The Relation of CdncnssidW^flfeBi^ and Spinal Cord to Inflammatory and Other Morbid Conditions of These Organs. BV B. A. WATSON,^A.M., M.D., CONSULTING SURGEON TO THE BAYONNE HOSPITAL, SURGEON TO JERSEY CltY HOSPITAL, ETC. Read in the Section of Surgery and Anatomy, at the Forty-second Annual Meeting of the American Medical Association, held at Washington, D. C., May, 1891. Reprinted from "The Journal of the American Medical Association," July 18, 1891. CHICAGO : Printed at the Office of the Association 1891. THE RELATION OF CONCUSSION OF THE BRAIN AND SPINAL CORD TO IN- FLAMMATORY AND OTHER MORBID CONDITIONS IN THESE ORGANS. BY B. A. WATSON, A.M., M.D., CONSULTING SURGEON TO THE BAYONNE HOSPITAL, SURGEON TO JERSEY CITY HOSPITAL, ETC. It is certainly apparent to all the members of the medical profession that brain and spinal sur- gery has received during the last quarter of this century an unusual and likewise unprecedented amount of attention. It is likewise equally ap- parent that great progress has been made by those who are devoted to this branch of surgery; it therefore becomes highly necessary, that he, who is about to enter this field of medical litera- ture, should first discover some dark spot or dis- puted question, on which he thinks he may pos- sibly throw a few rays of scientific light. The traumatisms of the brain and its membranes have been more fully studied than those of the spinal cord. Undoubtedly this may be accounted for in 2 part by the fact, that the first mentioned organ is much more frequently the seat of these lesions than the latter. I shall therefore direct the greater portion of my attention especially to lesions following traumatic injuries of the spinal cord and its membranes. It seems necessary to call attention to certain errors as a preliminary to the consideration of our first inquiry. One of the most important of these has been expressed by Mr. Erichsen in the following language:1 " 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 observ- ant practitioners." Since the above statement was made it has been clearly demonstrated to be erroneous by anatomical and experimental investigations. The anatomical studies have shown that the spinal cord is the best protec- ted organ in the body, and experimentation has fully confirmed this position. The experi- ments which I made on dogs-the total number being 141-which were arranged and conducted for the especial purpose of producing concussive lesion in the spinal cord and its membranes fully convinced me that it required a very severe blow, 1 On Concussion of the Spine. A New and Revised Edition. London: Longmans, Green & Co. 1882. 3 which must even be delivered on certain limited areas of the body, in order to accomplish this ob- ject. I am likewise satisfied that this conclusion must necessarily follow a careful study of my re- port entitled "An Experimental Study of Lesions Arising from Severe Concussions.''2 It should be furthermore stated that the lesions produced in the spinal cord and its membranes were rarely apparent to the unaided eye, but were readily revealed under the microscope. This statement, however, does not apply to those cases in which there were either fractures or dis- locations involving the vertebrae; since the le- sions here were comparatively coarse. The statement that a rupture of the spinal membranes has occurred, or that there has been a gross haemorrhage into the substance of the spinal cord, or between the cord and its mem- branes, is certainly not entitled to credence un- less coupled with the acknowledgment of either a fracture or a dislocation of a vertebra. This statement is based on my examination of the le- sions found in the spinal cord, and its membranes, and I am so thoroughly convinced on this point, that I feel fully warranted in making this posi- tive statement. The so-called "railway spine'' includes true concussion arising from blows, falls, gunshot wounds, lightning strokes, electric shocks, etc., likewise contusions on the back, sudden flexions of the spinal column, sprains, 2 P. Blakiston, Son & Co., Philadelphia, 1890. 4 wrenches, and twists. Dr. John A. Udell says, in discussing the consecutive effects of some of these injuries, that:3 "Among the remote effects of sprains, wrenches and twists of the spinal col- umn, are chronic inflammation of the vertebral ioints that are implicated, which is, often sup- purative in character, destruction of the articular cartilages and the intervertebral substances that are involved, and caries or necrosis of the adjoin- ing vertebral bodies." In such cases, the destruc- tive process begins more frequently at the junc- tion of the vertebrae with the intervertebral sub- stances than in the intervertebral substances or vertebrae themselves, because, as Mr. Hilton has pointed out, we know that in accidents, at least as far as we have been able to discover, "the most frequent lesion in injury to the spine is a partial severance of the vertebrae from the intervertebral substance. ' ' A number of illustrative examples have al- ready been presented, and inasmuch as this topic has already been pretty thoroughly discussed, no apparent need exists for presenting any addition- al instances of the same sort. I will, however, take space to present a very instructive case, in which there simultaneously occurred lumbo sa- cral abscess and suppurative spinal meningitis, in consequence of a blow on the spinal column. The following abstract made from the report of the history of this case supplies the essential 3 International Encyclopaedia of Surgery, Vol. IV, p. 870 et seq. Edited by John Ashhurst, Jr., M.D., Win. Wood & Co., New York. 1-884. 