Handbook of Spinal Cord Injuries and Related Disorders A Guide To Evaluation and Management 1st Edition Hyun Yoon Ko Sungchul Huh

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Hyun-Yoon Ko and Sungchul Huh
Handbook of Spinal Cord Injuries and
Related Disorders
A Guide to Evaluation and Management
1st ed. 2021
Hyun-Yoon Ko
Department of Rehabilitation Medicine, Rehabilitation Hospital, Pusan
National University Yangsan Hospital, Pusan National University
College of Medicine, Yangsan, Korea (Republic of)
Sungchul Huh
Department of Rehabilitation Medicine, Rehabilitation Hospital, Pusan
National University Yangsan Hospital, Yangsan, Korea (Republic of)
ISBN 978-981-16-3678-3 e-ISBN 978-981-16-3679-0

https://doi.org/10.1007/978-981-16-3679-0
© The Editor(s) (if applicable) and The Author(s), under exclusive

license to Springer Nature Singapore Pte Ltd. 2021
This work is subject to copyright. All rights are solely and exclusively
licensed by the Publisher, whether the whole or part of the material is
concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in
any other physical way, and transmission or information storage and
retrieval, electronic adaptation, computer software, or by similar or
dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks,

service marks, etc. in this publication does not imply, even in the
absence of a specific statement, that such names are exempt from the
relevant protective laws and regulations and therefore free for general
use.
The publisher, the authors and the editors are safe to assume that the
advice and information in this book are believed to be true and accurate
at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, expressed or implied, with respect to the
material contained herein or for any errors or omissions that may have
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Nature Singapore Pte Ltd.
The registered company address is: 152 Beach Road, #21-01/04
Gateway East, Singapore 189721, Singapore
To my mother and to the memory of my father, who gave me everything
and made me have a faithful mind.
To my mentors, who taught me with incredible generosity, shared their
advanced knowledge, gave me opportunities to learn a lot from them, and
inspire and motivate me.
To my special colleagues in the Department of Rehabilitation Medicine at
Pusan National University College of Medicine for their passion and
support.
To the most important person, my wife Insun, Dr. Park, for her
understanding and support.
Hyun-Yoon Ko, MD, PhD
My greatest thanks go to all of my patients throughout the years with
spinal cord injury.
To my wife, Sung Eun Lee, my little son, Junwoo Huh, and my parents for
all their sacrifices for me and for teaching me the meaning of my life.
I greatly appreciate my teacher and mentor, Dr. Hyun-Yoon Ko, for taking
the opportunity to participate in the writing.
Sungchul Huh, MD
Preface
Spinal cord medicine, which encompasses the diagnosis, treatment, and
rehabilitation of patients with spinal cord injuries, has developed
remarkably since World War II. Technology for the prevention and
treatment of complications that cause death after spinal cord injuries
such as cardiopulmonary and urinary complications and pressure
injuries associated with spinal cord injuries has also been developed,
and mortality and morbidity after the acute phase of spinal cord injury
have become almost similar to that of people without spinal cord injury.
In addition, it is good news that spinal cord injuries related to traffic
accidents and accidents at work are on the decline. However, the
lengthening of life expectancy after spinal cord injury over the past 20
years has been in a state of stagnation, and as the health age and
lifespan of the general population increase overall, the difference in life
expectancy between people with spinal cord injuries and the general
population is gradually increasing.
Spinal cord injury is a very devastating event as it can directly or
indirectly have negative effects on the person affected by spinal cord
injury and their family and friends, including the urinary system,
gastrointestinal system, sexuality, and psychosocial problems, as well as
motor and sensory functions below the level of injury. Fortunately,
however, most patients with spinal cord injuries can improve their
quality of life and social participation through personal effort,
rehabilitation, and medical assistance through spinal cord medicine.
Successful rehabilitation after spinal cord injury can be achieved
through a very comprehensive and well-planned effort by physicians
and medical personnel involved in spinal cord medicine, physical
therapists, occupational therapists, speech therapists, social workers,
and psychologists. Despite significant advances in spinal cord medicine,
physicians who are not involved in the treatment of patients with spinal
cord injuries or who do not specialize in spinal cord medicine may not
understand patients medically and may not provide proper primary
care. Physicians or primary care providers have to make continuous
efforts to be able to appropriately cope with medical situations and
emergencies of people with spinal cord injuries.
Various medical problems of people with spinal cord injuries can be
solved through a joint effort of internal medicine such as cardiology,
respiratory medicine, infections, and endocrinology, neurology,
orthopedic surgeon, neurosurgeon, urology, radiology, laboratory
medicine, and physiatry. Therefore, physicians involved in spinal cord
medicine must learn and acquire knowledge in a wide variety of fields
such as functional anatomy, neuroanatomy, neurology, urology,
orthopedics, and cardiopulmonary medicine, and strive to apply that
knowledge appropriately. Medical infrastructure is required for the
successful treatment and rehabilitation of patients with spinal cord
injuries. Medical professionals practicing spinal cord medicine should
endeavor to disseminate medical knowledge of spinal cord medicine
and medico-social movement in order to achieve successful
rehabilitation of our patients.
The knowledge of spinal cord medicine has been acquired from the
knowledge of various fields mentioned above, and many kinds of
specialized books related to spinal cord medicine are introduced. Some
books were biased to deal with surgical issues, while others were
quotes and descriptions from too many references, making it difficult to
easily acquire knowledge about spinal cord injuries. The authors wrote
this book with the intention of concisely presenting universal
knowledge that can be applied clinically throughout the book, and as a
book that can be easily referenced in the medical field. In addition, we
have tried to keep up-to-date knowledge while dealing with various
issues of spinal cord injury. Hopefully, if this book has an opportunity to
lead to another edition in the future, it can make up for the lack of
parts. The authors believe that this book can serve as a good reference
as it can be easily read by physiatrists involved in the treatment of
patients with spinal cord injuries, neurologists, urologists, internists,
orthopedic surgeons, and neurosurgeons in the medical field of spinal
cord medicine.
