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 Don Harris
Wen-Chin Li (Eds.)

Engineering Psychology
LNAI 12187

and Cognitive Ergonomics

Cognition and Design
17th International Conference, EPCE 2020
Held as Part of the 22nd HCI International Conference, HCII 2020
Copenhagen, Denmark, July 19–24, 2020, Proceedings, Part II

123
Lecture Notes in Artificial Intelligence 12187

Subseries of Lecture Notes in Computer Science

Series Editors
Randy Goebel
University of Alberta, Edmonton, Canada
Yuzuru Tanaka
Hokkaido University, Sapporo, Japan
Wolfgang Wahlster
DFKI and Saarland University, Saarbrücken, Germany

Founding Editor
Jörg Siekmann
DFKI and Saarland University, Saarbrücken, Germany
More information about this series at http://www.springer.com/series/1244
Don Harris Wen-Chin Li (Eds.)
•

Engineering Psychology
and Cognitive Ergonomics
Cognition and Design
17th International Conference, EPCE 2020
Held as Part of the 22nd HCI International Conference, HCII 2020
Copenhagen, Denmark, July 19–24, 2020
Proceedings, Part II

123
Editors
Don Harris Wen-Chin Li
Coventry University Cranfield University
Coventry, UK Cranfield, UK

ISSN 0302-9743 ISSN 1611-3349 (electronic)

Lecture Notes in Artificial Intelligence
ISBN 978-3-030-49182-6 ISBN 978-3-030-49183-3 (eBook)
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 Foreword

The 22nd International Conference on Human-Computer Interaction, HCI International

2020 (HCII 2020), was planned to be held at the AC Bella Sky Hotel and Bella Center,
Copenhagen, Denmark, during July 19–24, 2020. Due to the COVID-19 coronavirus
pandemic and the resolution of the Danish government not to allow events larger than
500 people to be hosted until September 1, 2020, HCII 2020 had to be held virtually. It
incorporated the 21 thematic areas and affiliated conferences listed on the following
page.
A total of 6,326 individuals from academia, research institutes, industry, and gov-
ernmental agencies from 97 countries submitted contributions, and 1,439 papers and
238 posters were included in the conference proceedings. These contributions address
the latest research and development efforts and highlight the human aspects of design
and use of computing systems. The contributions thoroughly cover the entire field of
human-computer interaction, addressing major advances in knowledge and effective
use of computers in a variety of application areas. The volumes constituting the full set
of the conference proceedings are listed in the following pages.
The HCI International (HCII) conference also offers the option of “late-breaking
work” which applies both for papers and posters and the corresponding volume(s)
of the proceedings will be published just after the conference. Full papers will be
included in the “HCII 2020 - Late Breaking Papers” volume of the proceedings to be
published in the Springer LNCS series, while poster extended abstracts will be included
as short papers in the “HCII 2020 - Late Breaking Posters” volume to be published in
the Springer CCIS series.
I would like to thank the program board chairs and the members of the program
boards of all thematic areas and affiliated conferences for their contribution to the
highest scientific quality and the overall success of the HCI International 2020
conference.
This conference would not have been possible without the continuous and unwa-
vering support and advice of the founder, Conference General Chair Emeritus and
Conference Scientific Advisor Prof. Gavriel Salvendy. For his outstanding efforts,
I would like to express my appreciation to the communications chair and editor of
HCI International News, Dr. Abbas Moallem.

July 2020 Constantine Stephanidis

 HCI International 2020 Thematic Areas
and Affiliated Conferences

Thematic areas:
• HCI 2020: Human-Computer Interaction
• HIMI 2020: Human Interface and the Management of Information
Affiliated conferences:
• EPCE: 17th International Conference on Engineering Psychology and Cognitive
Ergonomics
• UAHCI: 14th International Conference on Universal Access in Human-Computer
Interaction
• VAMR: 12th International Conference on Virtual, Augmented and Mixed Reality
• CCD: 12th International Conference on Cross-Cultural Design
• SCSM: 12th International Conference on Social Computing and Social Media
• AC: 14th International Conference on Augmented Cognition
• DHM: 11th International Conference on Digital Human Modeling and Applications
in Health, Safety, Ergonomics and Risk Management
• DUXU: 9th International Conference on Design, User Experience and Usability
• DAPI: 8th International Conference on Distributed, Ambient and Pervasive
Interactions
• HCIBGO: 7th International Conference on HCI in Business, Government and
Organizations
• LCT: 7th International Conference on Learning and Collaboration Technologies
• ITAP: 6th International Conference on Human Aspects of IT for the Aged
Population
• HCI-CPT: Second International Conference on HCI for Cybersecurity, Privacy and
Trust
• HCI-Games: Second International Conference on HCI in Games
• MobiTAS: Second International Conference on HCI in Mobility, Transport and
Automotive Systems
• AIS: Second International Conference on Adaptive Instructional Systems
• C&C: 8th International Conference on Culture and Computing
• MOBILE: First International Conference on Design, Operation and Evaluation of
Mobile Communications
• AI-HCI: First International Conference on Artificial Intelligence in HCI
 Conference Proceedings Volumes Full List

1. LNCS 12181, Human-Computer Interaction: Design and User Experience (Part I),
edited by Masaaki Kurosu
2. LNCS 12182, Human-Computer Interaction: Multimodal and Natural Interaction
(Part II), edited by Masaaki Kurosu
3. LNCS 12183, Human-Computer Interaction: Human Values and Quality of Life
(Part III), edited by Masaaki Kurosu
4. LNCS 12184, Human Interface and the Management of Information: Designing
Information (Part I), edited by Sakae Yamamoto and Hirohiko Mori
5. LNCS 12185, Human Interface and the Management of Information: Interacting
with Information (Part II), edited by Sakae Yamamoto and Hirohiko Mori
6. LNAI 12186, Engineering Psychology and Cognitive Ergonomics: Mental
Workload, Human Physiology, and Human Energy (Part I), edited by Don Harris
and Wen-Chin Li
7. LNAI 12187, Engineering Psychology and Cognitive Ergonomics: Cognition and
Design (Part II), edited by Don Harris and Wen-Chin Li
8. LNCS 12188, Universal Access in Human-Computer Interaction: Design
Approaches and Supporting Technologies (Part I), edited by Margherita Antona
and Constantine Stephanidis
9. LNCS 12189, Universal Access in Human-Computer Interaction: Applications and
Practice (Part II), edited by Margherita Antona and Constantine Stephanidis
10. LNCS 12190, Virtual, Augmented and Mixed Reality: Design and Interaction
(Part I), edited by Jessie Y. C. Chen and Gino Fragomeni
11. LNCS 12191, Virtual, Augmented and Mixed Reality: Industrial and Everyday
Life Applications (Part II), edited by Jessie Y. C. Chen and Gino Fragomeni
12. LNCS 12192, Cross-Cultural Design: User Experience of Products, Services, and
Intelligent Environments (Part I), edited by P. L. Patrick Rau
13. LNCS 12193, Cross-Cultural Design: Applications in Health, Learning,
Communication, and Creativity (Part II), edited by P. L. Patrick Rau
14. LNCS 12194, Social Computing and Social Media: Design, Ethics, User Behavior,
and Social Network Analysis (Part I), edited by Gabriele Meiselwitz
15. LNCS 12195, Social Computing and Social Media: Participation, User Experience,
Consumer Experience, and Applications of Social Computing (Part II), edited by
Gabriele Meiselwitz
16. LNAI 12196, Augmented Cognition: Theoretical and Technological Approaches
(Part I), edited by Dylan D. Schmorrow and Cali M. Fidopiastis
17. LNAI 12197, Augmented Cognition: Human Cognition and Behaviour (Part II),
edited by Dylan D. Schmorrow and Cali M. Fidopiastis
x Conference Proceedings Volumes Full List