5 points: A healthy lad, of 15 years, was struck by his playmate on the back with the fist. He thought little of it at the time, but was admitted to Guy's hospital nine days afterwards; was treated with leeches and somewhat recovered, but the pain soon returned and fever ensued. "An abscess formed on the right side of the sacrum, which was opened, and continued to discharge, the flow of pus being increased by pressure on the abdomen. He continued to get worse daily, having much irritative fever and severe pain in the back. During the last week of his life he was exceedingly restless, and often delirious; and he complained of pain in all parts of his body, but particularly in the extremities. On one or two occasions he had loss of power over the bladder and rectum, but had no other symptoms of para- plegia, and could move freely in bed.'' He died twenty-two days after the casualty. Autopsy.-An aperture in the integuments at the right side of the sacrum led into a very ex- tensive abscess, external to the peritoneum, which occupied the forepart of the sacrum behind the rectum, and external to the ilia on both sides behind the psoas muscles. The bones were ex- posed but not diseased. Although the abscess had discharged externally on the right, it was most extensive on the left. It had burrowed up to the left side of the last lumbar vertebra and the sacro-vertebral foramen into the spinal canal. When the theca was opened, it was found to con- tain a quantity of greenish pus, spread over its. 6 inner surface and over the cord itself. The spi- nal dura mater (theca) at the point indicated, was softened and destroyed, and the cauda equina was lying bathed in pus which filled the sacral canal. The membranes of the cord were inflamed throughout the whole extent, and there was pur- ulent effusion as high as the dorsal region. The spinal dura mater was thickened, and its inner surface had lost its smoothness and transparency, and was of a dull green color. Pus could be squeezed out from beneath the visceral arachnoid in considerable quantity. The spinal cord itself was firm, and the microscope revealed no morbid condition in its substance. On opening the cran- ium, traces of acute arachnitis were found over the whole surface of the brain, greenish-colored lymph being effused into the sub-arachnoid tissue, especially at the base. The inner surface of the dura mater, around the foramen magnum and on the adjacent part of the occipital fossa, was of a greenish color, from lymph effused upon it. Bronchial tubes filled with tenacious mucus. Lumbar and bronchial glands slightly enlarged. All other organs entirely healthy. The purulent infiltration of the spinal menin- ges which was observed in this case, occurring coincidently with the formation of a lumbar-sa- cral abscess, but without the production of paral- ysis, could scarcely have happened unless the :sacro-vertebral articulation had previously been opened, both externally and internally, by dis- ease of the articulation itself, in such a manner 7 as to allow the products of inflammatory action to flow freely out of it, as well as into the spinal canal. Otherwise the suppurative meningitis would pretty certainly have caused paralysis by compressing the spinal cord with its inflammatory products. The clinical history of this lad's case, inter- preted by the post-mortem appearances, appears to have been as follows: The blow on the back wrenched the sacro-vertebral articulation, and caused a suppurative inflammation to be lighted up therein, particularly on the left side; and in consequence of this, purulent matter escaped in an outward direction, and led to the formation of an immense lumbo-sacral abscess; it likewise es- caped in an inward direction, and caused the theca vertebralis to become softened and perfor- ated, and extensively destroyed, and a diffuse suppurative inflammation, which extended up- ward to the brain, to be kindled in the spinal arachnoid. ft has been aptly said that " in all science error precedes the truth, and it is better it should be first than last." 4 I have cited the case reported by Dr. Tidell, with all its details, in order that I might bring forward some of the results of my observations, made during my recent experi- ments, which afford a correct and rational expla- nation of the conditions revealed by that post- mortem examination. There will be found in 4 Walpole. 8 the report of my experiments eleven cases in which there was rupture of the ligaments of the sacro lumbar articulation. There were marked pathological changes in the organs and tissues within the pelvic and abdominal cavities in six of these cases, which were immediately connected with the rupture of the ligaments of the sacro- lumbar articulation. Let me here present the following abstracts from post-mortem examina- tions, for the purpose of giving a correct idea of the lesions:5 "Autopsy. This examination re- vealed a rupture of the ligaments between the last lumbar and the first sacral vertebrae, deep and extensive ecchymoses over the entire post- sacral and right lumbar regions. A profuse ex- travasation of blood into the abdominal cavity, marked engorgement of the kidneys. Brain ap- parently normal, slight increase of the cerebro- spinal fluid in the cavities, and the cord was con- gested, to the middle of the dorsal region.'' " Autopsy.6 This examination revealed the following lesions: Both kidneys congested ; the chymosis in the connective tissue covering the anterior surface of the last lumbar and the upper sacral vertebrae. The brain and spinal cord ap- parently hyperaemic. The removal of the integ- ument over the sacral and lumbar regions showed an ecchymotic condition of the muscles. There S An Experimental Study of Lesions Arising from Severe Con- cussions," by B. A. Watson, A.M., M.D., p. 32, Exp. 4. 