TRAUMATIC LESIONS OF THE SPINAL CORD. 
BY 
GEORGE J. PRESTON, M.D., 
PKOFfrSSOK OF PHYSIOLOGY AND DISEASES OF THE NERVOUS SYSTEM, COLLEGE 
OF PHYSICIANS AND SURGEONS, BALTIMORE. 
KROM 
THE MEDICAL NEWS, 
March i8, 1893. [Reprinted from The Medical News, March 18, 1893.] 
TRAUMATIC LESIONS OF THE SPINAL CORD.1 
By GEORGE J. PRESTON, M.D., 
PROFESSOR OF PHYSIOLOGY AND DISEASES OF THE NERVOUS SYSTEM, 
- COLLEGE OF PHYSICIANS AND SURGEONS, BALTIMORE. 
Injury to the cord, resulting from external vio- 
lence, is of rather more frequent occurrence than 
would be expected if we consider how well pro- 
tected the cord is. The peculiar construction of 
the vertebral canal, the strength of the individual 
vertebrae, the very perfect and extensive articula- 
tions with each other, the elastic intervertebral 
discs separating the segments, and the various liga- 
ments binding the parts together, require a high 
degree of violence to produce either dislocation or 
fracture. Added to this the spinal canal is much 
larger than its contained cord, and the latter is con- 
sequently not in direct contact with the bony walls, 
but is suspended from above, and steadied laterally 
by ligaments and emerging nerves. 
The most common form of injury to the cord is that 
which results from fracture of the vertebrae. This 
accident occurs as the result of a general crush, as 
by a fall of coal in a mine, or of earth or stone in a 
tunnel or quarry; also by external violence applied at 
1 Read before the Clinical Society of Maryland, December 16, 
1892. 2 
one point, as when a man is caught between cars. 
Not an uncommon cause is a fall, which may cause 
fracture of the vertebrae either directly, as when an 
individual falls flat upon the back, or indirectly 
from striking upon the head or feet, the force of the 
fall being felt most strongly at certain points along 
the vertebral column. Extreme flexion of the body, 
or twists, may produce dislocation or even fracture. 
Gunshot wounds involving the vertebrae, while not 
very common in civil, are often met with in mili- 
tary practice. 
As a result of these and similar injuries to the 
bony structures, the cord may be compressed, 
more or less lacerated, or entirely destroyed. 
Compression may be occasioned either by the 
broken bone impinging directly upon the cord 
in the shape of a fragment or spicule, or by a 
narrowing of the canal. The points at which frac- 
ture is most likely to occur are the cervical and 
lower dorsal regions, unfortunately the very points 
where the cord can least afford interference with 
its function. Compression of the cord may result 
from hemorrhage within the spinal canal, due to 
rupture of the spinal veins. Finally, when the cord 
itself is not injured, the meninges may be torn and 
the cord suffer secondarily. 
In addition to the class of cases already referred 
to must be added those cases in which, without 
any fracture or dislocation of the vertebrae, the 
cord suffers more or less severely. Concussion 
of the spine, or railway spine, as this condition 
is wrongly called, has occasioned a good deal 
of rather acrimonious debate, largely due to the 3 
fact that the subject has been so often in the 
courts. While concussion of the cord is infinitely 
less common than concussion of the brain, it un- 
doubtedly does occur, and we may have all grades 
of injury, from a mere temporary suspension of 
function up to a considerable degree of laceration, 
without fracture of the vertebrae. 
The symptomatology of injury of the cord is co- 
extensive with the functions of the cord, as any 
part of the latter may be involved. As far as loca- 
tion goes, we need consider only the cervical en- 
largement, the mid-dorsal region, and the lumbar 
enlargement. 
In the cervical and lumbar regions are situated 
the important centers for the muscles of the upper and 
lower extremities and for the thoracic and abdomi- 
nal viscera, and entering these portions of the cord 
are the sensory nerves from the extremities. Injury 
may therefore involve the nerve-centers or cells, or 
the white matter alone. In the dorsal region the 
gray matter sinks into insignificance, and we are 
concerned mainly with the extent of the involve- 
ment of the white matter or fiber-tracts in their pas- 
sage to and from the brain. 
