42ournal ofNeurology, Neurosurgery, and Psychiatry 1995;59:442-447

LESSON OF THE MONTH

Management of spontaneous extramedullaryspinal haematomas: results in eight patients afterMRI diagnosis and surgical decompression

J J Langmayr, M Ortler, A Dessl, K Twerdy, F Aichner, S Felber

AbstractSpinal cord compression due toextradural and subdural haemorrhage isa neurosurgical emergency. Differencesin clinical presentation in relation tolocalisation of the haematoma, value ofMRI as a diagnostic tool, surgical treat-ment, and prognosis were investigatedin a retrospective case series of eightpatients with extradural (n = four) andsubdural (n = four) haematomas.Results of MRI were compared withoperative findings and proved to be ofhigh sensitivity in defining the type ofbleeding and delineating craniocaudalextension and ventrodorsal location.Surgical treatment by decompressivelaminectomy, haematoma evacuation,and postoperative high dose cortico-steroids resulted in resolution of symp-toms in five patients and improvementin the clinical situation in two patients.One patient with a chronic subduralhaematoma had a second operationbecause of arachnoidal adhesions. Onepatient presented with a complete cordtransection syndrome due to an acutesubdural haematoma and remainedparaplegic. It is concluded that prompt,reliable, and non-invasive diagnosis byMRI leads to efficient surgical treatmentand a favourable outcome in this rarecondition.

(_ Neurol Neurosurg Psychiatry 1995;59:442-447)

Universitatsklinik ffirNeurochirurgie,Innsbruck, AustriaJ J LangmayrM OrtlerK TwerdyGemeinsameEinrichtung fiirMagnetresonanztomo-graphie und-spektroskopie,Innsbruck, AustriaA DesslF AichnerS FelberCorrespondence to:Dr J J Langmayr,Universitatsklinik fiirNeurochirurgie, 35,Anichstrasse, Innsbruck,Austria 6020.

Received 2 February 1994and in revised form15 May 1995Accepted 5 June 1995

Keywords: spinal haematomas; surgical decompres-sion; magnetic resonance imaging

Spontaneous spinal haematomas are rare andrepresent neurosurgical emergencies becausethey may lead to spinal cord compression.1 2Whereas a relatively large body of medicalliterature exists regarding extradural spinalhaematomas,3 only a few reports on sub-dural spinal haematomas have appeared."' 12We analyse the clinical presentation, MRI

results, intraoperative findings, and outcomein a series of eight patients with extraduraland intradural extramedullary spinalhaematomas. The discussion focuses on

pathogenetic factors of the bleeding; differ-ences in clinical presentation betweenextradural and intradural haematomas; therole of MRI compared with CT and myelo-

graphy for the investigation of patients withthis rare disorder; and strategies for surgicaltreatment.

MethodsThis case series includes eight patients withspontaneous extra-axial spinal haematomasseen between 1988 and 1993 at theNeurochirurgische Universitdtsklinik, Innsbruck,Austria, an academic neurosurgical unitwhich also serves as the primary referralcentre for all patients with suspected centralnervous disease requiring surgery. Dataregarding history and signs were gatheredretrospectively by analysis of patient records.

Neuroradiological investigation includedMRI in all patients; five patients also under-went myelography and CT. A 1-5 Tesla unit(Magnetom Siemens, Erlangen, Germany)was used for MRI. The imaging protocolconsisted of Ti (TR = 550 ms/TE = 15 ms)images and proton density/T2 weighteddouble spin echo sequences (TR = 1800 ms/TE = 15 and 90 ms) in a sagittal orientation,followed by transverse Ti weightedsequences. All patients were examined with aT2 weighted gradient echo sequence (TR =400 ms/TE = 18 ms/alpha = 150) in thetransverse orientation.

All patients underwent decompressivelaminectomy at the levels indicated by pre-operative imaging techniques and completeevacuation of the haematoma. Specimenswere sent for histological examination.Whenever a well defined membrane or othersigns of clot organisation were found atsurgery and confirmed by histology ahaematoma was classified as chronic. Allpatients received a postoperative short courseof antibiotics and high dose dexamethasone.

All patients were available for follow upthree to six months after surgery.

