                 89
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-mortem appearances that he details of patients
who have died of spinal meningitis, he describes the morbid conditions met with in the cranium, indicative of increased vascularity
and inflammation of the arachnoid. This complication of cerebral
with spinal meningitis is nothing more than we should expect 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 intracranial mischief are
described.
2. The spinal symptoms that occurred in the cases of " concussion
of the spine" which I have related, consisted briefly in pain at one
or more points of the spine, greatly increased on pressure, and on
movement of any kind, so as to occasion 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 pain 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 accompanied by muscular rigidity. It remits,
sometimes being much more severe than at others, and occasionally 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. 81-83, 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 are the very symptoms that are given by Ollivier and




90    SYMPTOMS DEPEND ON SPINAL INFLAMMATION.
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 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
(engourdissement). These sensations are first experienced in the
fingers and toes, and thence extend upwards along the limbs.
These sensations are most complained of in the morning soon
after leaving bed. They intermit at times, fluctuating in intensity,
and in the early 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 in
the 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.
Ollivier remarks, that in chronic myelitis patients often complain
of a sensation as of a cord ti.ed tightly round the body.
The gait (ddmarche) of patients affected with chronic myelitis is
peculiar. 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
progressive development and indefinite continuance, with those
which are described by Ollivier and other writers of acknowledged




DIAGNOSIS FROM CEREBRAL CONCUSSION.              91
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 phenomena arising
from shakes and jars of or blows on the body, and described at pp.
74 to 83 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 inflammation, and to the degree to which its resulting structural changes
may have developed themselves in the membranes or cord.
LECTURE THE SIXTH.
DIAGNOSIS, PROGNOSIS, TREATMENT, OF CONCUSSION OF
THE SPINE.
Diagnosis from Cerebral Concussion-From Rheumatism-From Hysteria-Prognosis of Concussion of the Spine-What is meant by Recovery-Probability of
Recovery-Period of Fatal Termination-Treatment-Importance of RestCounter Irritation-Medical Treatment.
FROM the account that has just been given of the symptoms that
may gradually develop themselves after concussion of the spine, I
need say little about the diagnosis of this injury from other forms
of cerebro-spinal disease. There are, however, three morbid states
for one or other of which I have known it to be confounded, and
from which it is necessary to diagnose it. These are, 1. The
secondary consequences of cerebral concussion; 2. Rheumatism;
and 3. Hysteria.
1. From the secondary effects of cerebral concussion 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 and rigidity of the spine, the pain on pressing upon
or on moving it in any direction, and the absence of any distinct
lesion about the head, will sufficiently mark the precise situation
of the injury.
The two conditions of cerebral and spinal concussion often co



92            DIAGNOSIS FROM RHEUMATISM.
exist primarily. The shock that jars injuriously one portion of the
nervous system, very commonly produces a corresponding 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 secondary 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
membranes 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 in the back, the 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 rheumatism,-the
diagnosis will be rendered comparatively easy; the more so when
we observe that in spinal concussion there is never any concomitant articular inflammation, and that although the urine may continue acid, it does not usually present evidences of a superabundance of lithates.
3. Hysteria is the disease for which I have more frequently seen
concussion of the spine, followed by meningo-myelitis, mistaken, and
it certainly has always appeared extraordinary to me that so great
an error of diagnosis could so easily be made.
Hysteria, whether in its emotional or its local form, is a disease of
women rather than of men, of the younger rather than of the middleaged and old, of people of an excitable, imaginative, or emotional
disposition rather than of hard-headed, active, practical men of
business. It is a disease that runs no definite or progressive course,
that assumes no permanence of action, that is ever varying in the
intensity, in the degree, and in the nature of its symptoms; that is
marked by excessive and violent outbreaks of an emotional character, or by severe exacerbations of its local symptoms, but that is
equally characterized by long-continued and complete intermissions
of its various phenomena.




