arranged for the better. It should be borne in mind, also, that from the
peculiar nature of causation of the injuries, stretcher or wagon
transport for short distances is preferable to the vibratory movements
of a long railway journey. Beyond this the administration of opium, and
in some cases the assumption of the prone position, are both useful in
the recent or possibly progressive stage of haemorrhage.

Lastly, as to active surgical treatment by operation. In no form of
spinal injury is this less often indicated, or less likely to be useful.
It is useless in the cases of severe concussion, contusion, or medullary
haemorrhage which form such a very large proportion of those exhibiting
total tranverse lesion, and equally unsuited to cases of partial lesion
of the same character. Extra-medullary haemorrhage can rarely be
extensive enough to produce signs calling for the mechanical relief of
pressure; the section of the cord cannot be remedied. In one case with
signs of total transverse lesion, in which a laminectomy was performed,
no apparent lesion was discovered, and this would frequently be the
case, since the damage is parenchymatous. The experience was indeed
exactly comparable to that which followed early exposure of the
peripheral nerves.

Only three indications for operation exist. 1. Excessive pain in the
area of the body above the paralysed segment; operation is here of
doubtful practical use, except in so far as it relieves the immediate
sufferings of the patient.

2. An incomplete or recovering lesion, when such is accompanied by
evidence furnished by the position of the wounds, pain, and signs of
irritation of pressure from without, or possibly palpable displacement
of parts of the vertebra, that the spinal canal is encroached upon by
fragments of bone.

3. Retention of the bullet, accompanied by similar signs to those
detailed under 2.

In both the latter cases the aid of the X-rays should be invoked before
resorting to exploration.

Operation, if decided upon, in either of the two latter circumstances,
may be performed at any date up to six weeks; but if pressure be the
actual source of trouble, it is obvious that the more promptly operation
is undertaken the better for early relief and ulterior prognostic
chances.

In only one case of the whole series I observed did it seem possible to
regret the omission of an exploration.

CHAPTER IX

INJURIES TO THE PERIPHERAL NERVE TRUNKS

The