Case seriesCLINICAL PRESENTATIONTable 1 gives a summary of the clinical data.Eight patients (three men, five women) with aspontaneous extradural (four patients) orsubdural (four patients) spinal haematomawere seen in six years. Mean age was 58(range 19 to 73) years. Seven patients wereolder than 50.

Five of the eight patients had a history ofanticoagulation. Prothrombin time at presen-

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Management ofspontaneous extramedullary spinal haematomas

tation in these patients was above 30%(normal range 70-110%). One patientreported a daily intake of 500 mg acetyl-salicylic acid.

Nearly all patients presented with backpain as the leading symptom (patients 1 to 7).Sometimes the pain was irradiating into theextremities mimicking radicular pain. Trueradicular pain was present in only onepatient, with an acute extradural haematoma(patient 6). In chronic haematomas, a pro-gressive paraparesis, perceived by the patientsas "tiredness" or "weakness" was the leadingsymptom in about half of the patients(patients 3 and 8).Although patient numbers are low, a cer-

tain difference in history between acute andchronic lesions was noted. Pain in acuteextradural haematomas was present for about35 hours (range 17-72 hours) before clinicalsigns appeared. In the only patient with a trueacute subdural haematoma, back pain was pre-sent within minutes after the rupture of ananeurysm of a radicular artery. Signs ofincomplete cord transection were noted 17hours later (patient 7). Another patient(patient 4) with a complete transection 12hours after a coeliac ganglion block showedsigns of new haemorrhage into an olderhaematoma at surgery. If this patient isincluded in the acute subdural haematomagroup, this type of haematoma in our seriesbecomes clinically appreciable slightly earlierthan the extradural counterpart.

In the patient with a chronic extraduralhaematoma (patient 3), weakness in both legswas the first symptom and pain was presentfor only a few hours before admission. In allpatients with a chronic subdural haematoma(patients 4, 5, 8), the time between onset ofsymptoms and appearance of signs was about15 days (10-21 days). As pointed out earlier,weakness occurred before pain as a symptomin chronic lesions.

Differential diagnosis between extraduraland intradural haematoma on clinical exami-nation alone was not possible. Signs of a par-tial or complete spinal cord transectionsyndrome were present in seven of eightpatients. Only one patient (patient 6 with anacute extradural haematoma) exhibited signsof an isolated radicular lesion. In all patientsthe clinical level of spinal cord transectioncorrelated with the results of the imagingstudies. Bladder dysfunction was present intwo patients.

IMAGINGThe table summarises the neuroradiologicaldata. An initial CT examination withoutcontrast agent was performed in five patientsand led to the diagnosis of an epiduralhaematoma in only one. Thoracic intraspinalhaematomas in two patients were notdetected on CT, the diagnosis of two lumbarhaematomas within the spinal canal remainedinconclusive because of isointensity of thehaematoma.

Myelography and postmyelography CTwere performed in three patients and delin-

eated the site of cord compression but werenot specific.

Magnetic resonance imaging correctlyidentified the presence and delineated thecervicocaudal extension of a haematoma in allpatients; MRI also distinguished betweenextradural and subdural haematoma in all butone patient. This patient (table, patient 7)had a combined subdural and subarachnoidhaemorrhage.

FINDINGS AT SURGERYFour epidural and four subdural haematomaswere evacuated. Macroscopic and histologicalsigns of chronic disease were present in onepatient in the epidural haematoma group andin two patients with a subdural haematoma.A bleeding source was identified only in thepatient with aneurysm of a radicular artery(patient 7). The rupture of the aneurysmcaused a combined subarachnoid/subduralhaemorrhage. In the other patients no bleed-ing source could be identified. Meninges inpatient 8 were thickened.

POSTOPERATIVE COURSEThe only surgical complication was a CSFfistula in patient 5. In the same patient a sec-ond intervention was performed after threeweeks because of subarachnoid adhesions atthe site of the primary haematoma.Histological examination of the thickenedmeninges of patient 8 showed neoplastic infil-tration of the meninges. Four patients with anepidural haematoma (patients 1, 3, 6, 7) andone with a chronic subdural haematoma(patient 5) recovered completely. Twopatients (2 and 8) regained walking capabilityafter surgery. One (patient 4) with a completetransection syndrome showed no clinicalimprovement after surgery. No deaths relatedto surgery were recorded.