18. LNCS 12198, Digital Human Modeling and Applications in Health, Safety,
Ergonomics and Risk Management: Posture, Motion and Health (Part I), edited
by Vincent G. Duffy
19. LNCS 12199, Digital Human Modeling and Applications in Health, Safety,
Ergonomics and Risk Management: Human Communication, Organization and
Work (Part II), edited by Vincent G. Duffy
20. LNCS 12200, Design, User Experience, and Usability: Interaction Design (Part I),
edited by Aaron Marcus and Elizabeth Rosenzweig
21. LNCS 12201, Design, User Experience, and Usability: Design for Contemporary
Interactive Environments (Part II), edited by Aaron Marcus and Elizabeth
Rosenzweig
22. LNCS 12202, Design, User Experience, and Usability: Case Studies in Public and
Personal Interactive Systems (Part III), edited by Aaron Marcus and Elizabeth
Rosenzweig
23. LNCS 12203, Distributed, Ambient and Pervasive Interactions, edited by Norbert
Streitz and Shin’ichi Konomi
24. LNCS 12204, HCI in Business, Government and Organizations, edited by Fiona
Fui-Hoon Nah and Keng Siau
25. LNCS 12205, Learning and Collaboration Technologies: Designing, Developing
and Deploying Learning Experiences (Part I), edited by Panayiotis Zaphiris and
Andri Ioannou
26. LNCS 12206, Learning and Collaboration Technologies: Human and Technology
Ecosystems (Part II), edited by Panayiotis Zaphiris and Andri Ioannou
27. LNCS 12207, Human Aspects of IT for the Aged Population: Technologies,
Design and User Experience (Part I), edited by Qin Gao and Jia Zhou
28. LNCS 12208, Human Aspects of IT for the Aged Population: Healthy and Active
Aging (Part II), edited by Qin Gao and Jia Zhou
29. LNCS 12209, Human Aspects of IT for the Aged Population: Technology and
Society (Part III), edited by Qin Gao and Jia Zhou
30. LNCS 12210, HCI for Cybersecurity, Privacy and Trust, edited by Abbas Moallem
31. LNCS 12211, HCI in Games, edited by Xiaowen Fang
32. LNCS 12212, HCI in Mobility, Transport and Automotive Systems: Automated
Driving and In-Vehicle Experience Design (Part I), edited by Heidi Krömker
33. LNCS 12213, HCI in Mobility, Transport and Automotive Systems: Driving
Behavior, Urban and Smart Mobility (Part II), edited by Heidi Krömker
34. LNCS 12214, Adaptive Instructional Systems, edited by Robert A. Sottilare and
Jessica Schwarz
35. LNCS 12215, Culture and Computing, edited by Matthias Rauterberg
36. LNCS 12216, Design, Operation and Evaluation of Mobile Communications,
edited by Gavriel Salvendy and June Wei
37. LNCS 12217, Artificial Intelligence in HCI, edited by Helmut Degen and Lauren
Reinerman-Jones
 Conference Proceedings Volumes Full List xi

38. CCIS 1224, HCI International 2020 Posters - Part I, edited by Constantine
Stephanidis and Margherita Antona
39. CCIS 1225, HCI International 2020 Posters - Part II, edited by Constantine
Stephanidis and Margherita Antona
40. CCIS 1226, HCI International 2020 Posters - Part III, edited by Constantine
Stephanidis and Margherita Antona

http://2020.hci.international/proceedings
17th International Conference on Engineering Psychology
and Cognitive Ergonomics (EPCE 2020)

Program Board Chairs: Don Harris, Coventry University, UK,

and Wen-Chin Li, Cranfield University, UK

• Shan Fu, China • Lothar Meyer, Sweden

• Crystal Ioannou, UAE • Ling Rothrock, USA
• Peter Kearney, Ireland • Axel Schulte, Germany
• Peng Liu, China • Lei Wang, China
• Heikki Mansikka, Finland • Jingyu Zhang, China

The full list with the Program Board Chairs and the members of the Program Boards of
all thematic areas and affiliated conferences is available online at:

http://www.hci.international/board-members-2020.php
 HCI International 2021
The 23rd International Conference on Human-Computer Interaction, HCI International
2021 (HCII 2021), will be held jointly with the affiliated conferences in
Washington DC, USA, at the Washington Hilton Hotel, July 24–29, 2021. It will
cover a broad spectrum of themes related to Human-Computer Interaction (HCI),
including theoretical issues, methods, tools, processes, and case studies in HCI design,
as well as novel interaction techniques, interfaces, and applications. The proceedings
will be published by Springer. More information will be available on the conference
website: http://2021.hci.international/.

General Chair
Prof. Constantine Stephanidis
University of Crete and ICS-FORTH
Heraklion, Crete, Greece
Email: general_chair@hcii2021.org

http://2021.hci.international/
 Contents – Part II

Cognition and Design of Complex and Safety Critical Systems

Measuring Situation Awareness in Control Room Teams . . . . . . . . . . . . . . . 3

Carolina Barzantny and Carmen Bruder

Exploring the Effects of Large Screen Overview Displays

in a Nuclear Control Room Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Alexandra Fernandes, Alf Ove Braseth, Robert McDonald,
and Maren Eitrheim

Operator Actions Outside the Control Room: A Field Study . . . . . . . . . . . . . 30

Alexandra Fernandes, Rossella Bisio, and Claire Blackett

Promoting Operational Readiness Through Procedures in Nuclear Domain . . . 42

Jari Laarni, Jatta Tomminen, Marja Liinasuo, Satu Pakarinen,
and Kristian Lukander

Research on BIM and Mobile Equipment in Substation Construction

Schedule Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Rui Liu and Fan Liu

Modeling Distributed Situational Awareness to Improve Handling

Emergency Calls in Operation Centres . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Marcel Saager and Marie-Christin Harre

Multidimensional Risk Dynamics Modeling on Operator Errors

of Nuclear Power Plant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Guanyin Wu, Yi Lu, Ming Jia, Zhen Wang, Caifang Peng, Yanyu Lu,
and Shan Fu

Using IDHEAS to Analyze Incident Reports in Nuclear Power Plant

Commissioning: A Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Zijian Yin, Zhaopeng Liu, Dongfang Yang, and Zhizhong Li

Cognitive-Based Severe Accident Information System Development

in a Human Factors Project . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Zheng Zhi, Qiuyu Wang, Haitao Lian, Yufan Wang, Fei Song,
and Shuhui Zhang
xviii Contents – Part II

Human Factors in Human Autonomy Teaming

and Intelligent Systems

Mixed-Initiative Human-Automated Agents Teaming:

Towards a Flexible Cooperation Framework . . . . . . . . . . . . . . . . . . . . . . . . 117
Caroline P. C. Chanel, Raphaëlle N. Roy, Nicolas Drougard,
and Frédéric Dehais

A Framework for Human-Autonomy Team Research. . . . . . . . . . . . . . . . . . 134