The symptoms of injury to the cord may be 
divided into primary and secondary. By primary 
symptoms are meant those that appear suddenly, as 
the immediate result of the injury—such, for ex- 
ample, as paraplegia. By secondary symptoms are 
meant those that come on at a later period in the 
form of degeneration of fiber and cell; this class 
is illustrated by the various muscular atrophies and 
trophic lesions generally. In discussing briefly the 4 
primary symptoms of injury to the cord, it is neces- 
sary first to note those symptoms of a general 
nature and not dependent upon the location of the 
injury, and then the special symptoms that depend 
upon the region involved and the extent of such 
involvement. 
The general symptoms of injury to the cord are 
few. Shock is present to a greater or less degree, 
sometimes being marked after slight injuries, and at 
other times present only to a slight degree, though 
the injury may have been severe. Consciousness is 
rarely lost, even in cases proving rapidly fatal. Of 
particular interest is the rise of temperature, noted 
especially in injury to the cervical cord, and, in 
lesser degree, in injuries in the lower dorsal and 
lumbar regions. No very satisfactory explanation 
of this phenomenon can be given. If it were met 
with only after injury to the cervical cord it might 
be explained on the ground of interference with the 
heat centers, supposed by some physiologists to 
be located in that region ; but as injury at any 
level may produce rise of temperature, we must 
conclude that this is due to interference with the 
fiber-tracts connected with the heat-regulating cen- 
ters. Varying degrees of pain may be present, de- 
pending upon the location and extent of the injury 
and the involvement of nerve-roots. Priapism is a 
common symptom, especially in injuries to the 
cervical cord. Rosenthal mentions a case of in- 
jury to the cervical cord in which the priapism 
lasted for seven days during life and for thirty-six 
hours after death. 
In discussing the special symptoms, it is important 5 
to bear in mind the fact that we may have all grades 
of injury, and consequently the intensity of the 
motor and sensory symptoms will vary accordingly. 
Again, the cord may be involved to a greater degree 
on one side than on the other, causing a difference 
in the symptoms of the two sides. When the middle 
of the cervical enlargement is involved, somewhere 
about the sixth or seventh cervical vertebra, there 
is loss of motion in all parts below the level of the 
lesion, and of sensation over the inner half of the 
arm and forearm and all below this level. The tem- 
perature is always notably raised, the pupils are con- 
tracted, and the breathing is diaphragmatic. Lesions 
high up in the cervical region cause loss of motion 
and sensation from the neck down, interfere seriously 
with respiration, and are usually rapidly fatal. The 
two following cases illustrate very well the symptoms 
of injury to the cervical cord : the first case is one 
of injury to the upper part of the cervical region; 
the second, of injury about the mid-cervical region. 
Case I.—A male, aged twenty-four, gave a 
history of having plunged head first into shallow 
water. When admitted into the hospital, some ten 
or twelve hours after the accident, examination 
showed no signs of injury to the head. The head 
was somewhat retracted and any movement of it 
caused intense pain. All four extremities were par- 
alyzed, the lower completely,the upper being capable 
of some slight movement. Sensation was lost from 
the neck down. Breathing was purely diaphrag- 
matic. The patellar reflex was present, and the 
pupils were contracted to pin-points. The tempera- 
ture was 104° F. The mind was perfectly clear. There 
was priapism and loss of control over the bladder and 6 
rectum. Death occurred on the evening of the day 
he was admitted into the hospital, which was the 
day following the reception of the injury. The tem- 
perature, taken in the rectum four hours after death, 
was iio° F. The autopsy revealed a fracture of the 
fifth cervical vertebra. The cord showed laceration 
at the point of fracture, with extravasation of blood 
extending about an inch vertically. 
Case II.—A male, aged thirty-seven, fell about 
forty feet upon a rough, irregular surface. Ex- 
amination shortly after the accident showed a 
lacerated wound of the scalp, but no fracture of 
the skull. He was perfectly conscious. There 
was complete paralysis of the lower extremities 
and partial paralysis of the upper. Sensation was 
entirely lost from the level of the third rib down, 
and impaired over the chest and arms. Respiration 
was diaphragmatic. Priapism was marked. There 
was paralysis of the bladder and rectum. The 
pupils were finely contracted. The temperature, 
103° F. an hour after admission, reached 109° F. 
just before death, which took place the day follow- 
ing the reception of the injury. 
At the autopsy it was seen that the laminae of the 
fourth and fifth cervical vertebrae were fractured on 
both sides; the dura was slit longitudinally and 
there was an extra-dural hemorrhage posteriorly. 
The cord opposite the fracture showed hemorrhage 
and disintegration of its substance. 