DIAGNOSIS FROM HYSTERIA.                  93
Does this in any way resemble what we see in "concussion of
the spine," or in the consecutive meningo-myelitis? In those cases
in which a man advanced in life, of energetic business habits, of
great mental activity and vigour, in no way subject to gusty fits of
emotion, or to local nervous disquietudes of any kind,-a man, in
fact, active in mind, accustomed to self-control, addicted to business,
and healthy in body, suddenly, and for the first time in his life,
after the infliction of a severe shock to the system, finds himself
affected by a train of symptoms indicative of serious and deepseated injury to the nervous system,-is it reasonable to say that
such a man has suddenly become "hysterical," like a love-sick
girl? Or is this term not rather employed merely to cloak a want
of precise knowledge as to the real pathological state that has
given rise to the alteration that is perceptible to the most casual
observer in the mental state and bodily condition of the patient?
To me, I confess, the sight of a man of forty-five, rendered " hysterical," not for a few hours or days even, by some sudden and overwhelming calamity that may for the time break down his mental
vigour, but permanently so for months or years, would be a novel
and a melancholy phenomenon, and is one that I have neither seen
described by any writer with whose works I am acquainted, nor
witnessed in a hospital experience of twenty-five years; and could
such a condition actually be induced, it would certainly be to my
mind an evidence of the most serious and disorganizing disease of
the nervous system.
But, in reality, there can be but little difficulty in establishing
the diagnosis between chronic meningo-myelitis and hysteria. The
persistence of the symptoms, their slow development, their progressive increase in severity notwithstanding occasional fluctuations
and intermissions in intensity, the invariable presence of more or
less paralysis of sensation, or of motion, or both, will easily enable
the surgeon to judge of the true nature of the case. That mental
emotion is occasionally manifested by an unfortunate individual
who has been seriously injured by an accident which tends to
shake his whole nervous system, can scarcely be matter of surprise,
the more so when, as commonly happens in these cases, he finds
himself progressively and steadily deteriorating in health and
strength, and sees in the future the gloomy prospect of a shattered
constitution, of impaired mental vigour, and of loss of bodily
activity; of the necessity of abandoning those occupations in which




94      PROGNOSIS OF CONCUSSION OF THE SPINE.
his life had been usefully spent, and on the continuance of which,
probably, the support of himself and his family is dependent.
That such an unhappy sufferer should occasionally be unnerved
and give way to mental emotion is natural enough. It certainly
appears to me that the term " hysteria," elastic as it is, can scarcely,
with any regard to truth or justice, be strained so far as to embrace
those feelings that naturally spring from the contemplation of so
gloomy a prospett as this; and even if it be considered applicable
to his mental state, it can in no way be looked upon as the cause
of those bodily sufferings and disabilities which constitute the most
important and serious part of his disease, and which have no
analogy in development or progress with the ordinary physical
phenomena of hysteria.
The prognosis of "concussion of the spine" and that of the consecutive meningo-myelitis is a question of extreme interest in a
medico-legal point of view, and is one that is often involved in no
little difficulty.
The prognosis requires to be made with regard, first, to the
life, and, secondly, to the health of the patient. So far as life is
concerned, it is only in those cases of severe and direct blows upon
the spine, in which intra-spinal hemorrhage to a considerable
extent has occurred (Case 4), or in which the cord or its membranes have been ruptured, that a speedily fatal termination may
be feared.
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 increasingly progressive breaking down of the
general health, and the slow extension of the paralytic symptoms.
I have heard of several instances in which concussion of the spine
has thus proved fatal some years after the occurrence of the accident. Mr. Gore, of Bath, who has had considerable experience in
these injuries, writes to me in reference to the case related p. 84,
that this is the third fatal case of which 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, as in the one related at p. 84, the fatal result is
the direct consequence of the structural changes that take place in
the cord and its membranes. Indeed, this one case proves in the
clearest and most incontestable manner the possibility of death




PROGNOSIS OF CONCUSSION OF THE SPINE.            95
occurring after a lapse of several years, from  the progressive
increase of those symptoms, which are dependent upon disease of
the nervous system from concussion of the spine occurring from
railway 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. This case establishes the fact beyond doubt that such a
fatal termination is by no means impossible after an interval of
several years, in cases of concussion of the spine in which deepseated 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 meningomyelitis 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 evideuce 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




96         PROGNOSIS IN SPINAL CONCUSSION.
says:' "Is spinal meningitis susceptible of cure? All observers
agree in stating that death is the inevitable result." He qualifies
this statement, 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 Frank relates another in which a fatal termination did not occur. The occurrence of convulsive movements
is a most unfavourable sign. They indicate the existence of
chronic myelitis, and are usually associated with deep disorganization 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. I 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 convulsive 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.
From 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 4); secondly, at a more remote date by the occurrence of
inflammation of the cord and its membranes (Ollivier); and, thirdly,
after a lapse of several years by the slow and progressive development of structural changes in the cord and its membranes (Mr.
Gore's Case, p. 84).
But though death may not occur, is recovery certain? Is there
no mid-state between a fatal result, proximate or remote, and the
absolute and complete recovery of the patient?
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
1 Vol. ii. p. 294.




