down such positive dicta? Views which were published in 1866, twenty-two years ago, remain according to his own statement in the latest edition, "substantially unchanged" to-day. Within recent years the minute and gross pathology of the spinal cord, has been almost entirely re-written. Intelligent discussion of the structural changes which occur in the cord in disease and injury are impossible without reference to the investigations of Charcot, Brown-Sequard, Gowers and Bramwell. Yet, most of these investigations have been made since the publication of Erichsen's treatise and therefore find no place in his system of pathology. This would not be surprising were it not also true that Erichsen held to substantially the same ideas in his latest writings.

What weight should now attach to expert evidence based only upon inference from clinical experience when diametrically opposite testimony rests on the firm basis of post-mortem and microscopic investigation?

That we may not appear in any particular to misrepresent this writer's opportunities for exact knowledge, we may quote his own words in his latest edition:-"No instance (of postmortem examination) has occurred to me in hospital or in private practice in which I could obtain one. The only case indeed on record with which I am acquainted, in which a postmortem examination has been made in a person who died from the remote effects of concussion of the spine was published by Dr. Lockhart Clark," etc., etc., in 1866.

What is surprising is not so much that these opportunities were wanting, for it is only of late years and in a few hospitals that anything like systematic work has been done in this line, but rather that on such a small basis of known fact so large a structure of inferential pathology has been built, and that it should be stated with the positiveness of well-proven facts and should have carried such weight in the medical world. Even with the same method and from the same observed facts, we find no agreement among those who would dogmatize as to the existence of lesions in preference to discovering them in the dead house and with the microscope. Erichsen has collated a large number of cases from various sources to illustrate cer

tain theories of spinal concussion. Page, on the other hand, pursuing the same clinical method, has drawn largely from the same sources and even from Erichsen's own published cases to support views of a nature directly opposite. Neither writer has utilized modern methods of study, and we are left with the impression that much of this discussion is but threshing old straw, so far as scientific results are concerned. If the conclusions of these older writers are in any measure weakened by being thus at variance, they certainly are still more discredited when it is found that they are at variance with modern ideas. Nevertheless, the old, not modern views still exert a deciding influence in many cases of alleged spinal injury which assume a medico-legal aspect, and many an expert has testified in court substantially to the ideas of a quarter of a century ago, in seeming ignorance of the revolution which cellular pathology has brought about in the last decade.

Erichsen is in accord with later writers in stating that when there have been actual structural changes in the cord, wellmarked symptoms are developed. He loses sight, however, of the additional fact that long continued functional disease produces structural change when he advances his argument in behalf of "railway spine" and claims it is essentially a functional disorder and therefore not accompanied by the usual symptoms following a structural change.

Many months, in the opinion of this writer, may intervene between the time of injury and the beginning of the symptoms of so-called spinal concussion. If, however, the two facts are connected, some functional or structural change must have been going on in the interval. If functional disorder cannot exist except transiently, it follows that the disorder must be or become structural or else cease to exist. But we have seen that structural disease produces definite symptoms and not vague and irregular phenomena. What becomes then of the theories of spinal concussion which, upon the assumed and wholly imaginary pathological state known as "anæmia of the cord," build up a symptomatology equally vague and illusory? In this symptomatology have been included all the mental, psychical and cerebral symptoms which a person who has not

met with an accident may suffer, as well as all the minor ills of each and every part of the body which could by any stretch of reasoning be traced to the nerve centers, and all are declared to have their origin in a condition of the cord which modern pathology knows not or recognizes only as transient.

If it be true that Erichsen's theories of pathology are undermined by the results of more modern investigators, what becomes of the vast superstructure of symptomatology which he has reared thereon? It is essential, if we would be scientific, that we refer only those symptoms to the spine which are known to be spinal. This is now very strongly insisted upon by writers too numerous to quote. No proven facts warrant the belief that mental and psychical disturbances, loss of memory, business inaptitude, depression of spirits and the like, have anything to do with the spinal cord. On the contrary, these are truly cerebral symptoms to the best of our present knowledge, and, as such, can be understood and accounted for on plain pathological grounds. Serious they may be, but they are removed from the realm of the mysterious when we recognize their true origin and we can speak rationally of their prognosis and treatment.