Lesions in the mid-dorsal region, if complete, 
cause loss of motion and sensation below the seat 
of injury. If the lesion be high enough, the arms 
may be slightly affected both as to motion and sen- 
sation, thus approximating the symptoms detailed. 
When the lesion is only partial, the differences be- 
tween dorsal lesions on the one hand and cervical 7 
or lumbar on the other, become much more ap- 
parent. This is very obvious if we consider that in 
the dorsal cord the gray matter and consequently 
the centers are very insignificant, the white matter 
or fibers composing almost the entire cord between 
the cervical and lumbar enlargements. 
A lesion in the lumbar region, involving the lum- 
bar enlargement, causes loss of motion and sensatiou 
in all parts below, loss of control over the bladder and 
rectum, and loss of the superficial and deep reflexes. 
It must be understood, of course, that the symptoms 
here detailed are only the immediate ones; the 
secondary symptoms, such as atrophy and the like, 
will be mentioned under the head of secondary 
symptoms. The following cases may be mentioned 
as illustrative : 
Case III.—A male, aged twenty-three,was crushed 
by a bank of earth falling upon him. There was no 
external injury of note. There was entire loss of 
motion and sensation below the level of the first 
lumbar vertebra, and loss of control over the blad- 
der and rectum. There was no loss ©f consciousness 
at any time. The superficial and deep reflexes were 
abolished. The temperature on the day of admission 
to hospital, which was the day of the injury, was 
102° F.; it remained at this point for five days, then 
sank to normal and did not rise again until just 
prior to death. Bedsores of a trophic nature de- 
veloped in the gluteal region, and cystitis was also 
a later complication. The patient was admitted 
March 26th, and died rather unexpectedly May 15th. 
The autopsy showed that the last dorsal and first 
lumbar vertebrae were crushed and dislocated for- 
ward, compressing the cord and reducing it to an 
almost empty sheath. 8 
Case IV.—A male, aged fifty-two, fell nine or ten 
feet into the hold of a vessel, striking upon his back 
and side. There was no loss of consciousness and 
very little pain, but there was instant paralysis of 
the lower extremities. Examination showed a scalp- 
wound, but no fracture of the skull. There was a 
marked projection of the tenth dorsal vertebra. 
There was total loss of power in the lower extremities 
and loss of sensation below the umbilicus. 
Bladder and rectum were both paralyzed. Cyst- 
itis, together with bedsores of a trophic nature, 
developed, and the patient died September ioth, 
having been admitted August 25th. The autopsy 
revealed a fracture of the tenth dorsal vertebra, 
greatly compressing and crushing the cord. 
Injury to the conus medullaris causes paralysis of 
the bladder and rectum and anesthesia in the 
gluteal region. Such cases are not very com- 
mon. The symptoms detailed and cases related are 
applicable only to total or nearly total transver e 
lesions, conditions in which the functions of the 
cord at the level of the injury are entirely abolished. 
It often happens, however, thit the injury does not 
involve the entire thickness of the cord. In this 
latter case the symptoms present wide variations. 
Sensation may be greatly or very slightly affected, 
and all grades of paralysis may exist. A partial 
lesion in the mid-dorsal region may not involve 
the sensory conducting-fibers to any appreciable 
extent, and the lower centers, as those for the bladder 
and rectum, may be intact. Motion in such a case as 
this would be interfered with to a moderate degree 
only, or more or less entirely lost. 
We may have one lateral half of the cord inter- 9 
feredwith, giving Brown-Sequard paralysis : motion 
lost on the side of the lesion, sensation on the 
opposite side. In the cases in which the lesion does 
not involve the entire thickness of the cord, the 
patellar rtflex is as a rule greatly exaggerated, unless 
the lesion be in the lumbar enlargement, when, of 
course, the knee-jerk is lost, because the center is 
involved and the reflex arc is broken. In those cases 
in which the cord is entirely severed, even though 
the lesion is in the cervical or dorsal region, the 
patellar reflex, as Bastian has pointed out, is lost and 
we have a flaccid paralysis. A case recently under 
my care showed the curious combination of entire 
loss of motion and sensation in the lower extremities, 
with greatly exaggerated reflexes and ankle clonus. 
The only explanation of such symptoms that can be 
given is that the cord was involved in almost its 
entire thickness, having intact only a few white 
fiber-tracts, probably the direct cerebellar columns. 
It must be borne in mind that occasionally the nerve- 
roots only are involved, without any injury to the 
cord : the local nature of the symptoms renders the 
diagnosis easy, as a rule. 