DiscussionEPIDEMIOLOGYThe entity is rare. The true incidence ofspontaneous extramedullary spinal haema-tomas is not known. A few hundred cases ofextradural and about 50 cases of subduralhaematomas have been reported.3 Male tofemale ratio was 1:1 for extradural and 1:3 forsubdural haematomas. In larger series a malepredominance for extradural and a femalepredominance for subdural haematomas werereported.2 Our youngest patient was 19 yearsold. All other patients were of advanced age.

PATHOGENESISPathogenetic mechanisms leading to a spon-taneous spinal haematoma are incompletelyunderstood. Data from the medical literaturesuggest that trauma including iatrogenicinjuries during lumbar puncture or epiduralanaesthesia,"3 and primary and secondarycoagulopathies such as anticoagulant therapyare important pathogenetic factors contribut-ing to the formation of a spinal extraduralhaematoma. The role of minor traumarelated to activities of daily living is contro-

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Langmayr, Ortler, Dessl, Twerdy, Aichner, Felber

Clinical and radiological data for eight patients with extramedullary spinal haematomas

Time betweenonset ofsymptoms and

Patient Age, appearance ofNo sex Pathogenesis Symptoms Signs signs MRIfindings Surgical diagnosis Outcome

1 63, M AC Back pain Absent on gross 72 h (= time Obliteration of the Acute extradural ComnIeteirradiatmg inboth legs

2 60, F AC, LP Back pain andpainirradiating inboth legs

3 73, F AC "Tiredness" inboth legs,sudden pain inthoracolumbarregion beforeadmission

l \

examination between onsetof symptomsand diagnosis)

16 h (2 h postLP)

14 days

TransectionTh 8, 2 h postLP

Transection

spinal canal toabout 50% at Th1 1-L3, isointensein TI,inhomogeneouslyhypointense inPD and T2

Lesion ventrallylocated at Th7-9, isointense inTI and mixedhypo- andhyperintense inPD and T2

Ventral lesion oflow signalintensity in TI,PD and T2

54, M Pancreaticcarcinoma,block ofcoeliacganglion

Chronic pain,probably relatedto primarydisease

5 63, F AC Back pain for3 weeks, bladderdysfunction for2 days

6 73, M ASA

7 59, F

Suddencervico-brachialgia

Frontal headache,followed byback pain

8 19, F Repeated LP, Slowly progressinggliomatosis weakness inof meninges both legs

Transection Th 12 12 h post coeliacganglion block

Transection C 5 21 days

C 7 radicularlesion includingtriceps paresis

Mild meningism,incompletetransectionTh 7-8

Flaccidparaparesis,bladderdysfunction

17 h

17 h

10 days

Ventral lesion,slightlyhyperintense inTi

LesionmediolaterallyC6 and secondlesiondorsolaterally Th1-5 isointense inTI and T2, higherin PD

Dorsally C2-6,isointense in TIand T2, of lowintensity in PD

C6/7 and Th5/6,isointense in Tiand PD, partiallyhyperintense onT2

Subacutehaematoma,isointense in T1,PD, T2 images

Subacutesubduralhaematoma(in partsubarachnoidal)

Chronic subduralhaematoma

Acute extraduralhaematoma

Acute subduralandsubarachnoidhaematoma,aneurysmradicular arteryTh 8

Chronicsubduralhaematoma

AC = Anticoagulants; ASA = acetylsalicylic acid; LP = lumbar puncture.

versial.3 Excessive blood pressure surges inthe valveless epidural veins during coughingand straining,3 axial movement of the thecalsac,'4 and tearing of epidural veins duringacute disc disruption as they pass through thethin membrane overlying the posterior longi-tudinal ligament'5 have all been implicated inminor trauma related extradural bleeding.None of our patients had a history of majortrauma. All patients with an extraduralhaematoma were under anticoagulant treat-ment or reported a heavy use of plateletaggregation inhibitors. No data exist on theexcursions of blood vessels within the spinalcanal during body movements. Increased ves-

sel friability and anticoagulation may lead to a

situation in which body excursions cause a

disruption of the vessel wall and haematomaformation. Limitation of haematomas withinthree spinal segments in most patients mightbe due to the venous origin of the bleeding,

the counter pressure exerted by structureswithin the spinal canal, or unknown coagula-tion enhancing factors within the spinal canal.