PROBABILITY OF RECOVERY.                 97
health to some, perhaps even a considerable, extent-an indefinite
prolongation 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? No, certainly not. 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. sustained-whether in all respects, mentally and bodily, he
will be restored to that state of intellectual vigour and of corporeal
activity that he enjoyed before the occurrence of the accidentwhether, 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, we have to look to two points, first, the recovery from the
primary and direct effects of the injury, and, secondly, from the
secondary and remote consequences of it.
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 organization 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 suffer, his chance of ultimate recovery
will be greater, provided always that no secondary and organic
lesions have developed themselves.
I believe that such recovery is more likely to ensue if the primary
and direct symptoms have been severe, and have at or almost
immediately after the occurrence of the accident attained to their
full intensity.  Case 1 is an instance of this, and many similar
ones must present themselves to the recollection of most surgeons,
and there are many such on record.
In these cases, under proper treatment the severity of the symptoms gradually subsides, and, week by week, the patient feels himself stronger and better, until usually in from three to six months
at the utmost all traces of the injury have disappeared.
7




98             PROBABILITY OF RECOVERY.
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 must prevent
complete recovery. When, therefore, we find a patient who, after
the receipt of a severe injury of the spine by which the cord has
been concussed, presents 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 a progressive amelioration of his symptoms, and
no evidence of the development of any inflammation, acute or
chronic, of the membranes and the cord.
But our opinion as to his ultimate recovery must necessarily be
very unfavourable if we find the progress of amendment cease
after some weeks or months, leaving a state of impaired innervation. 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 meningomyelitis have declared themselves. Under such circumstances of
the double combination, of the cessation of improvement and the
supervention of symptoms of intra-vertebral inflammatory action,
partial restoration to health may eventually be looked for; but
complete recovery is not 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 progressively developed themselves, the prognosis will
always be very unfavourable. And for this reason;-that as the
injury is not sufficient of itself to produce a direct and immediate
lesion of the cord, any symptoms that develop themselves must be
the result of structural changes taking place in it as the consequence of its inflammation; and these secondary structural changes




PROBABILITY OF RECOVERY.                 99
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 been
taking place in the cord and its membranes, dependent upon
pathological changes of a deep-seated and permanently incurable
character.
Abercrombie truly says: "Every injury of the spine should be
considered 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
effects of a slight injury of the spine, these effects having developed
in an insidious 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 tenderness 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 and a shattered constitution, you must, at any period of the case, however early, give
a most cautious prognosis. And if several 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 increase in the symptoms, however slow that may be,
is taking place, more and more complete paralysis will ensue, and
the patient will probably eventually die of those structural spinal
lesions that are described at p. 84.
I have purposely used the words " progressive amelioration" for
this reason, that it often happens in these cases that under the
influence of 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




100                 TREATMENT.-REST.
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 as to the patient's probable future state,
I believe that 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 least likely to recover in
which the symptoms affect the latter course.
The time that the symptoms have lasted is necessarily a most
important matter for consideration. When they have been of but
short duration, they may possibly be dependent on conditions that
are completely, and perhaps easily, removable by proper treatment,
as for instance, on extravasation of blood, or on acute serous inflammatory effusion (Case 14). 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 will undoubtedly 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
dependent on chronic inflammation of the cord and its membranes,
and on their consecutive structural lesions, had existed for twelve
months. And though, as Ollivier has observed, such a patient
may live for fifteen or twenty years in a broken state of health, the
probability is that he will die within three or four. There is no
structure of the body in which an organic lesion is recovered from
with so much difficulty and with so great a tendency to resulting
impairment of function as that of the spinal cord and brain. And,
with the exception probably of the eye, there is no part of the
body in which a slight permanent change of structure produces
such serious disturbance of function as in the spinal cord.
Treatment.-I have not much to say to you about the treatment
of these injuries that we have been discussing. But I feel that my
remarks on this subject would scarcely be complete were I to omit
so important a matter from our consideration.
In the early stages of a case of "concussion of the spine," the
first thing to be done is undoubtedly to give the injured part complete and absolute rest.