Hyun-Yoon Ko
Yangsan, Korea (Republic of)
April 2021
Contents
1 Clinical and Functional Anatomy of the Spinal Cord
1.1 Development of the Spinal Cord
1.2 Metamerism
1.3 Myelination
1.4 Anatomy of the Spinal Cord
1.4.1 Overview of Anatomy of the Spinal Cord
1.4.2 White Matter and Tracts
1.4.3 Gray Matter
1.5 Spinal Nerves and Roots
1.6 Meninges, Subarachnoid Space, and Cerebrospinal Fluid
1.7 Vascular Anatomy of the Spinal Cord
1.7.1 Arteries
1.7.2 Veins
References
2 Extremity Kinematics and Muscles for Functional Training of
Tetraplegics and Paraplegics
2.1 Potential Functions
2.2 Relevant Kinematics
2.2.1 Movement and Kinetic Chains
2.2.2 Muscle Contraction
2.2.3 Muscle Substitution
2.3 Contributing Muscles to Mobility Depending on the Motor
Level
2.3.1 Neurological Level of Injury:C4
2.3.6 Neurological Level of Injury:T1–9
2.3.7 Neurological Level of Injury:T10–T12
2.3.8 Neurological Level of Injury:L1
2.3.10 Neurological Level of Injury L3
2.3.13 Neurological Level of Injury:S1
2.4 Functional Anatomy of the Extremity Muscles
2.4.1 Muscles of the Upper Extremity
2.4.2 Muscles of the Lower Extremity
References
3 Physical and Neurological Differentiation of Spinal Cord Lesions
3.1 Neurological Assessment
3.1.1 Clinicoanatomical Considerations
3.1.2 Neurological Classification of Spinal Cord Injury
3.1.3 Upper Motor Neuron and Lower Motor Neuron Lesion
3.1.4 Muscle Bulk
3.1.5 Muscle Tone
3.1.6 Muscle Strength
3.1.7 Reflexes
3.1.8 Sensory Assessment
3.2 Functional Assessment
References
4 Laboratory Tests Commonly Encountered in Care of Spinal Cord
Injuries
4.1 Simple Blood Tests
4.1.1 Complete Blood Cell Counts
4.1.2 Electrolyte Disorders
4.1.3 Liver and Kidney Functions
4.2 Urinalysis
4.2.1 Physical Tests
4.2.2 Biochemical Tests
4.3 Infection/Inflammatory Markers
4.3.1 Erythrocyte Sedimentation Rate
4.3.2 C-Reactive Protein
4.4 Nutrition Markers
4.4.1 Serum Visceral Protein
4.4.2 Non-visceral Protein Markers
4.5 Bone Turnover Markers
4.5.1 Bone Formation Markers
4.5.2 Bone Resorption Markers
4.6 Coagulation Markers
4.6.1 Prothrombin Time and International Normalized
Ratio
4.6.2 Activated Partial Thromboplastin Time
4.6.3 Fibrinogen
4.6.4 D-Dimer
4.7 Metabolites
4.7.1 Glucose
4.7.2 Lactate
4.7.3 Urea
4.8 Arterial Blood Gas
4.8.1 pH
4.8.2 Partial Pressure of Oxygen
4.8.3 Partial Pressure of Carbon Dioxide
4.8.4 Bicarbonate
4.8.5 Base Excess
4.8.6 Anion Gap
4.8.7 Oxygen Saturation
4.9 Lipid Profile
4.9.1 Total Cholesterol
4.9.2 HDL Cholesterol
4.9.3 LDL Cholesterol
4.9.4 Triglycerides
4.10 Cardiac Markers
4.10.1 Cardiac Troponins
4.10.2 Creatine Kinase
4.10.3 Myoglobin
4.10.4 Homocysteine
4.11 Hormonal Markers
4.11.1 Antidiuretic Hormone
References
5 Pharmacotherapy in Spinal Cord Injuries
5.1 Basic Clinical Pharmacology
5.1.1 Pharmacokineticsand Drug Metabolism
5.1.2 Therapeutic Drug Monitoring
5.2 Altered Pharmacokineticsin Spinal Cord Injuries
5.2.1 Altered Pharmacokinetics
5.3 Medication Categories Commonly Prescribed in Spinal Cord
Injuries
5.3.1 Autonomic and Cardiovascular Drugs
5.3.2 Medications for Respiratory Dysfunction
5.3.3 Anticoagulants for Deep Venous Thrombosis and
Pulmonary Embolism
5.3.4 Medications for Bladder Dysfunction
5.3.5 Medications for Bowel Dysfunction
5.3.6 Medications for Spasticity
5.3.7 Pain Medications
5.3.8 Medications for Hypertension and Coronary Heart
Disease
5.3.9 Medications for Depression
5.3.10 Medications for Anxiety
5.3.11 Medication for Sleep Disorder
5.4 Polypharmacy in Spinal Cord Injuries
References
6 Imaging Assessment of Spinal Cord Injuries
6.1 Guidelines of Imaging Studies of Spinal Cord Injuries
6.2 Imaging Modalities
6.2.1 Plain Radiographs
6.2.2 Magnetic Resonance Imaging
6.3 Cervical Spine Imaging Study
6.4 Thoracic and Lumbar Spine Imaging Study
6.5 Imaging for Ankylosing Spondylitis or Diffuse Idiopathic
Skeletal Hyperostosis (DISH)
References
7 Functional Assessment and Expected Functional Outcomes
Following Spinal Cord Injuries
7.1 Initial Neurological and Functional Assessment After Spinal
Cord Injury
7.2 Factors Affecting Neurological and Functional Outcomes
7.3 Recovery of Ambulatory Function
7.4 Functional Assessment Measures for Spinal Cord Injuries
7.5 Expected Functional Outcomes of Spinal Cord Injuries
7.5.1 C2-C4 Tetraplegia
7.5.2 C5 Tetraplegia
7.5.3 C6 Tetraplegia
7.5.4 C7 and C8 Tetraplegia
7.5.5 Thoracic Paraplegia
7.6 Quality of Life After Spinal Cord Injury
References
8 Standard Neurological Classification of Spinal Cord Injuries
8.1 History of the ISNCSCI
8.2 Overview of the ISNCSCI
8.3 Two Major Changes with the Eighth Edition of ISNCSCI in
2019
8.3.1 General “*”-Concept
8.3.2 New Definition of Zone of PartialPreservation (ZPP)
8.4 Definitions of the Terms
8.4.1 Tetraplegia
8.4.2 Paraplegia
8.4.3 Tetraplegia and Paraplegia Vs.Tetraparesis and
Paraparesis
8.4.4 Dermatome
8.4.5 Myotome
8.4.6 Key Muscle Functions
8.4.7 Non-Key Muscle Functions
8.4.8 Sensory Level
8.4.9 Motor Level
8.4.10 Neurological Level of Injury (NLI)
8.4.11 Skeletal Level
8.4.12 Sensory Scores
8.4.13 Motor Scores
8.4.14 Sacral Sparing
8.4.15 Complete Injury
8.4.16 Incomplete Injury
8.4.17 Zone of Partial Preservation (ZPP)
8.4.18 Not Determinable (ND)
8.5 Neurological Examination
8.5.1 Sensory Examination
8.5.2 Motor Examination
8.5.3 Sensory and Motor Scores/Levels
8.5.4 Neurological Level of Injury (NLI)
8.6 ASIA Impairment Scale (AIS)
8.7 Zone of Partial Preservation (ZPP)
8.8 Clinical Syndromes
8.9 Expedited ISNCSCI
References
9 Spinal Shock:Definition and Clinical Implications
9.1 Definition of Spinal Shock
9.2 Pathophysiology
9.3 Clinical Implications of Spinal Shock
9.4 Clinical Observations of Reflex Evolution During Spinal
Shock
9.5 Changing Phases of Reflexes after Spinal Cord Injury
References
10 Acute Phase Management of Traumatic Spinal Cord Injuries
10.1 Initial Management of Spinal Cord Injuries
10.2 Neurological Assessment of Spinal Cord Injury
10.3 Decision of Surgery
10.4 Neuroprotective Medication
10.5 Polytrauma in Spinal Cord Injury
10.6 Acute Cardiovascular Management
10.7 Acute Pulmonary Management
10.8 Venous Thromboembolism
10.8.1 Prophylaxis of Deep Vein Thrombosis
10.8.2 Diagnosis of Venous Thromboembolism
10.8.3 Treatment of Venous Thromboembolism
10.9 Bladder Management
10.10 Bowel Management
10.10.1 Stress Ulcer Prophylaxis
10.10.2 Swallowing Dysfunction