Pathogenetic factors associated with spinalsubdural haemorrhage are similar to thosereported for extradural haematomas.1011Lumbar puncture in the presence of coagu-lopathies is a known cause. Major spinaltrauma is seldom associated with spinal sub-dural haematomas. In our patients a pancre-atic carcinoma, gliomatosis of the meninges,anticoagulation, and repeated lumbar punc-tures were associated with the bleeding.Vascular malformations can cause a sub-arachnoid haemorrhage with subsequent dis-ruption into the subdural space.

CLINICAL PRESENTATIONIn acute haematomas back pain was the firstsymptom, whereas in chronic haematomasweakness usually preceded pain by several

haematoma

Acute extraduralhaematoma

Chronicextraduralhaematoma

recovery

Incompleterecovery, walksalone

Completerecovery

Paraplegic, nowalking ability

Completerecovery. 2ndintervention3 weeks later:subarachnoidaladhesions

Completerecovery

Completerecovery

Incompleterecovery, walkswith help;histology:gliomatosis ofmeninges

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weeks. Eventually pain was the reason forseeking medical help in all but one patient.

Duration of history was different for acuteand chronic lesions. Patients with acutehaematomas had a history of roughly oneday, patients with chronic haematomas had ahistory of about two weeks.

Acute subdural haematomas were notedslightly earlier (after several hours) than acuteextradural haematomas (after one day). Anextradural accumulation of blood might leadto cord compression later due to the dampen-ing effect of the thecal sac fixed within thespinal canal by ligaments and the dural nerveroot sheets leaving the canal. Whether bloodcomponents themselves act as toxic factorsimpairing spinal cord function earlier in sub-dural than in extradural haematomas is notclear.

In agreement with other reports23 1011 theclinical examination gave no hint regardingthe nature of the lesion. All patients pre-sented with signs of spinal cord or nerve rootcompression possibly due to an extra-axialspinal pathology.The strongest factor favouring a

haematoma in the differential diagnosis was ahistory of anticoagulation. The absence ofsigns of infection in all patients and the pres-ence of signs at spinal levels where primarymanifestation of degenerative spinal disease israre in six of eight patients further restricteddifferential diagnosis.

IMAGINGAs pointed out by Johnston modem imagingreduces the need to make a diagnosis at thebedside.' Myelography was the diagnosticstandard for decades and demonstrates cordcompression but has a low specificity. In thecase of a complete blockage myelography isunable to show the entire craniocaudal exten-sion of the space occupying lesion. To thesurgeon approaching a spinal lesion a myelo-gram still gives vital information regardinganatomical landmarks and the relationbetween neural and bony structures by offer-

ing a two dimensional image of the threedimensional operative field. Due to its gen-eral availability, myelography will remain partof the diagnostic armamentarium unless a 24hour MRI service is available.The use of CT is not valuable for the diag-

nosis of intraspinal haematomas. Limitationsinclude isointensity of haematoma to thecalsac and spinal cord and an insufficient resolu-tion in the thoracic spine. In our series plainCT was inconclusive in four of five patients.This limits the use of CT as a non-invasivediagnostic modality. For accurate diagnosisCT has to be performed after application ofan intrathecal contrast agent.

In our series MRI proved superior to theother diagnostic methods and allowed surgi-cal planning with regard to craniocaudalextension and dorsoventral location of thelesion. Surface coil MRI permits examinationin any plane without moving the patient,which is advantageous in the patient withsevere pain; MRI exactly delineates the extentof cord compression and shows characteristicfindings in both types of spinal haematomas.Extradural haematomas on sagittal and axialorientation have a biconvex shape'7-'9 (fig 1A,B). Subdural haematomas appear with con-cave delineation on sagittal images and irreg-ular shape on axial images (fig 2A, B). Adistinction between extradural and subduralhaematoma localisation is possible on trans-verse T2 weighted gradient echo sequences orafter the application of gadolinium-DTPA.20Signal behaviour in MRI does not alwaysallow a distinction between acute and chronicbleeding although T2 weighted gradient echoimages are superior in demonstrating theinhomogenous signal intensity typical ofhaematomas examined hours after the initialbleeding. 1620