Nancy Cooke, Mustafa Demir, and Lixiao Huang

Safety Challenges of AI in Autonomous Systems Design – Solutions

from Human Factors Perspective Emphasizing AI Awareness . . . . . . . . . . . . 147
Hannu Karvonen, Eetu Heikkilä, and Mikael Wahlström

Human-Autonomy Teaming and Explainable AI Capabilities

in RTS Games . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
Crisrael Lucero, Christianne Izumigawa, Kurt Frederiksen, Lena Nans,
Rebecca Iden, and Douglas S. Lange

Rationality, Cognitive Bias, and Artificial Intelligence:

A Structural Perspective on Quantum Cognitive Science . . . . . . . . . . . . . . . 172
Yoshihiro Maruyama

A Concept on the Shared Use of Unmanned Assets by Multiple Users

in a Manned-Unmanned-Teaming Application . . . . . . . . . . . . . . . . . . . . . . 189
Gunar Roth and Axel Schulte

Allocation of Moral Decision-Making in Human-Agent Teams:

A Pattern Approach. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
Jasper van der Waa, Jurriaan van Diggelen,
Luciano Cavalcante Siebert, Mark Neerincx, and Catholijn Jonker

The Cueing Effect in Retrieval of Expertise: Designing for Future

Intelligent Knowledge Management System . . . . . . . . . . . . . . . . . . . . . . . . 221
Liang Zhang, Xiaoqin Li, Ting Xiong, Xiaoyue Pang, and Jingyu Zhang

The Effect of Group Membership, System Reliability and Anthropomorphic

Appearance on User’s Trust in Intelligent Decision Support System . . . . . . . 231
Xiangying Zou, Chunhui Lv, and Jingyu Zhang

Cognitive Psychology in Aviation and Automotive

Assessing Professional Cultural Differences Between Airline Pilots

and Air Traffic Controllers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
Wesley Tsz-Kin Chan and Wen-Chin Li
 Contents – Part II xix

Comparison of Pedestrians’ Gap Acceptance Behavior Towards Automated

and Human-Driven Vehicles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
Wenxiang Chen, Qianni Jiang, Xiangling Zhuang, and Guojie Ma

An Eye Catcher in the ATC Domain: Influence of Multiple Remote Tower

Operations on Distribution of Eye Movements . . . . . . . . . . . . . . . . . . . . . . 262
Maik Friedrich, Anneke Hamann, and Jörn Jakobi

Effects of Mental Workload and Risk Perception on Pilots’ Safety

Performance in Adverse Weather Contexts . . . . . . . . . . . . . . . . . . . . . . . . . 278
Shan Gao and Lei Wang

An Object Distance Detection Method for Driving

Performance Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
Yang Gao, Zhen Wang, and Shan Fu

Understanding Human Behaviour in Flight Operation

Using Eye-Tracking Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304
Wojciech Tomasz Korek, Arthur Mendez, Hafiz Ul Asad, Wen-Chin Li,
and Mudassir Lone

Research on Eye Ellipse of Chinese Drivers . . . . . . . . . . . . . . . . . . . . . . . . 321

Ding Li, Ding Yi, and Shi Huijuan

Evaluating Pilot’s Perceived Workload on Interacting with Augmented

Reality Device in Flight Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 332
Wen-Chin Li, Zepu Yan, Jingyi Zhang, Graham Braithwaite,
Samuel Court, Mudassir Lone, and Bikram Thapa

Human-in-the-Loop Evaluation of a Manned-Unmanned System Approach

to Derive Operational Requirements for Military Air Missions . . . . . . . . . . . 341
Sebastian Lindner and Axel Schulte

Establishment of National Safety Performance Evaluation

Indicator System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357
Min Luo, Yijie Sun, and Yanqiu Chen

The Application of Safety II in Commercial Aviation – The Operational

Learning Review (OLR). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368
Pete McCarthy

Spatial Knowledge Acquisition for Cognitive Maps

in Autonomous Vehicles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 384
Yue Qin and Hassan A. Karimi
xx Contents – Part II

Good Boy Here or Bad Boy Far Away? Effects of Digital Nudging
on Booking Decisions in Car Sharing . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398
Tim Schrills, Mourad Zoubir, Jacob Stahl, Katharina Drozniak,
and Thomas Franke

Experimental Validation of an Eye-Tracking-Based Computational Method

for Continuous Situation Awareness Assessment in an Aircraft Cockpit . . . . . 412
Simon Schwerd and Axel Schulte

Investigating the Effect of Conflicting Goals and Transparency on Trust

and Collaboration in Multi-team Systems . . . . . . . . . . . . . . . . . . . . . . . . . . 426
Verena Vogelpohl, Carmen Bruder, Jana Schadow,
and Dirk Schulze Kissing

Usability Evaluation of Car Cockpit Based on Multiple

Objective Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441
Chuanxiang Wei, Zhen Wang, and Shan Fu

Design and Research of Civil Aircraft Flap/Flap Control Lever

Based on Ergonomics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 454
Fang Zhang, Xianchao Ma, Yinbo Zhang, and Ruijie Fan

Author Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 463

10 C. Barzantny and C. Bruder

Fig. 4. Simplified illustration of the link between the three measures of situation awareness.
* p < .05, ** p < .01.

3.2 High Vs. Low Performers

Participants were split post-hoc into two groups, high and low performers, based on
their total number of detected failures using a median split (Mdn = 4.4). Two groups
were created, one with 26 high performers and the other with 26 low performers. High
performers detected a significantly higher number of failures than low performers
(U = 0, z = −6.40, p = < .001) and their mean response time was significantly lower
than that of low performers, t(49) = 2.39, p < .05 (Fig. 5). In order to test whether high
and low performers differed with regard to their eye movement data, a one-way
multivariate analysis of variance (MANOVA) was conducted. A statistically significant
MANOVA effect was obtained, Wilks-k = .63, F(10,41) = 2.44, p < .05, partial
η2 = .37. High performers had a higher relative fixation count and higher relative gaze
duration than low performers in the last three monitoring phases [verification, antici-
pation, detection] and a lower time to first fixation in the last phase [detection]. In terms
of their overall communication quality, high performers (Mdn = 3.25, n = 24) did not
significantly differ from low performers (Mdn = 2.75, n = 25), U = 207, z = −1.88,
p > .05.
 Measuring Situation Awareness in Control Room Teams 11

Failures detected (n) Response Time (s)

5.38

3.27

2.35
2.00

High Performers Low Performers

Fig. 5. Descriptive performance results of high and low performers.