TREATMENT.-REST.                    101
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 without rest, 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 absolute and
entire rest in these cases, for this reason, that 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. In more
advanced stages of the 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 efficiently the patient should be made to
lie on a prone couch. There are several reasons why the prone
should be preferred to the supine position.  In the first place, in
the prone attitude the spine is the highest part of the body, thus
passive venous congestion and determination of blood, 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 again, the absence of pressure upon the back is a
great comfort in those cases in which it is unduly sensitive and
tender, and is a matter of additional safety to the patient, if he is
paraplegic, by lessening the liability to sloughing from undue compression of the soft parts over the sacrum and nates. Lastly, the
prone position presents this advantage over the supine, that it
admits of the ready application of any local treatment that may be
desired to the spine.
In some instances, as in Case 14, complete and absolute rest may
be secured to the injured spine by the application of a gutta-percha
case to the back, embracing the shoulders, nape, and back of the




102    TREATMENT OF CONCUSSION OF THE SPINE.
head, or, as in Case 13, by letting the patient wear a stiff collar so
as to give the support that is needed to the neck.
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 liable 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 head, or flushings 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 emotions 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
until after many ineffectual efforts to attend to it.
During the early period of concussion of the spine, much advantage will usually be derived from dry cupping along the back on
either side of the vertebral column. In some cases I have seen
good effects follow the application of ice-bags to the injured part of
the spine.
At this period I believe that medicine is of little service beyond
such as is required for the regulation of the general health on
ordinary medical principles.
When the secondary effects of the concussion of the spine have
begun to develop themselves, more scope presents itself for proper
medical treatment, and much may often be done not only for the
mitigation of suffering, but for the cure of the patient by carefully
conducted local and constitutional treatment.
Rest as in the early stages must be persevered in, but in addition
to this counter-irritation may now be advantageously employed.
With this view the various forms in which this means is familiar
to the surgeon-stimulating embrocations, mustard poultices, blisters, and setons or issues-may be successfully employed.
With regard to internal treatment, I know no remedy in the
early period of the secondary stage, when subacute meningitis is
beginning to develop itself, that exercises so marked or beneficial
an influence as the bichloride of mercury in tincture of quinine or
of bark. I have seen this remedy produce the most beneficial




TREATMENT.-MEDICINE.                  103
effects, and have known patients come back to the hospital to ask
for the "bichloride" as the only medicine from which they had
derived advantage. At a more advanced period, and in some constitutions in which mercury is not well borne, the iodide or the
bromide of potass in full doses will be found highly beneficial,
more especially when there are indications, as in Case 14, of the
presence and the pressure of inflammatory effusion.
When all signs of inflammatory action have subsided-when the
symptoms have resolved themselves into those of paralysis whether
of sensation or of motion-but more especially in those cases in
which there is a loss of motor power, with a generally debilitated
and cachectic state, the preparations of nux vomica, of strychnine,
and of iron may be advantageously employed. But I would particularly caution you against the use of these remedies, and more
especially of strychnine, in all those cases in which inflammatory
action is still existing, or during that period of any given case in
which there are evidences of this condition. You will find that
under such circumstances the administration of strychnine is attended by the most prejudicial effects, increasing materially and
rapidly the patient's sufferings. But in the absence of this inflamma.
tory irritation it will, if properly administered, be found to be a most
useful remedy, more particularly in restoring lost motor power.
In those cases in which the strychnine may be advantageously
administered, great benefit will also be derived from warm saltwater douches to the spine, and galvanism to the limbs.
At a more advanced period of the case, when general cachexy
has been induced, and more or less paralysis of sensation and
motion continues in the limbs, and nothing of a specific nature cal
be done in the way of treatment, our whole object should be to
improve the general health on ordinary medical principles, so as to
prevent as far as possible the development of secondary diseases,
such as phthisis dependent on mal-nutrition and a generally broken
state of health, and which may, after a lapse of several years, lead
to a fatal termination.
THE END.