6 lb., p. 35, Exp. 10. 9 had been a rupture of ligaments between the last lumbar and upper sacral vertebrae." "Autopsy.7 This examination revealed the following lesions : Both kidneys congested; blad- der distended with urine; extensive ecchymoses in the lumbar and pelvic regions, involving psoas muscles; brain perfectly normal. The spinal cord was hyperaemic downward from the lumbar en- largement, including a portion of the cauda equina; rupture of the ligaments between the last lumbar and the firs| sacral vertebrae." The essen- tial point whieh Dr. Lidell has overlooked in his comments on the case which he has reported, are the pathological conditions of the organs and tissues within the pelvic and abdominal cavities. It was the existance of these lesions ■which gave rise to the inflammation and suppziration within these cavities. The post-mortem examination of Dr. Didell's case sufficiently demonstrates this position. Dr. Lidell says:8" the blow on the back wrenched the sacro-vertebral articulation, and caused a suppurative inflammation to be started up there." The autopsy in the case fails to show that there is any erosion of the bones or cartilage within this articulation, and its history reveals the fact, that it was only immediately be- fore death that there was the slightest indication of paraplegia. It is therefore certain that the wrench which he mentions consisted in produc- ing a rupture of the ligaments of the sacro-lum- 7 lb., page 40, Exp. 24. 8 Previously cited. 10 bar articulation, and likewise, as very frequently happens in those cases, some pathological lesions within the pelvic and abdominal cavities. The simple wrenching of any joint in a healthy sub- ject unattended with pathological lesions, has been amply shown to be a comparatively trivial injury, which does not lead to serious inflamma- tory complications or death. The one hundred and forty-one experiments, which I made on animals, does not afford a sin- gle example which justifies *the conclusion that* injuries to the vertebral articulations are a whit more serious than those produced in the carpal and tarsal.articulations; and, consequently, anal- agous reasonings may be here employed with entire propriety. We cannot pass over the his- tory of Dr. Ljdell's case without pointing out a glaring absurdity, which may possibly have had its origin in carelessness. In this report we are informed that a healthy boy, aged fifteen, "while playing with another lad, received a blow on the back with the fist,'' and in the absence of any additional statement bearing on this injury, we are left to infer that the pathological changes and even the death of the patient were caused by this blow. He who has examined the anatomical structure of the spinal column will readily perceive the absurdity of this statement. The blow inflicted was entirely inadequate for the production of the results which followed, unless there has been omitted from this report the most important factor in the history of this case. It is 11 true the force of the blow might cause the lad to fall-and if at this point, the history of the case showed that the boy fell across a bar, raised a few feet from the ground, in such a manner that his feet remained on one side while his head was on the other, then the very important factor of leverage having been added, which would result under these circumstances in the production of a sudden flexion of the spinal column, would cer- tainly bring within the limits of possibility the occurrence of the injuries which are reported in the autopsy. It is scarcely necessary to mention the fact, that nearly all the injuries grouped together un- der the unfortunate cognomen of " railway spine" -so far as their remote effects are concerned- take their origin, either directly or indirectly, in inflammatory processes. Consequently the con- sideration of the following queries assume im- portance: i. Do inflammatory and other morbid changes take their origin in traumatic injuries of the spi- nal cord and its membranes as frequently as the writings of Mr. Erichsen imply? 2. Do inflammatory and other morbid changes ever arise from traumatic injuries which are en- tirely uncomplicated by immediate symptoms ? 