3.3 Performance and Communication Over Time

In addition to linking the different measures and comparing them for the two groups of
high and low performers, consideration was also given to the development of perfor-
mance measures and communication quality over time. Figures 6 show the descriptive
results. A Cochran’s Q test determined a statistically significant difference over time in
the proportion of participants who detected a deviation successfully, p < .001. This
applied both to high and low performers, p < .001. Pairwise comparisons using
continuity-corrected McNemar’s tests with Bonferroni correction revealed that sig-
nificantly more high performers detected failures two to six than failure one, p < .01.
Correspondingly, it was shown that low performers detected failures three to six sig-
nificantly more often than failures one and two (p < .001). High and low performers
differed significantly in their mean response times as determined by independent-
samples t-tests when detecting failure three, t(42) = 3.28, p < .01, and five, t
(40) = 2.55, p < .05. In terms of the communication quality of individual participants,
statistically significant deviations were displayed between the six items (Friedman test:
v2(5) = 15.15, p = .01, n = 47). This applied to low performers, v2(5) = 20.48,
p = .001, n = 23, but not to high performers, v2(5) = 0.10, p > .05, n = 24. Post-hoc
analysis of low performers revealed a statistically significant difference between items
two and five, z = −3.63, p < .01, as well as two and six, z = −3.00, p < .05, as item
two had the lowest communication quality, whereas five and six had the highest. Mann-
Whitney U tests revealed that high and low performers differed significantly with
regard to item two, U = 187, z = −2.24, p < .05 and four, U = 198, z = 2.28, p < .05.
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Ulcerative endocarditis, infectious osteomyelitis, pulmonary
gangrene, general pyæmia, and, as is claimed by a few authors,
typhoid fever, are often accompanied by multiple abscesses in the
brain-substance. Usually the foci are small, as may be readily
inferred from the fact that they are of embolic origin, the emboli being
usually so small as to lodge in very small vessels, and that the
fatality of the primary disease is so great as to cut short life before
the abscess can reach larger dimensions. For the same reasons the
symptoms they produce are rarely distinctive. In chronic lung
affections accompanied by putrescence in bronchiectatic or other
cavities cerebral abscesses are not uncommon occurrences. Under
these circumstances, although we must assume an embolic origin,
the abscess is rarely multiple, and the symptoms are as marked as
in the ordinary varieties. Thus a patient suffering from chronic
phthisis, with or without prodromal malaise or somnolence,
experiences formications and pain in his right leg; he then notices a
slight halt in walking; twitches appear in the affected extremity; it
becomes distinctly paretic. The arm then becomes affected in like
manner; the pupils become unequal; a severe chill occurs, followed
by delirium, convulsions, coma, and death.

DIAGNOSIS.—There is little difficulty in recognizing the existence of a

cerebral abscess in which well-marked focal and constitutional
symptoms coincide, or where a distinct abscess-producing cause,
such as an ear trouble, a head injury, or a putrid bronchiectasis,
coexists.59 But there are a number of cases, varying from the latent
form to forms with obscure general symptoms, whose recognition is
impossible or at best a matter of conjecture. Such cases may be
readily confounded with certain tumors. The existence of febrile
symptoms, although not excluding tumor, as some tumors are
accompanied by such, is greatly in favor of abscess. On the other
hand, choked disc, which is rare with abscess and found only with
the very largest, is in favor of tumor.
59 Yet a leading and careful authority was misled into making the diagnosis of
abscess in a case of ear disease complicated by a cerebral tumor.
PROGNOSIS AND TREATMENT.—The majority of cerebral abscesses
must, from the nature of the case, be regarded as not influenceable
by medicinal measures or surgical treatment. The miliary and other
abscesses due to general septic causes or to mycotic invasion,
being in the nature of the case but features of intrinsically dangerous
or fatal primary diseases, do not call for special measures. It is
different with those due to local trouble about the head and to
surgical causes. Remarkable advances have been made in the
operative treatment of cerebral abscesses, chiefly owing to the
increasing accuracy of the localization of the affected areas through
the disturbance of their function, and to the perfection of surgical
methods. A number of cases by Gussenbauer, Wernicke, and others
have shown that some abscesses may be accurately located during
life by the focal symptoms produced by their presence. Wernicke's
observation of a large abscess in the occipital lobe showed two
facts. First, it permitted the study of the effect of large abscesses on
the cerebral movements, as it was found after trephining that the
pulsation movement of the brain was lost and the dura tensely
bulging, thus indicating a high degree of cerebral pressure.
Secondly, the operation showed that an abscess can be emptied of
its contents, under moderate aseptic precautions, without provoking
contiguous inflammatory reaction or infecting the meninges.
Notwithstanding these favorable local conditions, the patient died.
Gussenbauer60 was more fortunate. He surmised from the fluctuation
of some symptoms and the predominance of others that his patient
had an abscess in the frontal lobe. The suspicion was verified: an
abscess of the size of an apple was found, opened, and emptied of
its contents. The patient recovered without any immediate untoward
symptom.61
60 Prager medizinische Wochenschrift, 1885, Nos. 1, 2, and 3.

61 Epileptic and focal spasms subsequently developed, which shows that a new
inflammatory or other destructive process may have set in in the vicinity of the
emptied sac.
The uncertainties of localization in some districts of the brain are so
great that a number of attempts to repeat the explorations and
aspiration of Wernicke and Gussenbauer have failed. In one case
recently operated on in New York City the aspirating-needle was run
into the brain-substance in several different directions without
striking the pus. It is a question under such circumstances whether
the chances of an abscess becoming latent, minimal though they be
in cases with pronounced signs, are not to be preferred to those
which an uncertain operation can give. The superficial encephalitic
foci offer far better opportunities for surgical triumphs. Here not only
the symptoms are much more constant, and point more unerringly to
the site of the morbid spot, but there are often other signs, such as
the evidences of impaction of a foreign body, local tenderness on
percussion, or bone disease, which aid in determining the proper
spot for the application of the trephine. Several operations where
traumatic encephalitis existed with or without leptomeningitis of the
convexity, followed by complete recovery, were performed by
Macewen.62
62 The Lancet, 1885, vol. i. p. 881.

The medicinal treatment of abscess of the brain is limited to

derivative methods, whose aim is the relief of pressure—an aim
whose fulfilment is more frequently illusory than otherwise.

Benefit has been claimed from the energetic use of mercury, chiefly
in the form of calomel, by older writers; and recently Handfield Jones
has endorsed its administration, attributing to it a remission in a case
in which it was employed. It must be remembered, however, that
remissions occur spontaneously in this disease, and that the
purgative action of calomel may act well for the time being in an
affection so apt to be associated with hyperæmia and increased
cerebral pressure as is an abscess of the brain.63 In the nature of the
case, even this latter momentarily beneficial effect is at the best
temporary.
63 Brain, October, 1884, p. 398.
The prophylaxis of cerebral abscess can be carried out only in cases
due to cranial and aural affections. The importance of treating all
scalp and cranial injuries under aseptic64 precautions is recognized
by all surgeons. It is generally admitted that the trephining of a bone
suspected to be the site of an ostitic or necrotic process involves
fewer risks than the allowing it to remain. Similar principles govern
the treatment of the inflammatory involvement of the mastoid cells
often complicating otitis media. If trephined at all, these should be
trephined at the earliest moment. It was a belief among the older
aurists that the sudden cessation of an aural discharge was of evil
augury, and that cerebral complications were more apt to follow
under such circumstances than when the ear discharged freely. Von
Tröltsch, Politzer, Gruber, and Toynbee have opposed the exclusive
application of the old dogma. In so far as the older ear-surgeons
regarded a profuse aural discharge as an encouraging sign, in this
respect they were of course wrong. But their observation of the
frequent concurrence of cerebral sequelæ with suppression of
discharge is, I think, borne out by a large number of cases. It does
not apply, however, to the suppression of discharge by the rational
employment of aseptic injections.
64 This term is used in its widest sense here.

Spinal Hyperæmia.

