so many of the numerous and ill-defined symptoms following an injury, occur; patients who suffer with no systematized lesions, with nothing that can be referred to any disorganization proper of the spinal cord, no true paraplegia or hemiplegia; the lesions are those largely of an irregular distribution where the phenomena are largely mental, and possibly, in many cases, intellectual; and we must refer them chiefly to the brain rather than to the spinal cord. It is true of a great many of these cases that the symptoms presented are of this character instead of being symptoms of paralysis either of sensation, motion or nutrition.

We have a large class of cases presenting themselves after these injuries, to which the most convenient term we can apply is hysterical-hysterical conditions following injuries. These occur in males as well as in females. We perhaps have more right to expect the existence of hysteria in females who have suffered injury, but in many cases of males who have suffered injuries they are followed by hysteria, which can only be ascribed to a disorder of the cerebrum. In regard to these socalled hysterical symptoms-how far are they to be allowed weight in judging of the liability of a railroad? For example, in the case of an injury that has been sustained, the courts will hold that it matters not what the form of the disorder is, so long as there is a disorder, for the disorder is the consequence of the injury that has been sustained and the party inflicting the injury is liable for it. There is a certain amount of truth in that proposition; it must be taken into consideration that disorders of this kind are most intensely prone to exaggeration. as a consequence of the peculiar conditions which surround patients who have undergone the experience passed through by victims of a railroad accident. The injuries are of a nature to disturb the mental functions of the individual, and the anxieties that grow up, partly through the agency of physicians, and partly through the uneasiness attendant upon lawsuits connected with the railroad company, or parties implicated in the accident, lead to, disturbances of the mind to a great extent, and we should take those things into consideration in our estimate of the probabilities of recovery.

It is a matter of common observation that when patients have been injured in this way and manifest these mental or intellectual symptoms, conjoined with a certain amount of vital innutrition and disorder, when the mental perturbation is removed, there is a great improvement in the symptoms; so that the settlement of a claim against a railroad company is followed by rapid improvement in the condition of the patient. That is a fact which is often laid hold of by a certain class of physicians and surgeons and used as an argument against the genuineness of the conditions experienced by the patient. They say it was a matter of imagination, of self-deception, and sometimes go so far as to claim a form of malingering by the patient. But if you reflect upon the relation which exists between the mind and body, it is easy to understand how a person who is in anxiety of mind will suffer in an aggravated degree bodily symptoms and will improve again on relief from anxiety.

Many of these patients are permanently injured, though they have not received any injuries that are enduring from a surgical point of view. There have been no fractures, perhaps; no permanent strains or sprains or dislocations; no wounds anywhere, no depressions of the cranium, or anything of that kind. Many of these cases, therefore, when they have passed out of the immediate care of the surgeon, are considered cured, and surgically speaking they are cured; but we must remember that a case may be cured surgically, and yet not be cured medically, and therefore a certain class of patients must be recognized as never recovering fully from these injuries; they recover surgically and to a certain degree medically; as in cases of inflammation of the spinal cord, when a patient is suffering from myelitis we get recovery to a certain degree, in the majority of cases, but rarely a complete recovery.

The patients get to walking about with more or less comfort, but never recover the power of locomotion they once had; they have not the power of endurance they once had, and in every respect they are weaker and inferior in their condition to what they were before the injury was sustained. That is something that should be recognized and kept in mind, there

fore, that the opinions of physicians and surgeons who are called to examine these cases for injury, should be guarded. I do not know that there is any class of cases in which it is more improper to give a positive prognosis than in cases of severe injury. The probabilities are in favor of partial recovery, that the recovery will be progressive; and yet in every instance the possibility exists that the recovery will be arrested short of complete restoration; and it is impossible, so far as my knowledge extends, to judge in any particular case whether it is going to be a case that is completely curable, or whether it will come to a stand-still before recovery has been completed. There is a class of cases in which the difficulty is principally mental, and those cases may recover completely, I think; and yet it is not possible for the physician to predict positively in those cases, at an early period, that they are going to be of that curable character. And yet, where there is no palpable lesiou, no evidence of disorganization of the brain or spinal cord, where the female sex is present, especially in the person of comparative youth, and where there is the possibility of complete change of life and occupation coming in to assist, the prospects of recovery are good.