3. How soon are the inflammatory and other morbid changes developed after the receipt of traumatic injuries in the cord, etc.? In our consideration of the first question it is scarcely necessary to give a negative reply to 12 those who have perused the writings of Mr. Erichsen on this subject; since they have already reached this conclusion. Furthermore, the mere assumption that serious results frequently arise from wholly unimportant injuries is not sustained by clinical observations or experimental investi- gations. However, Mr. Erichsen, in writing of 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 an im- mediate lesion, probably of a molecular charac- ter, is sustained by the spinal cord, and disease of an inflammatory character, or of a disorganizing nature, is developed in it, the inflammatory action eventually creeping up to the membranes of the brain, says that the cases 9 " although necessarily more frequent in railway than other injuries, do occasionally occur as a consequence of ordinary accidents." A perusal of Mr. Erichsen's wri- tings has completely failed to convince me that he has supplied any basis for the support of the opinion advanced in the above statement. In order to demonstrate the correctness of this opinion, which conflicts with the positive knowl- edge we possess on this subject-and which can- not be supported by analogous reasoning-he should clearly establish the following facts, viz.: i. That no disease of the brain or spinal cord ex- isted at the time of the occurrence of the alleged 9On Concussion of the Spine, Nervous Shock, etc., p. 95. New York: Wm. Wood & Co. 1875. 13 accident. 2. That the consecutive inflammation did arise from traumatism, and was uot due in part, or wholly, to a vitiated constitution. This evidence is entirely wanting; and, consequently, we must maintain that Mr. Brichsen's statement should be excluded in cases of medico-legal evidence. We have now devoted our attention to the con- sideration of the material points involved in our first query ; but it would seem proper in this con- nection to give some additional thought to the consecutive results of concussive accidents. Mr. Brichsen says :10 " 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 identical with those dependent on chronic menin- gitis of the cord and sub acute myelitis." The term concussion, as employed in the above quo- tation, evidently refers only to traumatism of the spinal cord and its membranes, but elsewhere the same author in speaking of sprains, twists and wrenches of the spinal column, says,11 " It is im- portant to bear in mind that the vertebral column is more apt to suffer in these strains of the spine than in the other forms of inj ury that we are dis- cussing, and that in serious cases the full force of the mischief appears to be expended in the spine itself independently of its contents, which escape uninjured." The views expressed by Mr. Herbert 10 lb., page 157. 11 lb., page 128. 14 Page on this subject are as follows :12 " Happily there is no doubt of the exceeding rarity of spinal meningitis as an immediate result of localized injury to the vertebral column ; and I know of no case in which meningeal inflammation has been caused by injury of some part of the body remote from the spine." The experimental study of concussion of the spinal cord has satis- fied me on the following points : i. True con- cussion of the spinal cord from blows, falls, lightning strokes, etc., is an exceedingly rare oc- currence. 2. Secondary results, such as inflam- mation, suppuration, etc., very seldom follow the traumatism-owing to the fact-that the punctate haemorrhages, etc., are generally widely diffused in various parts of the spinal cord-while the pathological lesions are so slight as not to supply inflammatory foci. However, the danger aris- ing from a true concussion of the spinal cord produced by gun-shot injuries, the lodgment of a musket or rifle ball in the spinal column, is at- tended with much more danger from consecutive inflammation, etc., than those traumatisms which have been previously mentioned, because of the following peculiarities: i. The pathological lesions are more concentrated-resembling in this respect the ecchymoses arising from a con- centrated contusion. 2. The lodgment of a ball in the soinal column is very liable to give rise to a septic inflammation, pus formation, dis- 12 Railway Injuries, page 21. Philadelphia : P. Blakiston, Son & Co. 1891. 15 eased condition of bone, extension of the inflam- matory products to the spinal membranes, and even the cord itself. It must be universally ad- mitted that gunshot wounds, fractures and dislo- cations involving the spinal column, are very serious traumatisms, frequently producing death immediately, or within a few hours; even when this result does not follow, the danger is very great from the consecutive sequelae. Let us now take up the consideration of the second query: "Do inflammatory and other morbid changes ever arise from traumatic in- juries which are entirely unaccompanied by im- mediate symptoms ?'' The conclusions reached by a careful analysis of the above question, must depend, to some extent, on the interpretation which we give to this query. The fact must be admitted that it is not only possible for a patient to receive, under certain circumstances, severe traumatic injuries, of which he remains a longer or shorter period wholly unconscious, and these occurrences are by no means very rare. I can now recall a number of instances of this character occurring to officers and soldiers during the ex- citement of battle, while I was serving with the army. It also occasionally happens that drunk- enness dulls the sensibilities in certain cases to such an extent as to render the patient oblivious to an injury which he may have received, while the same condition will more or less embarass and sometimes even deceive the surgeon who is attempting