The spinal cord is found to vary considerably in color in different

individuals. To some extent this difference is influenced by the
position occupied by the body after death, but not as markedly as in
the case of the brain. Thus it will be paler in a body which has been
kept in the prone than in one which has been kept in the supine
position.65 It is usually found more injected in persons who have died
of febrile affection than in those who have died of exhausting
diseases; notably is this the case with typhus fever and with subjects
who die with congestive malarial chill. But the most intense
congestion, where the gray substance instead of having the normal
rosy hue appears like a blood-soaked sponge, and the white
substance instead of the tint to which it owes its name has a pink
shade, is found in subjects dying in convulsive disorders complicated
by asphyxia, such as epileptic status, tetanus, and certain toxic
disorders.
65 I have not seen it noticed anywhere, but it is a fact readily demonstrable in any
autopsy made in a well-preserved body that when a short segment of cord is
observed at the moment of section the section surface appears pale; but if it be again
examined after a few moments, it will show a reddish tinge, marked as a faint injection
would be; this tinge distinctly deepens under the eye. I have observed this in
specimens which were not held in the hand, so that the influence of pressure can be
excluded. Nor do I believe that the elasticity of the tissues is such as to account for
the phenomenon.

In attempting to apply the fact that varying degrees of vascular

injection are found on post-mortem examinations of the spinal cord
to the elucidation of certain clinical phenomena, we encounter the
same difficulties and sources of error that confronted us in the study
of nutritive brain disorders. The majority of writers have therefore
contented themselves with making a careful clinical study of the
mostly subjective signs of disorders which, once designated as
spinal anæmia and hyperæmia, are now classified under the non-
committal titles of spinal irritation and exhaustion (neurasthenia), as
in this volume. A number of these disorders, like the so-called
anæmic paralysis of Bouchut, Leroy d'Etiolles, Beroliet, Baimer, and
Brandis, would to-day be considered as hysterical or reflex; and a
few of the instances cited by their contemporaries as cases of spinal
hyperæmia have been since demonstrated to resemble the initial
phases of organic diseases of the cord.

The causes of active spinal hyperæmia are either direct, as when the
spinal centres are overtasked by muscular strain either through over-
exertion or through toxic convulsions, surprised by violent shocks,
such as concussion accidents, or collateral, as when a physiological
discharge (menstruation) or a pathological one (hemorrhoidal flux) is
suddenly checked. A few cases are reported where carbonic-oxide-
gas poisoning provoked spinal hyperæmia. But, like the alleged
cases of spinal hyperæmia after continued and exanthematic fevers,
they were probably cases of incipient or established myelitis.
Hammond claims that surface chilling exerts the same congesting
influence on the cord which he claims for the brain; but no definite
observations have been made in this direction.

Passive spinal hyperæmia has been attributed to obstructive cardiac

and chronic pulmonary affections. In such cases, as with most
causes acting on the circulation of blood in the nerve-centres, the
coexisting cerebral congestion usually masks the spinal. It is a
question how far the intense hyperæmia of the cord found in some
cases of tetanus, strychnia-poisoning, and the condition called
hydrophobia66 is primary and an indication of neural hyperexcitability,
and how far it is secondary to the asphyxia attending the last phases
of these convulsive states. The weight of opinion is in favor of an
acceptation of the latter as the chief or only factor.
66 In a case of hydrophobia clinically as well marked as has been recorded, which I
had the privilege of examining through the courtesy of Kretschmar, both brain and
cord were found remarkably anæmic.

Over-exertion and sexual excesses are frequently followed by a

sensation of fulness and tension in the sacral and lumbar regions,
which may be relieved by lying prone, while it is aggravated while
lying supine.67 From the location of this pain it is evident that it is not
due to congestion of the cord or its membranes, but to fulness of the
vertebral and spinal veins of the lower segment of the vertebral
column. A similar sensation, which may be relieved by the same
change in position or by a hemorrhoidal flux, is complained of by
patients suffering from portal obstruction. The veritable symptoms of
hyperæmia manifest themselves in the parts which receive their
nervous supply from the affected districts. The reflexes are usually
more active; paræsthesias of different kinds, such as formication,
tingling, and creeping sensations, are common; and there is more or
less motor weakness, the limbs feeling heavy and sometimes being
the seat of an acute pain. As a rule, these symptoms are limited to
the lower half of the body.
67 Although this fact has been questioned, I have no doubt whatever that it is true,
from a large number of observations. In many subjects suffering from the results of
excessive venery or masturbation, an intolerable, sometimes pulsating, feeling in the
lumbo-sacral region is only relieved by raising the lower end of the trunk with the back
up. This condition is influenced by a change of residence to a district having a
different level above the sea, and consequently a different barometric condition.

There is very little question when these symptoms exist for any
length of time, and become aggravated, that more subtle nutritive
changes than are covered by the single term hyperæmia become
responsible for them. In a pure hyperæmia the position-test of
Brown-Séquard, which shows relief when the patient is upright or
prone and aggravation when he is supine, particularly if the
gravitation of blood to the cord be facilitated by raising the head and
extremities, ought to yield constant results. But in some cases,
particularly those of long-standing, the very opposite is noted: the
patient's symptoms are aggravated by standing or sitting up, and
relieved by lying down. Here there is probably exhaustion or
malnutrition of the nerve-elements, rendering them abnormally
sensitive to exertion. This view is supported by the fact that
molecular disturbances, such as those which probably accompany
simple concussion, predispose the patient to the development of the
symptoms of spinal hyperæmia, and aggravate them if established
previous to such accident.

Hammond,68 who in his chapter on Spinal Congestion and Anæmia

follows rather the older authors, such as Ollivier, than the newer and
either more cautious or more sceptical writers on the subject,
describes the symptoms of congestion as comprising belt
sensations, paraplegia, erections of the penis, muscular twitches,
loss of expulsive power, and incontinence of the bladder, paralysis of
the abdominal muscles, paralysis of the anal sphincter, loss or
abolition of reflex excitability, diminution of electro-muscular
contractility, and occasionally hyperæsthesia and shooting pains. It is
not doubtful for a moment that if such a case were to occur in
hospital experience it would be regarded as one of organic disease,
and not incipient, but well-established organic disease of the cord.
Those making the diagnosis would have their opinion strengthened
if, as Hammond states, the process took place with great rapidity
and had a tendency to extend itself and eventually involve the whole
cord, or if, as Brown-Séquard is by him cited as stating, bed-sores
occurred in addition. Although Hammond describes certain
anatomical changes, such as increased development of blood-
vessels and distension and injection of them, I am unable to find any
cases recorded as spinal congestion during life, and carefully
examined with a due regard to sources of error after death, in which
such changes were found. It is true that after strychnine- and
cocaine-poisoning an intense hyperæmia69 of the cord is found. In
mammals it is of a far more pronounced character than in reptiles,
and usually more marked in proportion to the existing asphyxia. That
the characteristic toxic effects of these drugs is not to be sought for
in their direct or indirect congesting influence is shown by the fact
that exsanguinated frogs can be made to undergo strychnine tetanus
when their blood is replaced by a saline solution according to the
method of Salkowski. Little support, therefore, could be derived from
a pretended analogy between toxic and pathological hyperæmias,
even if the phenomena of both were similar; which is not the case.
68 Diseases of the Nervous System, 7th ed., p. 392.

69 It is true that in animals which are so organized that the congestion cannot be
attributed to asphyxia, as I showed (Hammond Prize Essay of the American
Neurological Association, 1878) in some experiments on strychnine, arterial
congestion and small foci of hemorrhage were found in the upper cervical cord of
frogs who had been kept in continuous strychnine tetanus for over seventy days.