But when these cerebral disturbances are referred to that vague state known as "spinal concussion" they seem to take on new terrors and the patient sees in the diagnosis a dreadful portent of hopeless invalidism or gradual progressive decay. If once he has had Erichsen's picture impressed upon his imagination, he certainly will not lack for material out of which to build a gloomy prognosis. To all intents this writer lays down the opinion that any and every bodily ill may find its explanation in "anæmia of the cord" resulting from "spinal concussion." That this invites not only self-deception but corrupt practices, we fear there can be no doubt and such a state of affairs may well be a cause of alarm. Medical men have good reason to fear a condition of things which tends to discredit scientific medicine and the value of expert evidence. Lawyers have good cause to fear a state of affairs which may impose pseudo-scientific doctrine upon the courts in such a way that it cannot be sifted and analyzed. Honest claimants

are doubly interested in keeping false claims from being allowed to the prejudice of honest ones. Finally, courts themselves have most of all to fear a state of uncertainty in high expert authority which will invite fraud and defeat the end for which courts of justice exist.

Spinal concussion, when used as Erichsen teaches, is a condition built up almost wholly of subjective symptoms. This renders malingering easy. To illustrate, a man who fears his back has been injured in an accident, consults a lawyer as to the liability of the corporation or individual for the occurrence of the accident. The lawyer, and there is a lawyer to every one hundred men in this city, sends the claimant to a physician, and there is a doctor to every one hundred men in this State, who goes over the ground very carefully with the claimant and asks if he suffers from such and such symptoms, and in order that there may be no mistake about it gives the claimant a written statement of the symptoms usually occurring in well-marked cases of spinal concussion without structural lesion. The claimant, even if he be an honest man, after carefully questioning himself, discovers that he has become the possessor of an inaptitude for business, a mental disquietude, a pain in the back, etc., etc. If he be a dishonest man, he studies his chart and has a stock of symptoms on hand when interrogated as to his condition, and in his business it is "no trouble to show goods." We thus see that the way to imposition is made easy. Avenues of fraud are opened up and capital, lawyers and courts are practically at the mercy of a clever malingerer.

The writers of this paper wish to emphasize the importance of careful and not superficial investigation, and do not believe that the dogmatic precision of an old and inferential pathology which conflicts with modern pathological views, should give answer to the questions arising in alleged injury to the spinal cord.

The paper was listened to with attention, and elicited the following discussion:

DISCUSSION.

DR. HENRY M. LYMAN:-I have listened with a great deal of interest to the valuable paper of Drs. Burry and Andrews, and I must subscribe most heartily to the propositions advanced in it. It is, as the Doctor has well said, true that the minds of the profession have for many years been too much under the influence of the dogmas laid down in Erichsen's work on Railway Injuries. I am thoroughly satisfied that a great deal of injustice has been done and carried out through the agency of the courts upon the basis of opinions that have been formuulated in accordance with that book, and I think it is really a very necessary thing to frequently give a word of caution like this to the profession that they avoid falling into the trap which is unwittingly opened before them by such a work. It has been well said that the pathology of the work is old and the inferences drawn from the cases are many of them strained, and yet it must be acknowledged that there is a sufficiency of truth in a good deal that is advanced in it to make the errors that accompany it doubly dangerous. If I were to speak of books in comparison with one another, I should say a book like Page's, while it may be open in many particulars to the charge made against Erichsen's work, of being oldfashioned and representing somewhat bygone pathology, of the two, is far the superior work. It is written in a much more judicial spirit and I think much more fully and really represents the advanced views of the profession in these matters than does Erichsen's work.

My own observation in cases of this kind leads me to feel that a very large proportion of the cases which have been reported and presented in the courts as cases of spinal concussion are really nothing of the kind; they are cases in which, when there is any real lesion, where any real injury has been sustained, it has fallen more largely upon the brain than the cord. Many of the symptoms presented by these patients can be much more accurately described by supposing that the brain is the organ that has suffered. It is in cases of this class that