to make an examination. These 16 statements possess only an indirect bearing on the question under consideration. The question relates to the immediate existence of symptoms and not to the observance of the same. A critical examination of this question in the same direction indicated in the above sentences, brings us to the following query: ' ' Are results ever produced without causes?" "Do inflam- matory and other morbid changes ever arise from traumatic injuries, which have failed to produce any lesions ?" My experimental studies of the lesions of the cerebro-spinal axis have clearly demonstrated the fact, that pathological changes are occasionally produced in this centre, some of which were even apparent to the unaided eye, while others required the aid of the microscope ; but which were not followed by any symptom in- dicative of these lesions during the life of the animal. The question will now be naturally asked with reference to these cases : Would they not have developed inflammatory changes at a later period? I have not before me the data which would justify me in positively asserting that this result was absolutely impossible; but I can aver that, in all these experiments, one hundred and forty one, there is not a single case which warrants giving an affirmative answer. Surgical observations and analogous reasoning fully sup- port the results obtained by our experimental re- search, not only with reference to the brain and spinal cord, but likewise in other organs of the body. Mr. Brichsen says in his recent work 17 "On Concussion of the Spine:''13 " There is a continuous chain of broken ill health, between the time of the occurrence of the accident and the development of the more serious symptoms. It is this that enables the surgeon to connect the two in the relation of cause and effect. This is not peculiar to railway injuries, but occurs in all cases of progressive paralysis after spinal con- cussion.'' It would appear from this quotation that Mr. Erichsen fully concurs with us in the opinion, that the production of a traumatic pathological lesion is always indicated by im- mediate symptoms, when the degree of injury has been sufficient to entitle it to our considera- tion. Observation has taught us that the exist- ence of a pathological lesion affords insufficient proof that this injury will be followed by inflam- mation or other morbid changes. In fact, every surgeon can recall to mind cases of severe trau- matic injuries of the brain in which there were extensive lacerations or contusion of this organ ; but in which the secondary changes were en- tirely absent or very slight. The same remark may also be made in regard to gross injuries in other parts, since the same general physiological and pathological principles prevail in the cerebro-spinal axis as in the other organs of the body. It is therefore entirely proper to introduce in connection with discus- sions of injuries of the cerebro spinal axis, in i3 A new and Revised Edition London: Longmans, Green & Co., 1882, page 158. 18 many cases, analogous reasoning drawn from studies and observations made in other parts of the body. It must be admitted, as a general rule in surgery, that the more extensive and the more destructive the primary traumatism, the greater will be the danger from secondary dis- organizing processes. Does it not, therefore, seem absurd to attribute to a single punctate haemorrhage, or even a half dozen of these little pathological lesions, the power of exciting a dis- organizing process in a healthy spinal cord which may ultimately produce the death of the patient? Is there a single well authenticated case in w'hich such a result has followed from such a cause ? Let us now proceed to the consideration of our third question, which has a very important bear- ing on medico-legal cases and likewise on the diagnosis and treatment of myelitis arising from syphilitic disease. Mr. Brichsen says:14 "It would appear that surgeons and writers on dis- eases of the nervous system have included four distinct pathological conditions under this one one term, 'concussion of the spine,'viz.: i. A jar or shake of the cord, disordering, to a greater or less degree, its functions without any lesion perceptible to the unaided eye. 2. Compression of the cord slowly produced by the extravasation of blood. 3. Compression of the cord by inflam- matory exudations, serum, lymph, or pus within the spinal canal; and 4, chronic alterations of M On Concussion of the Spine, p. 16. London: Longmans, Green & Co., 1882. 19 the structure of the cord itself as the result of impairment of nutrition consequent on the occur- rence of one or other of the preceding patholog- ical states, but chiefly on the third." We have already paid our respects in full to those subjects included under the headings i and 2, but we have yet to deal with those embraced under headings 3 and 4. There exists no reason to doubt that inflamma- tion, having its origin in the spinal cord or its membranes, may be either acute or sub-acute, or that the former need be developed at an earlier day than the latter. The important question be- fore us for our consideration, however, is how soon do traumatic inflammations arise after the receipt of the traumatism ? This question can not be definitely answered-the answer must necessarily be a mere approximation. Never- theless, I think that observation and experimen- tation fully justify the statement that traumatic inflammation commonly makes its appearance within four days after the receipt of the injury. In support of the above I will here present a series of experiments, which consisted in fractur- ing the right leg of twenty rabbits :15 "This was done without producing a single compound fract- ure. The temperature details were as follows: Average temperature before the fracture, 102.6°; average temperature two hours afterwards, 102.6°; subsequent daily average temperature, first, J5 Amputations and their Complications, p. 525. By B. A. Wat- son, M.D. Philadelphia: P. Blakiston, Son &Co., 1S85. 