TREATMENTManagement of extradural and subduralhaematomas is a neurosurgical emergency.Prognosis for recovery depends on the sever-ity and duration of neurological deficit before

Figure 1 Acuteextradural haematoma ina 73 year old man (patient6); MRI performed lessthan 24 hours after onsetofpain irradiating into theC 7 dermatome and paresisof the triceps muscle. (A)Sagittal Ti weightedimage (TR = 550 ms,TE = 15 ms) showscompression of the cervicalspinal cord by a dorsallylocated, convex, andisointense space occupyinglesion extendingfrom thethird cervical to the firstthoracic vertebra. (B)Transverse gradient echoimage (TR = 400 ms,TE = 18 ms, alpha =15°) demonstrates thedorsolateral left positionof a lesion with low signalintensity due to thepresence ofdeoxyhaemoglobin (arrow).

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Figure 2 Subacutesubdural spinalhaematoma in a 19yearold woman who had adiffuse meningeal spread ofa gliomatous tumour(patient 8). (A) Thesagittal T2 weighted image(TR = 2400 ms, TE =90 ms) shows a high signalintensity of the haematomadue to the presence ofmethaemoglobin. Thehaematoma is locatedventrally and extends fromvertebral body Th 1 1 to thesacrum. Compression anddislocation of conus andcauda are visible. (B) Thetransverse T2 weightedimage shows thehaematoma surroundingthe roots of the caudaequina (arrows), pointingto a subdural location ofthe bleeding.

F;.c.ltU.3.................;....

decompression.' 2122 Normalisation of pro-thrombin time in patients taking oral anti-coagulants can be obtained by intravenousadministration of fresh frozen plasma or theuse of concentrates highly enriched in vitaminK dependent proteins. We consider a pro-thrombin time above 50% as sufficient foremergency surgery. Surgical decompressionand evacuation of haematoma in all patientsis performed through a laminectomy extend-ing over all levels where MRI shows the pres-ence of haemorrhage. This is necessary fortwo reasons: (a) unless a haematoma is com-pletely liquified a limited approach would notallow the removal of solid clots at severalspinal levels; (b) only a laminectomy mightgenerate the space necessary to restore pulsa-tion to the dura and spinal cord, and preventa secondary cord compression if swelling ofthe myelon occurs postoperatively. If nohaematoma is found epidurally or preoper-ative imaging points to an intradural pathol-ogy the dura is opened. The haematoma isremoved with dissectors and careful suction.Before wound closure large bore suctiondrains are inserted between the dura andmusculature and left in situ for up to threedays. Care must be taken not to readapt mus-culature too tightly as this might cause com-pression of a thecal sac no longer protectedby spinal laminae. The drainage is set on con-tinuous suction on termination of surgery. IfCSF is aspirated the drainage is opened inter-mittently. A short course of postoperativeantibiotics and high dose dexamethasone isrecommended.

Evacuation of extradural spinal haema-tomas by radiographically guided punctureseems successful in expert hands.23 The riskof iatrogenic injury to blood vessels, nerveroots, and spinal cord, however, can be highand removal of solidified blood clots evenimpossible.

At present it is not clear whether refine-ments of minimal invasive techniques willallow endoscopic evacuation of spinalhaematomas, at least of those that are locatedextradurally. Magnetic resonance imaging

can provide information regarding haema-toma localisation in relation to the dural level.The problems that occur with solidified clotsand postoperative cord swelling have to beresolved satisfactorily before keyholeapproaches can be advocated.

PROGNOSISRapidly evacuated haematomas carry a goodprognosis. Five of our patients made a fullrecovery. The appearance of signs of motorimpairment or bladder dysfunction is critical.Treatment delays for several hours after theappearance of a complete transsection syn-drome may be disastrous. Medical educationmust aim at those who first see a patient withsuspect cord compression.22 After spinalbleeding, the signs of impaired motor func-tion evolve over hours. If these hours are lost,referral of the patient to a surgeon who car-ries out decompression too often remains adesperate act.