In considering the cases in which only moderate 
injury is done to the cord, a question of great in- 
terest arises, namely : To what extent may the cord 
be injured by blows, falls, and the like, which do not 
cause fracture or dislocation of the vertebrae ? We 
may, I think, have three varieties of cord injury re- 
sulting from external violence which has not been suffi- 
ciently great to cause any rupture of the bony parts : 
laceration to a moderate degree, compression from 
hemorrhage due to rupture of the spinal veins, and 10 
finally, a general disturbance of nutrition, without 
any immediate alteration of structure or marked 
symptoms, the condition known as concussion 
proper. The following case will illustrate the first 
variety, or moderate laceration without any fracture 
or dislocation of the vertebra: 
Case V.—A female, aged twenty-two, on July 
25th fell through a skylight to the floor beneath, a 
distance of fourteen feet. There was no loss of 
consciousness and but little shock. Examination 
showed a bruised and somewhat tender spot in the 
lumbar region, but no evidence of fracture or dislo- 
cation. 
The temperature was normal, as also were the 
pupillary reflexes. There was complete paralysis of 
the lower extremities and of the bladder and rectum. 
The deep and superficial reflexes, from the waist 
down, were abolished. There was anesthesia of the 
gluteal region and of nearly all the surface of the 
lower extremities. The patient has slowly improved, 
and at present, nearly six months after the injury, 
has recovered to some extent the use of her right 
leg. The left leg is still nearly powerless, and shows 
njarked foot-drop, and only partial return of sensi- 
bility. The reflexes are very feeble. 
The second variety of compression by intra-spinal 
hemorrhage without fracture is interesting, and has 
been confirmed by surgical operations for the relief 
of the pressure occasioned by the hemorrhage ; the 
bleeding generally is found to come from the rup- 
ture of the spinal veins. The following case might 
perhaps be included in this category. 
Case VI.—A male, aged sixty-two, was crushed 
in an elevator. Several ribs were broken, but no 11 
distinct fracture of the vertebrae could be made out. 
There was no displacement of the vertebrae. There 
was almost total loss of motion in the lower extremi- 
ties, with anesthesia extending to the crests of the ilia, 
and above this a very sharply-defined band of hyper- 
esthesia. There was no elevation of temperature. 
The patellar reflex was abolished; the bladder was 
not paralyzed. Examination on the following day 
showed that the hyperesthesia had disappeared, and 
in a few days motion and sensation began to return 
and the patient was discharged cured at the expira- 
tion of two weeks. The deep reflexes had not 
returned when the patient left the hospital. 
The third variety of injury to the cord, without 
fracture of the vertebrae, or any evidence of gross 
lesion, is that condition known as concussion of 
the spine. The limits of this paper do not permit 
any discussion of this interesting part of the general 
subject of injury to the cord. Ever since the ap- 
pearance of Erichsen’s notable paper, there have 
been bitter discussions in regard to the existence of 
such a condition. Unfortunately, the battle-grounds 
have been oftener in the courts than in the medical 
societies. 
While a certain proportion of the cases of “rail- 
way spine ” are fraudulent, or at least imaginary, 
and the symptoms stimulated by prospective “dam- 
ages,” there can be no doubt of the genuineness of 
many cases. Nor is the probable pathology hard to 
conceive. As we have seen, the cord may be in- 
jured severely by a blow or a fall that does not cause 
fracture or displacement of the vertebrae. Now, it 
would seem not improbable that a severe fall might 
seriously disturb the nutrition of certain parts of 12 
the cord, causing injury much less in degree than 
laceration or hemorrhage, which have already been 
considered. 
As the result of a concussion, there might be 
sufficient injury done to the gray matter to initiate 
a degenerative process in the cellular structure, and, 
as a consequence, muscular weakness and atrophy 
in the parts depending for their innervation and 
trophic influence upon the cells in question. 
Again, if the fiber tracts be even slightly injured, 
a myelitis may result and cause a more or less wide- 
spread secondary degeneration. Suppose an injury, 
to the posterior part of the cord, by a fall, blow, or 
twist; the immediate effects of such an injury may not 
be at all marked, yet if there has been decided dam- 
age done to the fiber-tracts there will be an up- 
ward degeneration of the posterior columns, or the 
pathologic lesion of tabes dorsalis. The specimen 
shown of Case II. very beautifully illustrates this 
point. The injury to the cord was in the lumbar 
region, and the cervical cord shows most marked 
degeneration of the posterior colums, as can be seen 
from the section exhibited. This very marked de- 
generation has taken place in two months. In like 
manner we may have degeneration of the lateral, 
the direct cerebellar columns, etc. 