20 102.6°; second, 102.6°; third, 103.1°; fourth, 103.1°; sixth, 103°; eighth, 103.1°; tenth, 102.8°; twelfth, 103°; fifteenth, 102.8°; seven- teenth, 103.2°; nineteenth, 103°; twenty second, 103°." In the case of the brain and spinal cord, when there is no open wound communication with these organs, the danger of inflammatory action is greatly diminished. Furthermore, the trivial character of lesions produced by concussion, and also the exceeding rarity of this traumatism-ex- cept when it is produced by lightning strokes, electric shocks or gunshot wounds-all combine to impress me with grave doubts in regard to its being followed by inflammation. In fact, there is not sufficient proof to justify the conclusion that any case of traumatic myelitis, or meningo-mye- litis, has ever had its origin from molecular dis- turbances or any pathological lesion which was invisible to the unaided eye in an otherwise healthy spinal cord or its membranes. Let us now briefly examine the history of con- cussion, in order that we may, if possible, dis- cover how these troublesome errors were en- grafted on the profession. The history of con- cussion dates from 1705, when M. Littre pub- lished his famous observations. A prisoner struck his bowed head against the wall of his cell and fell dead. The inspection of the head failed to reveal a contusion, tumor or wound in the scalp, or a fracture of the skull. The cranium was opened, when it was discovered that the 21 brain did not nearly fill the interior of the skull, while the entire brain substance seemed harder to the touch-more compact than usual. This observation has been reported hundreds of times, and it was long claimed that it demonstrated the fact that a violent shaking of the substance of the brain was capable of producing death with- out any appreciable lesion. Permit me here to call attention to the fact that in the report before me there is no evidence to show' that there was any post-mortem examination made of any por- tion of the spinal column, spinal cord or its mem- branes, or other portion of the body, except the head. The autopsy of the head, viewed in the light of modern science, is entirely worthless, while the position in which the head was placed at the moment the injury was inflicted suggests the possibility of a fracture or dislocation in some portion of the cervical region of the spine. It may be well to call attention to the fact that in this case, and all the other cases of concussion reported prior to the middle of the present cen- tury, the microscope was not employed to aid in the discovery of the pathological lesions. Post- mortem examinations were very rarely made even in cases of concussion of the brain, and, consequently, the case reported by M. Littre was accepted as a typical one. M. Littre, at the time he reported this case of so-called concussion of the brain, had become famous in the medical pro- fession and therefore the following may be very properly applied to him: "Great errors seldom 22 originate but with men of great minds."- Petrarch. Mr. Erichsen, in writing on concus- sion of the spine, in 1875, remarks:16 ''There is little opportunity, reason, or excuse for a post- mortem examination of that structure, which is probably the one that is least frequently exam- ined in the dead-house, viz., the spinal cord, as it is the one the correct pathological investiga- tion of which is attended by more difficulties than that of any other organ of the body So rare are post-mortem examinations of these cases that no instance has occurred to me in hos- pital or in private practice in which I could ob- tain one, and with one exception, I can find no record in the transactions of societies or in the periodical literature of the day of any such in- stance. The only case, indeed, 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 was published in the 'Transactions of the Pathological Society,' by Dr. Tockhart Clark. He had been in a railway collision, and without any sign of external in- jury, fracture, dislocation, wound, or bruise, be- gan to manifest the usual nervous symptoms. He gradually became partially paralyzed in the lower extremities, and died three years and a half after the accident." There is no reason to believe 16 Concussion of the Spine, Nervous Shock, etc., p. 177 et seq. New York: Wm. Wood & Co., 1875. 23 that this man died from even the remote effects of the traumatism. The history of this case en- tirely fails to connect the disease from which the patient died with the railway collision. There- fore it may be properly said of those who base an argument on this and all similar cases: "When people once are in the wrong, Bach line they add is much too long; Who fastest walks, but walks astray, Is only farthest from his way.'' -Prior.