I remember a case related to me by Dr. Wood, of Philadelphia, where a young woman had sustained an injury in a railroad accident. She had been examined by numerous physicians who had all given an unfavorable prognosis; not less than ten neurologists assuring her she would never recover. That woman came under the care of Dr. Wood, and he assured her there was nothing but hysteria the matter. He put her upon a course of treatment, and finally she engaged in a love match which terminated in marriage, and she was completely cured. I think there is nothing so good as something to absorb the attention of the patient, and turn the current of thought entire. ly from one's self and maladies, into another channel; it is the very best influence towards the restoration of health to the mind, and in many of these cases it is a mental disorder that exists. I do not wish to take up the time of the society, but would call attention to the fact that there is a class of people who are in such a state of mental instability, that it needs

only an excess or injury of some kind to start them upon a course of mental disorder which will have, we know not what termination. In patients of that class, injured by railroad disaster, followed by opinions of men in high standing, and by long litigation, nothing is better calculated to set up a state of ill health, the termination of which can never be predicted.

DR. L. L. MCARTHUR:-The advances which have been made in the line of nervous diseases, and the advance in the pathology of the spinal cord, have enabled the neurologists to clear up many of the nervous diseases which were classed under the head of spinal concussion. Spinal concussion can be limited to concussion; as in the brain, and yet in concussion of the brain we always expect the symptoms to manifest themselves at or very soon after the injury. But in the class of cases which come under the head of spinal concussion-identically similar in their nature, that is, believed to be without any actual structural lesion of the spinal cord are cases claimed to occur weeks or months afterward. Hence, I feel inclined to ask the gentleman who closes the discussion, if we have any symptoms which we may rely on as confirming, or being diagnostic of, spinal concussion? If he can in any way enlighten us so as to distinguish those cases in our diagnosis from other troubles of the spinal cord, or if the neurologist has some means of arriving at a positive conclusion, some characteristic symptom which like vertigo, calls our attention to the ear or cerebellum, or the peculiar gait of locomotor ataxia? There seems to be nothing definite conveyed, by the term spinal concussion. Other names have been suggested, rather than this term which covers up ignorance; and comotio-spi-` nalis might be applied. We know that concussion of the spine is not shock. Moreover, as advances are made in medicine the list of functional diseases are disappearing. Formerly it was satisfactory to make a diagnosis of a case as paralysis; but the diagnosis paralysis being insufficient, has become obsolete. In the same way the functional diseases are, as advances are made, disappearing. We cannot expect to have phenomena take place of a physiological or pathological nature without some textural change; especially if these phenomena per

sist, and are constantly making themselves evident. Temporarily we might have a functional derangement of the cord in which some symptoms were manifested; but as for weeks, months and years, as in the case of Dr. Phillips, it is unreasonable, in the light of our pathological literature, to expect it without some structural changes.

DR. J. G. KIERNAN:-I did not hear the paper and am not therefore very well prepared to discuss it. With regard to one point raised by Dr. McArthur, I shall have to take issue; first as to the textural question. It seems to me perfectly possible that for a long time there may be very marked symptoms without textural lesions. Cases have been under observation in which no lesion was found and yet in which the symptoms were well marked. I was much pleased to hear Dr. Lyman refer to the fact that many cases could be considered rather as cerebral than as spinal cases. The fact is lost sight of that when the patient recovers from cerebral concussion, he passes out of the surgeon's hands. When I was connected with the institution on Ward's Island, I remember distinctly four cases of supposed recovery from cerebral concussion in which the patients died in two or three years, under my charge in the insane hospital; they did not recover from cerebral concussion. I think if cerebral concussion was as frequently made a matter of litigation and as frequently examined as spinal concussion, a great many more cases might be developed. A large number of the recoveries drift into the insane and poor hospitals and die there.

In regard to the point raised by Dr. Lyman, particularly with respect to the cases classified as mental disorder; the fact that many of these make good recoveries is signally shown in a case of Page's that I have always been suspicious of. Page relates the case of a woman, which he decided, after careful examination, was one entitled to pretty heavy damages; she was incurable, and yet she recovered, married, had children and lived a happy life thereafter. But unfortunately very often those cases do not have such a fortunate outcome. Dr. McElvaine of Peoria, at a meeting of railway surgeons, reported a case in which a woman rallied from the effects of an