1 Johnston RA. The management of acute spinal cord com-pression. _7 Neurol Neurosurg Psychiatry 1993;56:1046-54.

2 Cowie RA. Acute spinal haematoma. In: Findlay G, OwenR, eds. Surgery of the spine. Oxford: Blackwell, 1992:823-7.

3 Bruyn GW, Bosma NJ. Spinal extradural haematoma. In:Vinken PJ, Bruyn GW, eds. Handbook of clinical neurol-ogy. Vol 13. Amsterdam: Elsevier, 1976:1-30.

4 Markham JW, Lynge HN, Stahlmann GEB. The syn-drome of spontaneous spinal epidural hematoma.7 Neurosurg 1967;26:334-42.

5 Pendl G, Ganglberger JA, Horcajada J. Das spinale epidu-rale Hamatom. Acta Neurochir (Wien) 197 1;24:207-17.

6 Mattle H, Sieb JP, Rohner M, Mumenthaler M.Nontraumatic spinal epidural and subdural hematomas.Neurology 1987;37:1351-6.

7 Santa M, Sulla I, Fagula J. Spontaneous spinal epiduralhematoma. Zentralblatt fur Neurochirurgie 1990;51:164-5.

8 Flaschka G, Sutter B, Ebner F, Klein GE, Tilz G. Dasspinale Epiduralhamatom. Langzeitergebnisse von 4eigenen Fallen. Nervenarzt 1990;61:629-33.

9 Major 0, Sipos L, Czirjak S, Benoist G, Horvath M,Pasztor E. Spontaneous spinal epidural haematomas.Acta Neurochir (Wien) 1991;111:40-2.

10 Edelson RN. Spinal subdural hematoma. In: Vinken PJ,Bruyn GW, eds. Handbook of clinical neurology. Vol 26,Injuries of the spine and spinal cord, Pt II. Amsterdam:Elsevier, 1976:31-8.

11 Russell NA, Benoit BG. Spinal subdural hematoma. Areview. Surg Neurol 1983;20:133-7.

12 Khosla VK, Kak VK, Mathuriya SN. Chronic spinal sub-dural hematomas. Report of two cases. _7 Neurosurg1985;63:636-9.

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13 Gingrich TF. Spinal epidural hematoma following contin-uing epidural anesthesia. Anesthesiology 1968;29:162-3.

14 Beatty RM, Winston KR. Spontaneous cervical epiduralhematoma. A consideration of etiology. Y Neurosurg1984;61:143-8.

15 Gundry CR, Heithoff KB. Epidural hematoma of thelumbar spine: 18 surgically confirmed cases. Radiology1993;187:427-31.

16 Larsson EM, Holtas S, Cronqvist S. Emergency magneticresonance examination of patients with spinal cordsymptoms. Acta Radiol 1988;29:69-75.

17 Bernsen PLJA, Haan J, Vielvoje GJ, Peerlinck KMJ.Spinal epidural hematoma visualized by magnetic reso-nance imaging. Neuroradiology 1988;30:280.

18 Avrahami E, Tadmor R, Ram Z, Feibel M, Itzhak Y. MRdemonstration of spontaneous acute epidural hematomaof the thoracic spine. Neuroradiology 1989;31:89-92.

19 Di Lorenzo N, Rizzo A, Fortuna A. Spontaneous spinalepidural hematoma: preoperative diagnosis by MRI.Clin Neurol Neurosurg 1990;92:357-9.

20 Crisi G, Sorgato P, Colombo A, Scarpa M, Falasca A,Angiari P. Gadolinium-DTPA-enhanced MR imagingin the diagnosis of spinal epidural hematoma.Neuroradiology 1990;32:64-6.

21 Grollmus F, Hoff J. Spontaneous spinal epidural haemor-rhage: good results after early treatment. J NeurolNeurosurg Psychiatny 1975;38:89-90.

22 Maurice-Williams RS, Richardson PL. Spinal cord com-pression: delay in the diagnosis and referral of a com-mon neurosurgical emergency. Br J Neurosurg 1988;2:55-60.

23 Solymosi L, Wappenschmidt J. A new neuroradiologicmethod for therapy of spinal epidural hematomas.Neuroradiology 1985;27:67-9.