The introduction of subaqueous caissons for workmen engaged in

the building of bridges, in which those employed labor under
abnormal atmospheric pressure, has led to the development of a
previously-unknown cerebro-spinal affection known as the caisson
disease, and in which, it is generally supposed, either congestion or
hemorrhage of the spinal cord occurs in consequence of sudden
changes of vascular pressure resulting from sudden diminution of
the barometric pressure. Clinically, this affection has been studied in
England, France, and above all in America in connection with the
building of the East River Bridge and the one over the Mississippi at
St. Louis.70 Experiments by Hoppe-Seyler, Bert, and I. Rosenthal
have shown that a sudden diminution of pressure leads to
hemorrhages in various tissues, and, according to the two first-
named, a development of gas occurs in the vascular and other fluids
of the body. A number of peculiar symptoms which do not specially
interest us here occur in conjunction with the so-called caisson
disease: these are—pain in the ear, with or without otitis sicca;
peculiar pains in the joints, which occur on leaving the caisson, and
are probably due to hyperæmia of the joint-surfaces and sudden
increase of the intra-articular fluid; and retardation of the pulse-rate.
In some cases cerebral hyperæmia is added, the patients tottering
about as if drunk. The spinal symptoms consist of a paraplegiform
affection. The paralysis is usually sudden; in some cases the patient
a few minutes after stepping from the air-chamber falls down
perfectly helpless as far as the lower half of the body is concerned.
The expulsive power of the bladder is usually weakened, and there
is anæsthesia to all forms of sensation in the affected limbs, as well
as diminished electro-cutaneous sensibility. The patient often
complains of a strange feeling, as if the lower half of his body were a
foreign substance. With this the electro-muscular reactions are
normal. In the majority of cases these symptoms disappear entirely
in from three to ten days, but occasionally they remain longer;
imperfect recovery of motion and sensation occurs, or, as happened
in a few cases, one of which was carefully examined during life by
Lehwess and after death by Leyden, death occurs as in myelitis. In
the only case where an autopsy and careful microscopical
examination were made under these circumstances71 peculiar
fissures were found in the substance of the spinal cord, surrounded
by areas of reactive myelitis and filled with granule-cells. The
absence of any pigmentary relics of a hemorrhage induced Leyden
to assume that the lacunæ were not of hemorrhagic origin. He
inclines to the view that they were due to the escape of gas from the
blood-plasma, and consequent multilocular inflation of the tissue. If
his observation be confirmed, it constitutes a strong objection to the
hyperæmia theory of the caisson disease. There is neither
permanent hyperæmia nor congestive or hemorrhagic myelitis
developed, as far as the limited material thus far studied permits a
conclusion.
70 Clark, St. Louis Med. and Surg. Journ., cited from Hammond, loc. cit.

71 E. Leyden, Archiv für Psychiatrie, ix. p. 316.

Pure spinal hyperæmia rarely presents itself for treatment. The form
due to over-exertion is recovered from by rest in a very short time;
that due to suppressed discharges, by the re-establishment of the
latter or by the application of leeches to the lumbo-sacral and iliac
region. Ergotin is recommended by Hammond in very large doses. It
is a question whether this drug may not exert a bad effect in
protracted cases where its use has to be continued for a long time.72
In using it, it is well to bear in mind that imperfect nutrition of nerve-
elements is perfectly compatible with an increased blood-amount.
72 A young physician, who for a long period took ergotin in twelve-grain doses for the
relief of symptoms regarded as congestive, acquired a tolerance of the drug such as I
have not seen recorded anywhere, and in addition presents some obscure signs of
cerebellar disease and initial optic-nerve atrophy.

Strychnia has been given with benefit in the caisson disease—

another evidence, as this drug is theoretically contraindicated in true
hyperæmia, that this disease is not, as Hammond and the majority of
authors with him regard it, essentially a congestive affection. The
treatment of those numerous cases in which signs of venous fulness
accompany spinal exhaustion and irritation is detailed in the articles
dealing with those affections.

Spinal Anæmia.
Anæmia of the cord-substance proper, like hyperæmia, is practically
inseparable from the corresponding condition of the membranes.
The influence of a reduced blood-amount on the functional activity of
the spinal cord is more susceptible of exact demonstration than the
corresponding nutritive disturbance of the brain. As the functions of
this segment of the nervous axis are far simpler than those of the
higher organ, there is more unanimity among observers as to the
interpretation of their disordered states. In Stenon's experiment, and
the more elaborate modifications made by those who have followed
his method, it is found that interference with the supply of arterial
blood to the spinal cord is followed by abolition of the function of the
gray matter; if the supply be still further diminished, the functions of
the white tracts become eliminated; next the peripheral nerves, and
ultimately the muscles themselves, lose their normal excitability. On
the re-establishment of the circulation these various parts regain
their functional capacity in the inverse order of its suspension—the
muscles first, next the nerves, then the white substance, and last the
gray substance of the cord. The initial symptoms of some cases of
myelitis from refrigeration correspond more nearly to such a result of
artificial anæmia of the cord than they do to anything that is
customarily regarded as hyperæmia.73
73 I have seen distinct pallor of the spinal meninges on dipping the posterior
extremities of a dog, whose cord had been exposed, into water. It is to be remarked,
however, that other observers, notably Hammond, have either obtained different
results or interpreted the consequences of refrigeration differently.

No one has gone farther than Hammond in erecting a theoretical

anatomical framework which elaborately provides for the
accommodation of various symptoms of spinal anæmia. He
describes anæmia of the posterior columns, and sharply
discriminates between it and anæmia of the antero-lateral columns.
It is a question whether the conducting tracts of these columns are
seriously affected in their functions by anæmia as long as the
centres of innervation are well nourished. Undoubtedly, it is the gray
substance of the cord which is most vulnerable to the influence of
disturbed circulation and nutrition, as Stenon's experiment has
shown; and a glance at the distribution of the blood-vessels will show
that a partial anæmia or hyperæmia, limited to special cornua in any
considerable length of the cord, is an exceedingly improbable
occurrence. With regard to isolated anæmia of the white columns, it
is to be admitted that the posterior are most vulnerable to
malnutrition. But it is doubtful whether this vulnerability is so great as
to allow of an exclusively posterior anæmia, or whether a protracted
anæmia of this kind could exist for years as a purely symptomatic—
or, as some designate it, functional—disorder.

Hammond candidly states that in specifically locating the lesions in

these affections he is aware that post-mortem examinations are
wanting to support them, and admits that what he calls anæmia of
special parts of the cord is the spinal irritation of most authors, and in
part the reflex paraplegia of others.

The most clearly-established form of cerebral anæmia is the one

which is indicated by the ischæmic paraplegia of Jaccoud and the
paraplegia following profuse hemorrhages. The former is produced
by all causes which, by obstructing the flow of arterial blood in the
abdominal or thoracic aorta, cut off the proper blood-supply to the
cord, which the latter receives through the intercostal and upper
lumbar arteries. Aneurism, compression by tumors, and embolism of
the aorta produce this result. The consequence is paraplegia
corresponding in all features of its development to the phenomena
observed in Stenon's experiment. These features, already detailed,
suffice to show that it is not the anæmia of the peripheral nerves and
muscles that is chiefly responsible for the paraplegia, but the
insufficient irrigation of the gray and white substance of the cord
itself. The same is true of the paraplegia following hemorrhage which
has been noted after uterine, renal, and enteric hemorrhages. Both
affections are exceedingly rare.