10.11 Hyponatremia
10.12 Autonomic Vascular Dysfunction
10.13 Noninfectious Fever and Abnormal Temperature
Regulation
10.14 Pressure Injuries
10.15 Contractures
10.16 Pain
10.17 Nutritional Support
10.18 Psychological Adaptation
References
11 Clinical Syndromes of Incomplete Spinal Cord Lesions
11.1 1.Anatomy of the Relevant White Matter Tracts to
Incomplete Spinal Cord Syndromes
11.1.1 Corticospinal Tract
11.1.2 Posterior Columns
11.1.3 Spinothalamic Tract
11.2 Incomplete Spinal Cord Syndrome
11.2.1 Central Cord Syndrome
11.2.2 Brown-Séquard Syndrome (Unilateral Cord
Syndrome)
11.2.3 Anterior Cord Syndrome
11.2.4 Cauda Equina and Conus Medullaris Syndrome
11.2.5 Posterior Cord Syndrome
11.2.6 Subacute Combined Degeneration Myelopathy
(Posterolateral Column Syndrome)
11.2.7 Cruciate Paralysis
11.2.8 Anterior Horn Syndrome
References
12 Posttraumatic Syringomyelia and Chiari Malformations
12.1 Posttraumatic Syringomyelia
12.1.1 Epidemiology
12.1.2 Pathogenesis
12.1.3 Classification
12.1.4 Clinical Presentation
12.1.5 Diagnosis
12.1.6 Management
12.2 Chiari Malformations
12.2.1 Classification
12.2.2 Pathogenesis of Chiari I Malformation and
Syringomyelia
References
13 Cauda Equina and Conus Medullaris Lesions
13.1 Cauda Equina Syndrome
13.1.1 Development and Anatomical Features of the Cauda
Equina
13.1.2 Etiology
13.1.3 Pathophysiology
13.1.5 Physical Examination
13.1.6 Management
13.1.7 Prognosis
13.2 Cauda Equina Vs.Conus Medullaris Lesions
References
14 Nontraumatic Spinal Cord Lesions/Diseases
14.1 Degenerative Cervical Myelopathy
14.1.1 Epidemiology
14.1.3 Physical/Neurological Examination and Clinical
Presentation
14.1.4 Imaging Study
14.1.5 Differential Diagnosis
14.1.6 Management
14.2 Cauda Equina Lesion
14.3 Adjacent Segment Disease
14.4 Spine and Spinal Cord Tumors
14.4.1 Symptoms and Signs
14.4.2 Diagnosis
14.4.3 Management
14.5 Multiple Sclerosis
14.6 Neuromyelitis Optica Spectrum Disorder
14.7 Idiopathic Transverse Myelitis
14.8 Amyotrophic Lateral Sclerosis
14.8.1 Prognostic Factors
14.8.2 Clinical Presentations
14.8.3 Diagnostic Criteria
14.8.4 Management
14.9 Vascular Disease and Ischemic Injury
14.9.1 Vascular Disease of the Spinal Cord
14.9.2 Arteriovenous Malformations
14.10 Ossification of the Posterior Longitudinal Ligament
14.11 Arachnoiditis
14.12 Poliomyelitis
14.13 Spine and Spinal Cord Infection
14.14 Nutritional Myelopathy
14.15 Myelopathy Due to Electrical or Lightning Injuries
14.16 Myelopathy Due to Decompression Sickness
14.17 Radiation Myelopathy
References
15 Autonomic Nervous System in Spinal Cord Injuries
15.1 Anatomy of Autonomic Nervous System
15.1.1 Sympathetic Nervous System
15.1.2 Parasympathetic Nervous System
15.2 Neurotransmitters
15.3 Evaluation of Autonomic Function
15.3.1 Tests of Autonomic Cardiovascular Reflexes
15.3.2 Heart Rate Variability
15.3.3 Testing of Sudomotor Function
15.4 Autonomic Nervous System Dysfunction in Spinal Cord
Injury
15.4.1 Cardiovascular Dysfunction
15.4.2 Abnormal Response to Hypoglycemia
15.4.3 Impairment of Gastric Motility
15.4.4 Disorder of Temperature Regulation
References
16 Cardiovascular Dysfunction in Spinal Cord Injuries
16.1 Cardiovascular Consequences as Autonomic Dysfunction
16.1.1 Pathophysiology of Cardiovascular Consequences as
Autonomic Dysfunction
16.1.2 Neurogenic Shock
16.1.3 Resting Blood Pressure
16.1.4 Bradycardia
16.1.5 Orthostatic Hypotension
16.1.6 Autonomic Dysreflexia
16.2 Cardiovascular Consequences as Metabolic Disorder
16.3 Deep Venous Thrombosis
16.4 Peripheral Arterial Disease
16.4.1 Assessment and Management of Peripheral Arterial
Disease
References
17 Orthostatic Hypotension and Associated Supine Hypertension
17.1 Orthostatic Hypotension
17.1.1 Epidemiology
17.1.2 Precipitating Factors
17.1.4 Clinical Presentations
17.1.5 Symptom Grading of Orthostatic Intolerance
17.1.6 Diagnosis
17.1.7 Management
17.2 Supine Hypertension
References
18 Autonomic Dysreflexia
18.1 Epidemiology and Etiology
18.2 Pathophysiology
18.3 Clinical Presentation
18.4 Assessment
18.5 Management
18.6 Prevention and Education
References
19 Venous Thromboembolism in Spinal Cord Injuries
19.2 Diagnosis
19.2.1 Deep Vein Thrombosis
19.2.2 Pulmonary Embolism
19.3 Prevention of Deep Vein Thrombosis
19.4 Treatment of Deep Vein Thrombosis and Pulmonary
Embolism
19.4.1 Unfractionated Heparin
19.4.2 Low Molecular Weight Heparin
19.4.3 Warfarin
19.4.4 Direct Oral Anticoagulants (Non-Vitamin K Oral
Anticoagulants)
19.4.5 Inferior Vena Cava Filter
19.4.6 Others
References
20 Respiratory Dysfunction in Spinal Cord Injuries
20.1 Respiratory Anatomy
20.1.1 Respiratory Muscles
20.1.2 Inspiratory Muscles
20.1.3 Expiratory Muscles
20.2.1 Respiratory Muscle Weakness
20.2.2 Altered Compliance of the Thorax
20.2.3 Altered Coordination of the Thoracic Cage and
Abdomen
20.2.4 Effect of Altered Airway
20.2.5 Effect of Position
20.3 Assessment
20.3.1 Pulmonary Function Test
20.3.2 Maximum Inspiratory Pressure (MIP) and Maximum
Expiratory Pressure (MEP)
20.3.3 Peak Cough Flow (PCF)
20.3.4 Arterial Blood Gas Analysis
20.3.5 Chest Measurement
20.4 Management of Respiratory Dysfunction
20.4.1 Secretion Management
20.4.2 Management of Respiratory Muscle Weakness and
Breathing Fatigue
20.4.3 Mechanical Ventilation in the Acute Phase
20.5 Rehabilitation of Ventilated Patients During the Acute
Phase
20.5.1 Tracheostomy and Tracheostomy Tube
20.5.2 Communication and Mobilization
20.5.3 GlossopharyngealBreathing
20.5.4 Weaning of Mechanical Ventilator
20.5.5 Weaning of Tracheostomy
20.5.6 Long-Term Mechanical Ventilation
20.5.7 Noninvasive Ventilation
20.5.8 Alternatives for Long-Term Mechanical Ventilation
20.6 Respiratory Complications
20.6.1 Atelectasis
20.6.2 Pneumonia
20.6.3 Ventilator-Associated Pneumonia
20.6.4 Sleep Apnea
References
21 Electrolyte Disorders and Management in Spinal Cord Injuries
21.1 Sodium
21.1.1 Hyponatremia
21.1.2 Hypernatremia
21.2 Potassium
21.2.1 Hypokalemia
21.2.2 Hyperkalemia
21.3 Calcium
21.3.1 Hypercalcemia
21.3.2 Hypocalcemia
21.4 Hormonal Changes
21.5 Chronic Dependent Edema
References
22 Metabolic Disorders in Spinal Cord Injuries
22.1 Disorder of Glycemic Regulation
22.2 Bone Loss After Spinal Cord Injury
22.2.1 Assessment
22.2.2 Management
22.3 Fractures
22.4 Metabolic Syndrome
22.4.1 Changes in Body Composition After Spinal Cord
Injury