It is, I think, quite possible that we have under- 
estimated the importance of traumatism, in searching 
for some satisfactory etiology of the chronic system- 
degenerations or scleroses of the spinal cord. As a 
matter of fact, we have reports of cases pointing 
clearly to traumatism as their starting-point, and it 
is a common observation that an apparently trivial 13 
accident will often hasten and develop a case of 
incipient sclerosis. 
The foregoing remarks sufficiently illustrate the 
nature of the changes of a secondary character that 
take place in the cord. As a result of these second- 
ary degenerations, we have muscular atrophy, con- 
tractures, bedsores, cystitis, and like symptoms. 
Cystitis is especially troublesome and very com- 
monly leads to secondary kidney-changes. 
The diagnosis of these cases is not generally 
difficult, but, as Gray has suggested, it is always well 
to write out carefully all the symptoms, so that we 
may compare them with the tables given in the books 
and express the limits of the involvement of the 
cord in terms of the vertebrae. 
The question of treatment in these cases of trau- 
matic injury of the cord is an exceedingly difficult 
one to determine. As we know, we can expect little 
from medicine. Rest, counter-irritation, electricity, 
gold and silver salts, mercury, arsenic, and many 
other therapeutic agents are employed, but it is very 
questionable whether any of them influence in any 
degree the morbid processes. Undoubtedly, some 
cases do recover, but everything probably depends 
upon the degree of injury and the subsidence of the 
compression. The prognosis in those cases in 
which the cord is crushed and its whole substance 
destroyed is, if treated medically, absolutely hope- 
less. Such cases either die at once, or drag out a 
miserable existence through a few months and die 
of exhaustion from bedsores or secondary kidney- 
changes set up by the almost inevitable cystitis. 
All we can do is to nourish the patient, to keep 14 
the bladder washed out, and to minimize as far as 
possible the evil effect of the bedsores, which nearly 
always occur, in spite of the most scrupulous care, 
and which, in most cases, must be regarded as 
trophic lesions. Such being the gloomy outlook in 
the medical treatment of these cases, we naturally 
turn to surgery. 
It is out of place in this paper to discuss this part 
of the subject, but a few considerations as to the 
class of cases suitable for operation may be per- 
mitted. There is hardly any question about the 
propriety of operating when we have cases in which 
there are marked signs of compression, without evi- 
dence of total destruction of the cord. The main 
points to be regarded in making the differential 
diagnosis between partial and total destruction of 
the cord have already been considered. A consid- 
erable number of cases successfully operated upon 
attest the correctness of this position. If the com- 
pressing agency be removed early, the cord may 
recover in great part, but if operation is long de- 
layed, secondary degeneration is likely to set in 
and interference to be rendered useless. 
In those cases in which there is total destruction 
of the cord, most neurologists advise strongly against 
any operation as useless. It has always seemed to 
me that, in view of the fact that these cases practi- 
cally always prove fatal under medical treatment, 
we should not advise against what would seem to be 
a natural surgical procedure. We have broken 
bone, crushing and compressing the cord, and the 
most natural thing would be to clear away the debris 
and give a chance to whatever bit of cord there 15 
might be left uninjured. Observations in a num- 
ber of autopsies of cases that presented all the 
symptoms of complete crush of the cord have con- 
vinced me that it is rare to see the cord entirely 
destroyed by the traumatism, and in a considerable 
proportion of these cases there was distinct evi- 
dence that part of the damage was due to second- 
ary inflammatory processes. Operative procedure 
offers not merely the best chance, but in nearly all 
of these cases the only chance, and if properly car- 
ried out does not materially add to the gravity of the 
prognosis, even if it accomplishes nothing. Abbe’s 
brilliant work upon the cord, while as yet rather 
barren of results, is full of suggestion. As has been 
already noted, an operation, to be of any avail, must 
be done early. We should allow only time enough 
to make it certain that the symptoms are not due to 
shock or temporary interference with function. I 
know of no class of cases that more strongly appeal to 
me than these cases of injury to the cord, for I always 
feel instinctively that something ought to be done 
for them, and I am confident that the surgery of the 
future will make this possible. The Medical News. 
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