The influence of general anæmia on the functions of the spinal cord

is not susceptible of accurate study. The cerebral enlargement of the
nervous axis is so much more unfavorably situated than the cord that
it suffers first and most when general anæmia is present. The
consequence is that the signs of cerebral anæmia mask those of
spinal anæmia. It is supposed, however, by many authorities that the
effect of anæmia on the cord may be regarded as an auxiliary factor
in the production of hysterical and neurasthenic symptoms.

How far the spinal cord is liable to suffer from arterial spasm is as yet
a matter of conjecture. It is supposable that just as a powerful
psychical impression provokes a sudden spasm of the cerebral
arteries, so a peripheral irritation may provoke a spasm of the spinal
arteries. In this way the reflex paralyses, motor and vaso-motor, are
explained by many writers.

The subject of reflex palsy has been so much confused by improper

cataloguing—if it can be so called—that some of the best authorities
have become sceptical as to its occurrence. Among the chief
sources of error has been the attributing to irritation of the genital
organs various convulsive, psychical, and paralytic disorders.
Adherence of the prepuce and its excessive length were charged
with being responsible for idiocy, imbecility, epilepsy, and every form
of paraplegia and panplegia. It was further claimed that instances of
complete cure of each of these affections had followed the removal
of the exuberant or adherent prepuce. I cannot find a single instance
recorded where such a cure was effected in any of our large medical
centres, so as to prove convincing to critical colleagues. On the
contrary, L. C. Gray74 has shown that various surgical procedures
have been needlessly resorted to on this erroneous theory in cases
of organic diseases of the spinal cord. I have seen two unfortunate
children suffering from the worst forms of anterior poliomyelitis, one
afflicted with pseudo-hypertrophic paralysis, and several
hydrocephalous and microcephalous idiots, whose prepuces had
been sacrificed to the theory alluded to—it is needless to add without
any result, good or bad.
74 Reflex Irritation from Genital Irritation. In this paper written communications from all
or nearly all neurologists in the United States—certainly including all those of national
fame and large experience—are cited, in which they testify to never having seen a
 case of this character cured by operations on the penis (Annals of Anatomy and
Surgery, Jan. and Feb., 1882.)

The possibility of a reflex paralysis occurring from genital irritation in

the male cannot be denied; among the lower animals a ligature
around the spermatic cords sometimes produces paraparesis, and
paraplegia is a common complication of renal and vesical troubles in
others. But analogous observations in man are rare, and becoming
rarer with our increasing acumen in diagnosis. In females peculiar
reflex disturbances are found associated with uterine and ovarian
derangements. In one case of retroflexion, with possible dislocation
of the ovary, referred to me by H. J. Boldt, there is a remarkable
vaso-motor paralysis of the right arm during each menstrual period:
this member becomes greatly enlarged, of a purplish-blue color, and
cold. Equally remarkable are the reflex disturbances resulting from
the presence of worms in the intestinal canal. Every form of spinal
and cerebral paralysis, even aphasia, has been observed in
connection with helminthiasis. Such disorders yield as rapidly as
they are developed to the exhibition of vermifuges.

Special interest has been aroused by the discovery laid down in the
joint treatise of J. W. Mitchell, Morehouse, and Keen of reflex
paralysis following injuries, observed in the War of the Rebellion. The
cases cited by them appear singular on first sight. The paralysis is
often observed in parts of the body which are not only remote from
the seat of injury, but have no direct connection, physiologically or
otherwise, with it. The hand may be injured and the opposite leg
paralyzed.

Since Mitchell, Morehouse, and Keen first announced the existence

of this peculiar form of reflex paralysis a careful search has been
made by military surgeons engaged in other campaigns for like
results. Notably was this done in the Franco-Prussian War. A number
of confirmatory instances have been collected, some of which rival in
singularity those related by the discoverers of the affection. In one
case a unilateral paralysis agitans followed a punctured wound of the
opposite shoulder, and in another reflex aphasia followed a gunshot
wound of the lumbar region.75 A discrimination is to be made
between such cases where the paralysis, anæsthesia, or neuralgia is
an immediate result of the injury, and those where they follow after
weeks or months. In the latter instance we have not true reflex
disorders to deal with, an ascending neuritis having been found in
the few cases which could be carefully followed up.76
75 Sanitäts Bericht über die deutschen Heere im Krieg gegen Frankreich, 1870-71,
vol. vii.—abstracted in Neurologisches Centralblatt, 1886, p. 207.

76 In a case of Mollenhauer's, vesical paralysis and paresis of the right leg occurred
six years ago (1880) in a veteran of our civil war who had a gunshot wound of the
right hand, with signs, which are still present, of occasional exacerbation of brachial
neuritis. Prodromal signs of paresis were noticed at intervals since his return from the
campaign. The bladder trouble and paresis are now apparently stationary. Such a
case can be accounted for only on the assumption of an organic cord-change
secondary to a neuritis.

The theory that the reflex paralysis from utero-ovarian, intestinal, and
surgical affections, when acutely produced, is due to central
anæmia, is as acceptable as any other would be in the absence of
decisive observations.

Spinal anæmia will but rarely present itself as a subject for special
and separate treatment. When not associated with an intrinsically
grave condition, such as aortic obstruction, dysentery, fatal
hemorrhage, or typhoid fever, it is an exceedingly benign affection,
rapidly yielding to tonic and restorative measures combined with
rest.

Embolism, Thrombosis, Hemorrhage, and Abscess of the Spinal

Cord.

Although the spinal cord is a segment of the same central organ as

the brain, nourished in a similar way, and subject to the same
physiological and pathological laws, lesions of the vascular
apparatus, which play so important a part in brain pathology, play a
comparatively insignificant one in that of the spinal cord. Embolic,
thrombic, and primary hemorrhagic lesions of the cord are so rare
that their possible existence has even been denied. A primary
thrombosis of the cord has not yet been satisfactorily demonstrated
to occur independently of syphilitic lesions; and when it occurs the
ensuing tissue-changes, as described by Heubner, Julliard, and
Greiff, are usually in the background as compared to the
gummatous, sclerotic, or meningitic changes which coexist. The
clinical as well as the anatomical picture is accordingly either one of
a myelitis or meningitis, as the cases of Charcot-Gombault, Heubner,
McDowell, Wilks, Wagner, Zambaco, Homolle, Winge, Moxon,
Schultze, Westphal, Julliard, and Greiff show. (See Myelitis and
Spinal Meningitis.)

With regard to the occurrence of hemorrhage into the substance of

the spinal cord (hæmato-myelia), it is so rare an occurrence that I
can recall but a single case in which I entertained the diagnosis of
this lesion; and in that very case I am unable to declare that it was
not a hemorrhagic myelitis. Aneurismal changes of the spinal
arteries are comparatively of rare occurrence, and as other
predisposing causes to primary vascular rupture are rare in the cord,
the probability of its occurrence is very much diminished. Hebold,77
in a young girl who had developed severe cerebro-spinal symptoms
during a period of nine months following an erysipelatous disorder,
found the upper dorsal cord, on section, dotted with numerous
reddish and round points. These points corresponded to aneurismal
dilatations of the vessels. As there were other inflammatory and
vascular lesions in the same subject, the author referred their
causation to a general constitutional vice, the result either of the
phlegmonous or of a tuberculous disorder.
77 Archiv für Psychiatrie, xvi. 3. Rupture of miliary and other aneurisms in the
meninges has been reported by Astley Cooper, Traube, and others. It is remarkable
that such cases are more and more rarely recorded from year to year in inverse ratio
to the accuracy of our spinal autopsies. I have never found a miliary aneurism below
 the uppermost cervical level of the cord. On the other hand, I have found extensive
spinal hemorrhage in cases where the vessels of the cord proper were fairly healthy.