22.4.2 Diagnosis
22.4.3 Treatment
22.5 Nutrition
22.5.1 Nutritional Problems in the Acute Phase of Spinal
Cord Injury
22.5.2 Nutritional Support
22.6 Coronary Heart Disease
22.6.1 Diagnosis
22.6.2 Management
References
23 Voiding Dysfunction and Genitourinary Complications
23.1 Anatomy of the Urinary Tract
23.2 Innervation of the Lower Urinary Tract
23.3 Functions of the Lower Urinary Tract
23.3.1 Storage
23.3.2 Emptying
23.4 Physical and Neurological Examination
23.5 Neurogenic Bladder Dysfunction
23.5.1 Lower Motor Neuron Lesion Bladder Dysfunction
23.5.2 Upper Motor Neuron Lesion Bladder Dysfunction
(Suprasacral Lesion)
23.5.3 Assessment
23.6 Medical and Social Concerns
23.7 Voiding Methods
23.7.1 Intermittent Catheterization
23.7.2 Credé and Valsalva Maneuver
23.7.3 Reflex Voiding
23.7.4 Indwelling Catheter
23.7.5 Sacral Root Stimulation and Rhizotomy
23.8 Management
23.8.1 Neurogenic Bladder Management Routines
23.8.2 Pharmacological Management
23.9 Urinary Tract Infection
23.9.1 Diagnosis
23.9.2 Treatment of Urinary Tract Infection
23.9.3 Recurrent Urinary Tract Infection
23.9.4 Prevention of Urinary Tract Infection
23.10 Vesicoureteral Reflux
23.11 Urinary Stones
23.12 Malignancy
23.13 Nocturnal Polyuria
23.14 Epididymitis
23.15 Follow-Up Evaluation
23.16 Special Considerations of the Urological Management in
Elderly Patients with Spinal Cord Injuries
23.16.1 Upper Urinary Tract Changes with Aging
23.16.2 Lower Urinary Tract Changes with Aging
References
24 Bowel Dysfunction and GastrointestinalComplications
24.1 Functional Anatomy and Physiology of the Bowel
24.1.1 Colon and Anorectum
24.1.2 Neural Innervations
24.1.3 Colonic Reflexes
24.1.4 Defecation
24.2 Neurogenic Bowel Dysfunction
24.2.1 Upper Motor Neuron Neurogenic Bowel
24.2.2 Lower Motor Neuron Neurogenic Bowel
24.2.3 Assessment
24.2.4 Management of Neurogenic Bowel Dysfunction
24.3 Other GastrointestinalProblems
24.3.1 Fecal Impaction
24.3.2 Constipation
24.3.3 GastroesophagealReflux
24.3.4 Acute Abdomen and GastrointestinalBleeding
24.3.5 Gallbladder Disease
24.3.6 Clostridium difficile Infection
24.3.7 Superior Mesenteric Artery Syndrome
24.3.8 Hemorrhoids
24.4 Lifespan Care of Neurogenic Bowel Dysfunction
References
25 Sexuality Changes after Spinal Cord Injuries
25.1 Neurophysiology of Sexual Arousal
25.2 Physical Examinations on Sexual Dysfunction in Spinal
Cord Injuries
25.3 Psychological Considerations
25.4 Male Sexuality
25.4.1 Erection
25.4.2 Ejaculation
25.5 Female Sexuality
25.6 Erectile Dysfunction and Management
25.6.1 Phosphodiesterase Type 5 (PDE-5) Inhibitors
25.6.2 Intracavernosal Injections
25.6.3 Vacuum Erection Device
25.6.4 Intreurethral Alprostadil (Medicated Urethral System
for Erection, MUSE)
25.6.5 Penile Prosthesis
25.7 Sexual Arousal in Males and Females with Spinal Cord
Injuries
25.7.1 Sexual Dysfunction in Males with Spinal Cord Injuries
25.7.2 Sexual Dysfunction in Females with Spinal Cord
Injuries
25.8 Fertility in Patients with Spinal Cord Injuries
25.8.1 Male Fertility
25.8.2 Menstruation, Birth Control, and Female Fertility
25.9 Sexual Activity of Spinal Cord Injuries in Practice
References
26 Spasticity
26.1.1 Evolution of Reflexes and Spasticity After Spinal Cord
Injury
26.1.2 Upper Motor Neuron Syndrome and Function
26.2 Assessment
26.2.1 Clinical Scales to Quantify Spasticity
26.3 Treatment
26.3.1 Positioning
26.3.2 Physical Therapy
26.3.3 Orthoses
26.3.4 Medications
26.3.5 Chemoneurolysis
26.3.6 Botulinum Toxin
26.3.7 Intrathecal Baclofen
26.3.8 Surgical Procedures
26.4 Contracture
26.4.1 Common Sites of Contractures
26.4.2 Beneficial Contractures
26.4.3 Prevention of Disadvantageous Contractures
26.4.4 Treatment of Contractures
References
27 Pressure Injuries
27.2 Staging and Assessment of Pressure Injuries
27.2.1 Additional Pressure Injury Definitions
27.3 Beds for Pressure Injuries
27.4 Pressure Injury Prevention
27.5 Treatment of Pressure Injuries
27.5.1 Basic Nonsurgical Care:Cleaning, Debridement, and
Dressing
27.5.2 Pressure Injury Management in Practice
27.5.3 Surgical Management
27.6 Marjolin’s Ulcer
References
28 Heterotopic Ossification
28.1 Pathogenesis
28.2 Clinical Features
28.3 Diagnosis
28.4 Classifications of Heterotopic Ossification
28.5 Prophylaxis
28.6 Management
References
29 Pain Types and Taxonomies
29.2 Pain Terminology and Classification of Spinal Cord Injury
29.2.1 Nociceptive Pain
29.2.2 Neuropathic Pain
29.3 Diagnosis and Screening of Pain
29.4 Treatment
References
30 ThermoregulatoryImpairment
30.1 Anatomy and Physiology of Thermoregulation
30.2 Disorder of Thermoregulationin Spinal Cord Injuries
30.3 Management of Poikilothermia
References
Index
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021
H.-Y. Ko, S. Huh, Handbook of Spinal Cord Injuries and Related Disorders
https://doi.org/10.1007/978-981-16-3679-0_1
1. Clinical and Functional Anatomy of the

Spinal Cord
Hyun-Yoon Ko1 and Sungchul Huh2
(1) Department of Rehabilitation Medicine, Rehabilitation Hospital, Pusan
National University Yangsan Hospital, Pusan National University College
of Medicine, Yangsan, Korea (Republic of)
(2) Department of Rehabilitation Medicine, Rehabilitation Hospital, Pusan
National University Yangsan Hospital, Yangsan, Korea (Republic of)
Keywords Spinal cord – Development – Metamerism – Myotome –

Dermatome – Myelination – Descending tracts – Ascending tracts
The spinal cord controls the voluntary muscles of the trunk as well as the
upper and lower extremities and receives sensory information from the areas
of the body. It is anchored to the dura mater by denticulate ligaments and
extends from the cervicomedullary junction to the tip of the conus medullaris
at the lower border of the first lumbar vertebra, which is individually variable
(Bican et al. 2013). There are 20 or 21 pairs of denticulate ligament attached to
the anterolateral segment of the spinal cord. The spinal cord is anchored
caudally by filum terminale: filum terminale internum in the dural sac and
filum terminale externum outside the dural sac up to the coccyx. Basic
knowledge of anatomy and embryologic development, including metamerism
of the myotomes and dermatomes is very important for the interpretation and
understanding of the pathological findings of the spinal cord, as well as for the
diagnosis and lesion localization of the lesions.
