Sacral cyst, showing defect in sacrum. (Warren Museum.)
Every tumor of this general character and in this location should be removed as early as possible unless it can be determined that it is not only cystic but dangerously large. Of even these, however, it may be said that to leave them is to expose the patient to more danger of infection than is incurred during a legitimate surgical operation. There should be, then, about such a case serious complications and perplexities, which would tend to make a competent surgeon decline to operate ([Fig. 412]).
SPRAIN OF THE SPINAL COLUMN.
Concussion of the Spine; Railroad Spine; Litigation Spine.
—In 1866 Erichsen published a series of lectures dealing with “Certain obscure injuries of the nervous system commonly met with as the result of shock received in collisions on railways.” In 1875 he expanded these lectures into his celebrated monograph on Concussion of the Spine, a work which served first to arouse the greatest interest in a hitherto neglected subject, and which has unfortunately served in later years as a basis for many a damage suit. The injuries described by him may occur as the result of railway accidents, hence the name often applied to the condition which they cause—railway spine. Cynical observers have noted the frequency with which these cases appear in court and have stigmatized the condition with the name litigation spine. Erichsen’s original work is now superseded by much better monographs, although his clinical descriptions were full and complete. Nevertheless he had no knowledge of minute changes in the nervous system and many of his explanations were based upon theories then prevalent but now abandoned.
These injuries involve the spine as a whole, and the spinal column is so firmly held together by powerful ligaments, and so abundantly protected by muscular and aponeurotic coverings, that its contents are exempt from injuries which would easily involve those of more exposed joints. An injury which would cause serious disintegration within the spinal cord must be so severe as to inflict other and well-marked damage upon the surrounding structures. Consequently a large part of the injury received consists in what may well be called strain and wrenching of all of these component structures. These may be accompanied by minute hemorrhages into the cord, with or without laceration, while exudates may result therefrom which may press upon the spinal nerve roots or cause adhesions within or without their sheaths, all of which may lead to signs and symptoms which may persist for a long time. But the theory to which too many have held in time past, that a mere concussion of these parts, without other injuries, can be followed by such extensive and durable lesions is not tenable.
Obviously these cases are of a character frequently to appear in court. Unfortunately the signs and symptoms are so vague, so variable, and the latter so subjective that opportunity is afforded for deception, opportunity of which both dishonest patients and dishonest lawyers too frequently avail themselves; this to an extent which has almost brought the condition into disrepute among the better class of practitioners and caused it to be in some sense neglected. That serious lesions do follow injuries to the back is undeniable; that many of the resulting conditions can be simulated is unfortunately too true.
Nervous demoralization and more or less chronic invalidism frequently follow these injuries, producing symptoms which are mainly functional and maybe grouped among the traumatic neuroses. These symptoms are mostly ill-defined, often contradictory, and accompanied by very few objective features.
If malingering can be excluded the best way to regard these clinical pictures is to consider them as indicating a traumatic neurosis—that is, a nervous disturbance, with perversion rather than abolition of function, comparable with similar conditions from other causes. As Angell has said, its symptomatology is largely built up of the emotional features, with such grotesque nervous disturbances as to be quite inconsistent with any true organic malady. In the latter there will always be definite indications with positive changes and normal reactions, while each segment of the spinal cord will have its own definite features. Quite the reverse is the case in a so-called railway spine, where paralyses are incomplete, where loss of sensibility fails to correspond with anatomical relations, where the reflexes are contradictory and the complaints out of all proportion to the injury received. Such a condition is, therefore, a psychosis or neurosis rather than a somatic disease. (Angell.) As a mental perversion it is often dependent upon the dominating influence of an imperative conception, which may or may not have an honest basis. Even if a patient be not tempted to malinger or simulate, his troubles may be exaggerated by expectant attention, which of itself has nothing to do with the injury, but rather with his mental attitude. This is a predominant feature of those cases which go to trial, and while it may persist after a settlement is reached, it should be admitted that the morbid condition usually subsides when litigation is terminated.
These imperative conceptions are intensified by emotion, fear, sympathy, or anxiety, while attention becomes more and more self-centred, the condition finally terminating in a more or less self-induced hypnotic state—a species of autosuggestion. Similar cases of non-traumatic origin are frequently observed, which are then called neurasthenia or hysteria. When in an individual already neurasthenic injury occurs it almost invariably produces exaggerated symptoms. To use Angell’s own expression: “Railway spine is a convenient and picturesque term which hypnotizes juries, even as shock has hypnotized patients. It is dramatic, but not accurate. The damage is not to the spine nor to the spinal cord, but to the mind. It is a psychical disorder, not a physical one, although it has a physical expression in its symptomatology.”