NEUROLOGY IN LITERATURE

More doctorsThe Medical profession comes off rather badly inthese extracts, using whatever skills they possess forpersonal gain rather than for the benefit of theirpatients. Venality and cynicism have not disappearedfrom the profession although I suspect that cynicism isnow more directed at the management structure of theservice rather than at the humble patient. After a sur-

feit of neurological outpatient clinics, I suspect some

neurologists would share Dr Weinrock's sentiments!

Charles Lamb, 1823, Essays. Amicus RedivivusMonoculus-for so in default of catching his truename, I choose to designate the medical gentlemanwho now appeared-is a grave, middle-aged person,who without having studied at the college or truckledto the pedantry of a diploma, hath employed a greatportion of his valuable time in experimental processesupon the bodies of unfortunate fellow-creatures, inwhom the vital spark, to mere vulgar thinking, wouldseem extinct, and lost for ever. He omitteth no occa-

sion of obtruding his services, from a case of commonsurfeit-suffocation to the ignobler obstructions,sometimes induced by a too wilful application of theplant cannabis. Outwardly but though he declinethnot altogether these drier extractions, his occupationtendeth for the most part to water-practice; for theconvenience of which, he hath judiciously fixed hisquarters near the grand repository of the stream men-

tioned, where, day and night, from his little watch-tower, at the Middleton's-Head, he listeneth to detectthe wrecks of drowned mortality, partly, as he saith tobe upon the spot-and partly, because the liquidswhich he useth to prescribe to himself and hispatients, on these distressing occasions, are ordinarymore conveniently to be found at these common

hostelries than in the shops and phials of the apothe-caries.

Herman Melville, 1851, Moby Dick"Oh! A great watcher, and very dietetically severe, isDr Bunger. (Bunger, you dog, laugh out! why don'tye? You know you're a precious jolly rascal.) But,heave ahead, boy, I'd rather be killed by you than keptalive by any other man".

Thomas Hardy, 1886, The Mayor of CasterbridgeHenchard, who treated her kindly, except in momentsof irritation, sent at once for the richest, busiest doc-tor, whom he supposed to be the best.

Thomas Hardy, 1887, The woodlandersMr Fitzpiers entered the sick chamber as a doctor iswont to do on such occasions and pre-eminently whenthe room is that of the humble cottager; looking roundtowards the patient with a preoccupied gaze which soplainly reveals that he has well-nigh forgotten all aboutthe case and the circumstances since he dismissedthem from his mind at his last exit from the sameapartment.

M V Hughes, 1934, A London child of the 1870sThe doctor himself was a dear. He saw us through allour infectious diseases and coughs, curing most of ourailments more by jollity than physic. He was speciallyfond ofme because as he frequently said, he had savedmy life. I had almost gone with measles, and whenhope had practically departed he ordered champagne.I was only six years old, but I remember thatchampagne, and my father bringing it to me in hisshirt-sleeves that hot summer evening. The very word"champagne", connected as it was with festivity, andmy father's face all smiles, put new life into me, andgave me kick enough to pull through.

Henry Green, 1939, Party going"What did he do?" she echoed, "why, what do doctorsdo? Of course he got his fee, Robert paid him, but youknow what they are; he went away again; she mightdie for all he cared."

Thomas Mann, 1954, Confessions of Felix Krull:confidence manThis unworthy disciple of Aesculapius was both stupidand ambitious and had achieved his title through per-sonal influence, exploitation of wine-house acquain-tances, and the receipt of patronage; he was alwaysgoing to Wiesbaden to advance his interests with theauthorities. Most indicative to me was the fact that hedid not receive the patients who came to his waiting-room in the order in which they arrived, but took themore influential first, letting the humbler sit and wait.His manner towards the former class was obsequious,towards the latter harsh and cynical, indicating oftenthat he did not believe in their complaints.

J7oseph Heller, 1979, Good as gold"I wouldn't take you, Bruce," Dr Weinrock answeredwith frankness. "Oh, I would never take on a patientwho really needed help. I don't enjoy being aroundsick people."

G D PERKINRegional Neurosciences Centre

Channg Cross Hospital,London W6 8RF, UK

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