1.1 Development of the Spinal Cord

The mantle layer of the neural crest between the ventricular zone and the
marginal zone is located around the primitive spinal cord and arises from
multiple neuroepithelial cell divisions. The mantle layer becomes the gray
matter of the spinal cord. The marginal zone eventually becomes the white
matter of the mature spinal cord. Two distinct paired regions can be observed
in the mantle layer: the dorsal thickening is called the alar plate (future
sensory areas of the spinal cord), and the ventral thickening is the basal plate
(future motor area of the spinal cord).
Development of motor neurons that form the nuclei of the ventral gray
columns progresses in the caudal direction and reaches the site of the cervical
enlargement at about 30 days. The subdivisions of the ventral gray column
begin to appear apparent before the end of the 6th week. The neurons of the
ventral horn arise from five different columnar subpopulations. The lateral
motoneurons located in the cervical and lumbosacral enlargement of the
spinal cord will later innervate the muscles of the extremities (Tomlinson et al.
1973). The medial motor neurons, which are found in the entire spinal cord,
will later innervate axial muscles. The visceral motor neurons occur in the
intermediolateral column in the thoracic and upper lumbar segments.
The development of skeletal muscle fibers from myotomes and limb bud
mesenchyme is parallel to the development of neural structures. Myofibrils
appear in human myoblasts during 5 weeks, and the cross striations are visible
at 7 weeks. Figure 1.1 shows both quantitative and qualitative changes in the
developing spinal cord of a GW 4.5 embryo. The quantitative change is the
growth of the lateral neuroepithelium. The formation of the cluster of
differentiating cell signals the onset of the exodus of postmitotic cells from the
ventral neuroepithelium and the onset of differentiation of the earliest spinal
cord neurons, the ventral horn motor neurons. Nerve fibers enter the
primordial muscles, and simple nerve endings are present among myoblasts in
human embryos at 7 weeks (Fig. 1.2). There are neurons in the spinal ganglia
of the human embryos before the beginning of the fifth week. The ganglion
cells are initially bipolar, and their central processes reach the spinal cord,
where they initiate the posterior funiculi. Interneurons are born both in the
areas of the dorsal root plate as well as the ventral root plate. The posterior
spinal cord forms six distinct progenitor pools (dp1–dp6). Interestingly, most
of these early subtypes develop into commissural interneurons projecting to
the contralateral side of the spinal cord. In the mature central nervous system,
these commissural interneurons are essential components of left-right
locomotor coordination and are major components of central pattern
generators playing a fundamental role in the rhythmic, coordinated movement
of the limbs and trunk (Vallstedt and Kullander 2013).
Fig. 1.1 GW 4.5. The cluster of differentiating cells that flank the ventral neuroepithelium
(red outline) is the earliest motoneurons of the incipient ventral horn. From Altman and
Bayer (2001)
Fig. 1.2 GW 7.0. The cervical spinal cord in a GW 7.0 embryo. The ventral canal and the
ventral neuroepithelium are disappearing, and the ventral horn motoneurons have grown
considerably, but the population of dorsal interneurons (yellow) is small. From Altman and
Bayer (2001)
Regression is the process of formation of the filum terminale and the cauda
equina and the migration of the conus medullaris to its adult level at the L1/L2
vertebral body. On days 43–48 of gestation, the future site of the conus
medullaris, known as the ventriculus terminalis, develops. Initially, it is located
at the level of the second coccygeal vertebra. At 3 months, the appearance of
the spinal cord is similar to that of the adult, but unlike the adult, it occupies
the entire spinal canal. Until then, the mantle layer has a shape that
characterizes mature gray columns, and the posterior and anterior horns are
connected by an isthmus, including the central canal lined by ependymal cells.
The nerve fibers of the marginal layer are unmyelinated and, until the middle
of the gestation period, the myelination begins to produce white matter in the
spinal cord. The caudal neural tube may then regress, and the ventriculus
terminalis around the spinal canal is obliterated, thus allowing the ventriculus
terminalis to rise within the spinal canal. This is 18 weeks at the level of L4
vertebral body because it is relatively fast at the beginning. Then, the rise is
slowed down and the tip of the spinal cord is at the L2–L3 interspace at birth
and reaches the adult level of the L1–L2 interspace by the first 3 postnatal
months. When the neural tube rises, there remains a fibrous band between the
ventricularis medullaris and the tip of the coccygeal vertebrae, which becomes
the filum terminale. During this ascent, the nerve roots that originally leave the
spinal canal opposite to their segmental origin of the spinal cord must be long
to be cauda equina (Keegan and Garrett 1948).
The discrepancy between the position of spinal cord segments with their
nerve roots and corresponding bony structures due to differences in growth
rates during embryonic development becomes more evident in the more
caudal spinal cord segments so that the nerve roots connected to the lower
lumbar, sacral, and coccygeal spinal cord segments have to travel longer
distances before reaching appropriate intervertebral foramina to pass. As the
nerve roots descend to their corresponding vertebral level, they become more
oblique from rostral to caudal so that the lumbar and sacral nerves descend
almost vertically to reach their exit points. These long spinal nerve roots
surrounding the filum terminale form the cauda equina, in which most caudal
segments are most centrally located. The three vertebrae (T11–L1) usually lie
over all ten lumbosacral spinal cord segments (L1–S5) (Fig. 1.3). From C5 to C8
spinal cord segment level is 1 level higher than the corresponding vertebral
body. Thus, the C5 cervical vertebral body corresponds to the level of the C6
spinal cord segment. In the upper thoracic region, the vertebral body is two
segments above the corresponding cord segment. In the lower thoracic and
upper lumbar regions, the difference between the vertebral level and spinal
cord segment level is two or three segments so that a spinal cord sensory level
at T9 would correspond to a pathologic abnormality at the T6 or T7 vertebral
body. The levels of the lumbar and sacral spinal cord segments correspond to
vertebral T12–L1 levels (Table 1.1).
Fig. 1.3 Diagrammatic representation of spinal cord segments in their relations to vertebral
bodies and spinous process, and levels of the emergence of spinal nerves. From Windle (1980)
Table 1.1 Vertebral bodies in their relations to corresponding spinal cord segments
Vertebral body Corresponding spinal cord segment

Upper cervical (C1–C4) Same spinal cord segment
Lower cervical (C5–C7) Add 1 segment
Upper thoracic (T1–T6) Add 2 segments
Lower thoracic (T7–T10) Add 3 segments
T11–T12 Lumbar segments
T12–L1 Sacral segments (conus medullaris)
Below L1 Cauda equina
The cord is an approximately cylindrical structure of average length 45 cm
in the male and less than 43 cm in the female. The spinal cord has an uneven
contour due to the presence of cervical and lumbar enlargements associated
with the spinal nerves for the upper and lower extremities. The enlargements
appear first in the embryo at the time of formation of the limbs. The size of the
spinal cord in adults is four times longer than at birth. Its weight increases
from 7 to 90 g or more, and its volume in adults increases from 6 to nearly
80 mL.