It is claimed that suppression of the menses, over-exertion, lifting

heavy weights, and concussion are causes of spinal hemorrhage.
The same causes are also mentioned for acute hemorrhagic
myelitis; and it is a question whether the supposed hemorrhage is an
initial lesion or secondary to congestive or anæmic softening.78
78 I have never found vascular ruptures, although carefully searching for them, in the
spinal cord of persons dying instantly after falls from a great height, or, as in one case
which I was fortunately able to secure the cord of, where the subject had been
violently thrown down. Where hemorrhages have been found under these
circumstances they were, as far as I am able to learn from the cases recorded,
meningeal.

The symptoms attributed to spinal hemorrhage are the same, taking

the same locality of the cord, as those of a very rapidly-developed
transverse myelitis. It is unnecessary to enumerate these here in
anticipation of the next section. They are described as being much
more sudden. This suddenness is the only diagnostic aid on which
we can rely.79 The fate of the patient is said by Erb to be decided
within a few days. If he survive the immediate consequences of the
hemorrhage, he is apt to recover, as to life, altogether, with such
permanent atrophies, paralyses, and anæsthesias as are entailed by
the destruction of the tracts and gray substance involved in the
hemorrhage. The treatment recommended for this condition consists
of rest, either in the lateral or prone position, local depletion and
derivation to the intestinal canal, as well as the internal use of
ergotin. The local application of ice, which is also advised, is
probably based on illusory views.80 After the immediate danger is
past the case is to be treated as one of myelitis—a very safe
recommendation in view of the probability that it was a case of
myelitis from the beginning.
79 And even this sign is unavailable as a distinguishing feature in supposed
hemorrhage from concussion, as sudden paraplegias of motion and sensation are
 found in some cases of railway spine, and, although a number of cases terminating
fatally have been examined, there was not always hemorrhage even in the meninges.

80 Until authorities shall have agreed as to what effect the exposure of the bodily
periphery to certain temperatures has on the circulation of the cord, it would be
premature to make any special recommendations as to the temperature at which they
should be kept. I am inclined to believe that while, as is universally accepted, a
general cooling of the bodily surface tends to increase vascular fulness in the cord, as
in all other internal organs, a partial cooling, as of the feet, produces local anæmia at
the level of origin of the nerves supplying the cooled part. Certainly, the bilateral
neural effects of unilateral cooling are in favor of this view.

The descriptions given of the hemorrhagic foci as observed after

death strengthen the view that they were in the majority of cases of
myelitic origin. Usually, they are stated to extend up and down the
cord in the direction of least resistance—that is, in the gray
substance—resembling an ordinary apoplectic clot. But in their
neighborhood there was usually considerable softening, and, to
judge by the descriptions given, this softening differed in no wise
from that which is the characteristic feature of acute myelitis;81 and
often the transition from a peripheral zone of white softening, through
an intermediate zone of red softening, to a central compact clot, is so
gradual as to leave it unquestionable that the softening pre-existed,
and that a vessel had broken down in the midst of the myelitic
detritus. Many ancient foci of myelitis betray the hemorrhagic
complication of their initial period by the presence of pigmented
residue of the absorbed clot.
81 In the latest treatise on nervous diseases published in our language (Ross, loc. cit.,
vol. ii. p. 325) the insufficient foundation on which a whole chapter has been built up is
illustrated by the admission that the usual evidence of acute central myelitis may be
observed far beyond the limits of the hemorrhagic infiltration. If a large area of
softening in the brain were found to contain a central or peripheral clot of blood, and
histologically resembling a typical embolic or thrombic softening, no one would be in
doubt as to which of the two was the primary lesion.

Embolisms and embolic softenings of that part of the spinal cord

which is supplied by the small spinal vessels are so rarely observed
in the dead-house that our knowledge of their possible occurrence
and character is almost entirely the result of experimental
observations or based on analogy. The situation of these vessels,
the angle at which their supply-tubes are given off from the aorta, all
act as protectors of the cord against what is one of the chief dangers
to which the brain is exposed. No definite symptoms have been
attributed to the few doubtful cases of simple embolic occlusion of
the spinal arteries found accidentally in human subjects. Even those
emboli which, when once let loose in the circulation, are found
distributed in nearly every organ of the body, those derived from
ulcerative endocarditis and those due to the invasion of micrococci,
are comparatively rare in the cord. Leyden found multiple capillary
emboli in the spinal cord from the former cause. Small grayish white
foci in a similar distribution were found to be due to an invasion of
cocco-bacteria from a decubitus by Rovigli.82 In this latter case an
increase of pain and muscular spasm in the history of the case of
sclerosis which was thus complicated was attributed to the parasitic
affection.
82 Rivista sperimentale di Freniatria, 1884, x. p. 227.

Just as simple and infectious embolic lesions are frequent in the

brain and rare in the cord, so purulent inflammation or abscess is an
exceptional occurrence in spinal as compared with cerebral
pathology, and probably for the same reasons.

Simple Acute Myelitis.

SYNONYMS.—Spontane (primäre) acute Rückenmarkserweichung,

Softening of the spinal cord, Ramollissement blanc de la moelle,
Myélite aiguë.

As Leyden, whose treatise83 may be regarded as the foundation of

our knowledge on this subject, correctly avers, it is to Abercrombie
and Ollivier that we owe the determination of the existence of that
acute structural disease of the spinal cord, now termed myelitis, as
an affection independent of meningeal changes. The anatomical
descriptions given by these older writers may be accepted at the
present day as models of accurate observation by the naked eye.
Their statement that in acute myelitis the substance of the spinal
cord is softened and changed into a puriform, yellowish, diffluent
mass; that while the disorganization is sometimes more marked in
the posterior, at others in the anterior, and occasionally in the lateral
half, it is most pronounced in the axis of the cord, because the
central gray substance is the favorite starting-point of the morbid
process,—requires no modification to-day. Considerable doubt
existed in the minds of the contemporaries of Ollivier and
Abercrombie as to whether this change was the result of a true
inflammation; and one of the clearest thinkers of the day, Recamier,84
regarded myelitic softening as a lesion peculiar to the nervous
apparatus, and different from ordinary inflammation. I believe that
the most profound investigators of the present day have not been
able to rid themselves of a similar doubt. The discovery of Gluge's
so-called inflammatory corpuscles, which was regarded as settling
the question, only served to confuse the student by the confidence
with which it was urged that they were infallible criteria of the
inflammatory process. Under the non-committal designation of
granule-cells these bodies still flourish in the annals of cerebro-spinal
pathology. As we shall see, a number of products of real disease, of
artifice, and of cadaverous change have passed and do pass muster
under this name. The first substantial progress in our knowledge of
the minute processes underlying inflammation of the spinal cord was
made by Frommann and Mannkopf, but it applied altogether to the
chronic inflammatory or cirrhotic affections of the cord. The
difference between acute and chronic myelitis is greater than is the
difference between acute and chronic inflammation in any other
organ; and it must be admitted that if Recamier is to be regarded as
having erred in asserting that acute myelitis is not a true
inflammation, he is justified in so far as he asserted many features of
the process to be altogether peculiar to the organ affected. Leyden
himself attempted to throw light on the subject by provoking myelitis
experimentally in dogs. He injected Fowler's solution into the spinal