1.2 Metamerism
The spinal cord is a segmental organ. Each of the 31 pairs of spinal nerves
supplies a metamere or body segment derived from an embryonic somite.
Metamerism is more evident in the thoracic than in other regions of the adult
body, and the fields of sensory innervation are easier to identify than those of
motor innervation. The outgrowth of limb buds in the embryo causes
complicated metameric patterns.
The body surface areas supplied by the nerve fibers from a single dorsal
root ganglion are defined as a dermatome. The dermatomes are orderly in the
embryo, but they are distorted by outgrowth of the limbs so that the C4
dermatome is above T2 at the level of the sternal angle. Finally, the C5
dermatome is located next to the T1 dermatome (Biller et al. 2017; Vanderah
and Gould 2016) (Fig. 1.4). The junctions are marked by “axial lines” in the
diagram. A similar relationship exists in the lower extremities. At the 8th week,
medial rotation of the lower limb reverses the preaxial and postaxial borders,
creating a spiral arrangement of dermatomes (Fig. 1.5). Spinal nerve segments
on the anterior surface of the lower extremity extend medially and inferiorly.
The great toe is supplied by nerves from a more rostral dermatome (L4) rather
than the little toe (S1). The lower extremity is an extension of the trunk, and
most caudal dermatomes supply the perineum, not the foot (Felten et al.
2016). Cervical dermatomes maintain a relatively orderly distribution in the
upper extremity with minimal rotation. Within the same spinal cord segment,
the region of the sensation is also determined by the typical topographic
organization (Altman and Bayer 2001) (Fig. 1.6). Most dermatomes overlap
one another to a varying extent, but there is less overlap with pain and
temperature than with touch. An overlap of sensory fibers, which can reach
25–40 mm, occurs along the midline (Kellgren 1939).
Fig. 1.4 Development of dermatomes of the upper extremity of human embryos. Outgrowth
of limb buds in the embryo results in complications of the metameric patterns. Finally, the C5
dermatome lies next to the T1 dermatome due to outgrowth of the upper extremities carrying
the intervening dermatomes. From Biller et al. (2017)
Fig. 1.5 Changes in ventral dermatome pattern during limb development with limb rotation.
Rotation of the lower limb results in a reversal of the preaxial and postaxial borders,
producing a spiral arrangement of dermatomes. Spinal nerve segments on the anterior surface
of the lower extremity extend medially and inferiorly; the great toe (hallux) is supplied by
nerves from a more rostral dermatome (L4) than the little toe (S1). The lower extremity is an
extension of the trunk, and the most caudal dermatomes (sacral and coccygeal) supply the
perineum, not the foot. Cervical dermatomes maintain a relatively orderly distribution to the
upper extremity with minimal rotation. From Felten et al. (2016)
Fig. 1.6 Somatotopic organization of cutaneous afferents in laminae II-III of the cervical and
upper thoracic spinal cord of the cat. Sensory fibers from the dorsal skin, arm, forearm, and
hand are arranged in a lateral to medial order. Digit II, III, and IV are represented in a rostral-
to-caudal order. From Altman and Bayer (2001)
Metamerism also occurs in the innervation of skeletal muscles. Few
muscles have been derived from a single somite. The adductor pollicis and
some of the small deep muscles of the back may have a monosegmental
innervation. Other muscles receive nerve fibers from two to five ventral roots,
especially in the upper and lower extremities (Keegan and Garrett 1948).
1.3 Myelination
Myelin formation on nerve fibers of the spinal cord occurs only in the middle of
fetal life. It is then thought to be associated with differentiation of glioblasts
into oligodendrocytes. The first myelination of axons in the human is observed
in the early fetal spinal cord at less than 16 weeks of gestation. Although not
many mammals, myelination in the human is part of the postnatal
developmental period. The earliest structure to myelinate is the medial
longitudinal fascicles in the upper cervical spinal cord at 20 weeks, with the
corticospinal tract being the last, and myelination during the first year after
birth (Armand 1982; Weidenheim et al. 1996). The process of myelin
formation continues for several years, but the exact time of its completion is
unknown (Fig. 1.7).
Fig. 1.7 Schematic summary of the myelination of the corticofugal tract. A corticospinal
tract that descends through the internal capsule, the cerebral peduncle, the pontine gray, and
crosses in the pyramid is the absence of myelin at birth. At 1 month of age, a small
complement of myelinating corticofugal fibers reaches the pontine gray. But the bulk of the
corticofugal tract remains unmyelinated. There is an increase in the proportion of myelinated
fibers in the upper corticofugal tract between 2 and 3 months. The myelination of the bulk of
the lower corticospinal tract occurs between 4 and 8 months of age. From Altman and Bayer
(2001)
1.4 Anatomy of the Spinal Cord

The spinal cord consists of outer white matter with ascending sensory and
descending motor tracts and inner gray matter with nerve cell bodies. The
volume of gray matter is largest in the cervical and lumbar regions, while the
white matter volume gradually tapers craniocaudally. The gray matter
surrounds a central canal, which is anatomically an extension of the fourth
ventricle and is lined with ependymal cells and filled with cerebrospinal fluid.
In addition to the dorsal and ventral horns in the gray matter, a lateral horn
(intermediolateral cell column), which contains the cell bodies of preganglionic
sympathetic neurons, is visible in the thoracic and upper lumbar segments.
1.4.1 Overview of Anatomy of the Spinal Cord

The spinal cord is responsible for the motor, somatosensory, and visceral
innervation of the extremities, trunk, and large parts of the neck, and inner
organs. The spinal cord has a relatively simple structure and function
compared to the brain and occupies about 2% of the total human nervous
system. However, even a small sized injury of the spinal cord can cause a
variety of neurological symptoms and signs, including motor, sensory, and
autonomic nervous system, because structures in the spinal cord are compact
and concentrated in a small and narrow space. The topography and
cytoarchitecture of the human spinal cord are well known, but the functional
implications of well-described structures are difficult to explain (Cho 2015).
The spinal cord is anatomically defined as a structure of the central
nervous system located between the cervicomedullary junction and the tip of
the conus medullaris. Clinically, however, a spinal cord injury is defined to
include the concept of the cauda equina as well as the spinal cord. The cauda
equina is the structure of a bundle of lumbar and sacral nerve roots located
below the tip of the conus medullaris in the spinal canal (Barson 1970). The
mean length of the spinal cord from the cervicomedullary junction to the tip of
the conus medullaris is 41–43 cm in females and 45 cm in males, and its width
ranges from 1.27 cm in cervical and lumbar regions to 64 mm in the thoracic
region (Bican et al. 2013). There is no significant difference in length according
to height, but a tendency for the tip of the conus medullaris to be higher in
taller person than the shorter person is noted. In the cervical and lumbar
regions of the spinal cord, there are enlargements where the neurons
innervate the upper and lower extremities, respectively.
The spinal canal extends from the foramen magnum to the tip of the
sacrum, to the sacral hiatus of the fourth sacral spine, and contains various
neural or non-neural structures. During development and up to 14 weeks after
conception, the spinal cord covers the entire length of the embryo, and the
spinal nerves leave the vertebral column through the corresponding
intervertebral foramina. Subsequent growth and elongation of the vertebral
column cause relative growth, ascensus medullae. The spinal cord extends
from the foramen magnum to the lower part of the first lumbar vertebra or the
space between the first lumbar spine and the second lumbar spine, where the
spinal cord terminates in the adult as the conus medullaris (Barson 1970). The
cervical and upper thoracic rootlets are perpendicular to the spinal cord, while
the lower thoracic, lumbar, and sacral rootlets are increasingly oblique due to
the difference in length between the spinal cord and vertebra. Thus, the spinal
cord segment does not correspond to the vertebral level below the upper
cervical spinal cord segments. This discrepancy between the spinal cord
segments and vertebral levels is gradually more pronounced for the more
caudal segments of the spinal cord as the spine grows faster than the spinal
cord during development.
A spinal cord segment is defined as a spinal cord between the proximal and
distal ends of attachment sites of the ventral and dorsal roots, with the ventral
and dorsal root filaments of each nerve root attached to the spinal cord (Fig.
1.8). Thirty-one spinal cord segments, from the first cervical to the fifth sacral
spinal cord segment, have different quantitative measures. The weight of each
spinal cord segment is about 1 g, but the length is variable according to the
regions: about 25 mm in the midthoracic spinal cord, about 12 mm in the mid
cervical spinal cord, and about 10 mm in the mid lumbar spinal cord (Fig. 1.9).
The spinal cord segment T6 is the longest, with an average length of 22.4 mm.
The longest segment in the cervical and lumbar spinal cord is the segment C5
and L1, respectively, with an average length of 15.5 mm. The anteroposterior
diameter of each spinal cord segment is 6–8 mm, relatively uniform, but there
are differences in the lateral diameters. The longer the length, the shorter the
lateral diameter. The diameter of the cervical and lumbar enlargements is
greater than that of the other parts of the spinal cord, and the quantitative
features of the cervical and lumbar enlargements are determined by the lateral
diameters (Ko et al. 2004).
Fig. 1.8 Spinal cord segment
Fig. 1.9 (a) Sagittal diameter and (b) lateral diameter of each segment of spinal cord
In the center, the gray matter forms the sensory dorsal and motor ventral
horns of the nerve cells. The white matter containing the long motor and
sensory tracts is distributed on the periphery. The blood supply to the spinal
cord consists of one anterior and two posterior longitudinal spinal arteries.
Arising from the vertebral artery at the foramen magnum, the anterior and
posterior spinal arteries receive additional branches from radicular arteries
that enter the spinal canal along with the nerve roots (Turnbull et al. 1966).
The branches of the anterior and posterior spinal arteries form a
circumferential network around the spinal cord and penetrate into the spinal
cord from the outside. They are completely exposed to the cerebrospinal fluid
in the subarachnoid space and can easily be damaged by tumors, infection, or
toxins in the space. In the spinal cord, the anterior spinal artery feeds mainly
the anterior two-thirds, and the posterior spinal arteries supply the posterior
third, which distinguish the anatomical origin from the vascular ischemic
lesion of the spinal cord (Cole and Weller 1998; Etz et al. 2011; Novy et al.
2006; Rubin and Rabinstein 2013).
The main descending motor pathway from the brain occupies the lateral
part of the cord and enters the ventral horn to synapse with segmental motor
nuclei. The lower motor neurons from the motor nuclei, both alpha and
gamma, leave the spinal cord through the ventral roots to innervate their
target muscle fibers (extrafusal and intrafusal). Classical clinical examination
of motor function in the spinal cord is mainly concerned with the examination
of the pyramidal tract. Other motor tracts from extrapyramidal system are
considered to be related to more proximal automatic movements. The
relationship between descending tracts and motor function is a very complex
issue that is not clinically or physiologically significant in spinal cord pathology
(Norenberg et al. 2004).
Sensory afferent neurons have their cell bodies in the dorsal root ganglia.
The proximal parts of the sensory axons enter the cord through the dorsal
roots. Large myelinated sensory fibers mediate a low threshold cutaneous
mechanoreceptor and muscle and joint information, pass through the dorsal
horn and ascend in the ipsilateral dorsal column nuclei to make the synapses
in the dorsal column nuclei. Small myelinated and unmyelinated fibers that
transmit information about temperature, pain, and muscle fatigue synapse in
the laminae of the dorsal horn before ascending in the contralateral
spinothalamic tracts (Bican et al. 2013). This crosses at or near the segmental
level in the anterior part of the cord that is close to the central canal, making
these fibers susceptible to the pressure effects associated with a syrinx and
leading to classical dissociated sensory loss.
1.4.2 White Matter and Tracts

The white matter includes ascending and descending tracts composed of nerve
fibers from ganglia of dorsal roots, nerve fibers from nerve cells of the spinal
gray matter, and nerve fibers from nerve cells at higher levels, the brain. In
addition to the nerve fibers, the white matter also has neuroglia cells with their
processes and blood vessels. In addition to axonal tracts, the white matter
contains a variety of glial cells: oligodendrocyte, astrocytes, and microglia. The
ascending neurons in humans appear at 10 gestational weeks (Clowry et al.
2005). At 13 weeks of gestation, the lateral corticospinal tract in humans
reaches the caudal medulla oblongata. Two weeks later, the pyramidal
decussation is completed (ten Donkelaar et al. 2004; Armand 1982). The
lateral corticospinal tract reaches the cervical spinal cord between 14 and 16
Another random document with
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“Not at all,” replied Ned. “If you will look at your contract again,
you will see that it is clearly stated that those prices are f. o. b.
Shopton.”
“Scalping us like regular Indians,” snarled Hankinshaw.
Thompson silenced him with a look. A long debate ensued, which
ended with Ned’s carrying his point.
“Now there’s one other point,” said Thompson. “How about this
proviso that five thousand of the amount shall be paid down on the
signing of the contract? It doesn’t seem to me that that is necessary
or usual.”
“It’s usual enough in an affair of this size,” replied Ned. “It’s only a
matter of prudence or self-protection. You must realize, Mr.
Thompson, that our acquaintance has been of very short duration
and that we have never done business with you before. We have no
doubt, of course, that everything is all right. There is nothing
personal in this. It is just a matter of ordinary business precaution
and procedure. This is a new line of work for us, and we shall have
to incur a large initial expense for new tools that we have not hitherto
required. Under the circumstances, therefore, we shall have to
require that five thousand be paid down on the signing of the
contract, five thousand more two weeks from now, five thousand four
weeks from now and the balance on completion of the work. If you
were building a house you would have to make some arrangement
of the kind. We are asking nothing more of you than we do of others
who are doing business with us for the first time.”
“I should think that Mr. Damon’s recommendation would have
been sufficient,” grumbled Hankinshaw.
“Mr. Damon’s acquaintance was limited to Mr. Thompson, and I
gathered was not very intimate,” replied Ned. “I guess we’ll have to
leave him out of this.”
Hankinshaw was for continuing the argument, but the more
astute Thompson, who saw that extended controversy on this point
was liable to convey the impression that their financial responsibility
was not what it should be, yielded the point.
“You certainly are a hard-boiled lot,” he said, with an attempt at
jocularity. “But I guess you have us where you want us and that we’ll
have to sign on the dotted line. That is,” he added, looking at his
companions, “if my partners agree.”
They nodded, Bragden reluctantly and Hankinshaw scowlingly.
Tom and his father affixed their signatures, which were followed
by those of the three visitors.
“Well, now that that’s settled,” remarked Thompson, as he rose
from his chair, “I guess we’ll have to be getting along. Mr. Bragden
and I have to get the night train. Mr. Hankinshaw will stay here for a
while to take care of our interests and keep an eye on the work.”
“Just a moment,” put in Ned. “That matter of the initial check for
five thousand.”
“Oh, yes,” said Thompson. “How careless of me to overlook that.
If you’ll hand me that pen, I’ll fix it up.”
He took out a checkbook and wrote a check for five thousand
dollars.
“There you are,” he said, handing it to Ned with a flourish.
Ned scanned it closely.
“The amount is all right,” he said, after an instant, “but the date is
wrong. You’ve got it the 27th of May, while this is only the 21st.”
“Sure enough,” replied Thompson, with an air of vexation, as he
looked at it. “I made it the 21st, but there must have been a hair on
the pen and that made it a seven. Tear that one up and I’ll make you
out another. And this time I’ll see that the pen is clean.”
He rubbed the pen carefully and made out another check that
was correct. Ned examined it, folded it and put it in his pocket.
“The receipt of this is already acknowledged in the contract,” he
reminded Thompson, and the latter nodded.
The visitors said good-night and took their leave, Rad opening
the door for them with a profound bow that put such a crick in his
back that he had hard work straightening up again.
“Well, Ned,” said Tom, “I have to hand it to you for the way you
carried your points. You’re all wool and a yard wide as a business
man.”
“You surely are, Ned,” agreed Tom’s father warmly. “You and Tom
make a good team, he for the inventive and you for the financial end
of the business. But now, as I’m pretty tired, I guess I’ll go over to the
house and take Rad along.”
“All right, Dad,” said Tom. “I’ll be over before long. Hope you’ll get
a good night’s sleep.”
“I shall if that tooth will let me,” and Mr. Swift smiled faintly. He
had been having a great deal of trouble with his teeth.
“Better see a dentist in the morning and have it out if it doesn’t
behave.”
“I guess that is what I’ll have to do, Tom.”
“Tom, the next thing for you to invent will be a painless tooth-
pulling machine,” remarked Ned.
“Sounds fine,” returned Mr. Swift, with a smile, and then passed
out.
Left alone, the young men looked at each other.
“On the level now, Ned, what do you think of those birds?” asked
Tom.
“I should call them eels instead of birds,” replied Ned. “They
strike me as being just about as slippery as they come. It was all
right, of course, trying to get better terms. That was just what any
business men would do. But that matter of the check looked fishy to
me. In the first place, he didn’t forget about it as he pretended to do.
Men don’t forget a thing like that.”
“What do you suppose his idea was?” asked Tom.
“Just to get out of reach before we thought, of it. Then perhaps
he thought that we’d go on with the work anyway so as to lose no
time, since we’ve got to get it through in six weeks. We’d have to
correspond with him about it, and he could palter and delay until
we’d got so far along with the work that we’d go on with it anyway.
And then when I nailed him down to it, did you see how he post-
dated the check? Hair on the pen! Tell that to the marines. The idea
was to make the check no good until nearly a week had passed.
That would keep their money in the bank a week longer, or if they
haven’t got the money now to meet it, they’d have a week to get the
funds together to meet it when presented. They may be operating on
a shoestring, anyway.
“Then, too, the check is on a San Francisco bank. That may be
all right, but in the natural course of exchange it will take nearly a
week to collect it. There again we’d be supposed to be well on our
way with the work, so far in fact that we couldn’t back out. But they’ll
get slipped up if they’re trying any funny business there, for I’ll
telegraph the first thing to-morrow morning to find out whether the
check is good, and you’d better not do a stroke of work on the
contract until we’re sure it is.”
“I’m almost sorry we’ve undertaken the work,” said Tom.
“I’m not,” replied Ned. “Of course, it’s much more comfortable to
feel that we’re dealing with perfectly responsible people, but we’ve
got the thing sewed up so that we can’t lose, anyway. They might like
to cheat us, but they can’t. In the first place, we won’t spend a penny
until we’re absolutely sure of five thousand dollars. That will cover
everything until the next payment comes due two weeks from now. If
they renege then, we’ll stop and be money in pocket. If they pay,
we’ll have received ten thousand dollars. The payments after that
they’ll have to make, anyway, for they will already have paid more
than they can afford to lose. We’ve got them every way.
“Then, too, we’ve got a nice little profit in this proposition. It may
also open up a new line that will be big in possibilities. You know
already what I think of oil. The demand already for oil-well machinery
is greater than the supply, and I know of some factories that are
running three shifts and working the whole twenty-four hours to keep
up with their orders. With the new oil fields that are being opened up,
that demand is bound to increase, and there’s no reason why we
shouldn’t get our share of the business. This first order will perhaps
set us on the road to doing this. Then, too, I’m banking on your
inventing something new that will be so good that every oil field will
have to have it. You’ve never tackled anything yet that you haven’t
improved upon.”
“Thanks for the bouquet,” said Tom, grinning.
“No bouquet at all,” answered Ned. “It’s the simple truth, and you
know it.”
“Well,” said Tom, “I’ll do my best. I feel the old urge coming on,
and I’m hankering to get at it. There’s just one thing that’s bothering
me now.”
“What’s that?” asked Ned.
“Hankinshaw,” replied Tom.
CHAPTER VII
TROUBLE BREWING
Ned stopped in his work of gathering up his papers and looked

inquiringly at Tom.
“Hankinshaw!” he repeated. “What about him? What have you
got against him outside of his smoking vile tobacco?”
“A good deal,” answered Tom emphatically. “He’s just about as
popular with me as a rattlesnake at a picnic party.”
“Why the snake?” asked Ned quizzically. “I’m not much of an
authority on natural history, but I’d call him an old crab and let it go at
that. What has he done especially that peeves you?”
“Several things,” replied Tom, who did not care to mention Mary’s
name and tell of the annoyance she had experienced. “For one
thing, I’m pretty sure that he was driving a machine last night that
nearly sent me to kingdom come. Hogged the road and made me go
into a ditch. Then grinned like a gargoyle as he whizzed past. I tell
you for a minute I saw red, and it’s a lucky thing for him that I didn’t
get my hands on him.”
“I imagine that’s the type of fellow he is,” said Ned. “I don’t
wonder that you felt like beating him up. Sorry that Thompson or
Bragden didn’t stop over to look after the work instead of him. They
may be no better than he is at heart, but at least they have the
manners of gentlemen. But, after all, it will be for only a few weeks,
and we’ll try to make the best of it.”
The next day Ned telegraphed to the California bank, and to his
satisfaction learned that the check was good.
“It’s all right,” he told Tom.
“Then I’ll go ahead,” said the young inventor. “I’ll start in right
away and order the material we need, and I’ll get busy gathering all
the information on oil-well machinery and trying to improve on it. No
more car rides or airplane spins, or anything else, for a while. Here’s
where I shed my coat and work night and day. Watch my smoke.”
The next week was one of intense energy and application for the
young inventor. He had the gift of losing himself in his work,
especially when that work interested him. And the further he went
into the subject the greater the grip it got upon him. His enthusiasm
grew as he plunged into the fascinating study of the tremendous
riches in oil that the earth held beneath its surface. Soon he was
absorbed in it as in a thrilling romance. He traced the gradual steps
by which men of all climes and in all ages had sought to possess
themselves of this marvelous wealth stored in nature’s caverns and
only yielded up reluctantly.
“Do you know,” he said one night to Ned, as they sat discussing
the matter in the office, “that the Chinese were the pioneers in the
matter of oil-well digging?”
“No, I didn’t,” replied Ned. “But I’m not surprised. Those old
Chinamen seem to have started most of the things we’ve improved
on later. There’s gunpowder and the compass and a raft of other
things.”
“Well, digging for oil was one of them,” said Tom. “And the
principles they applied underlie the methods we’re using to-day. Of
course, they didn’t use steam power, and that’s where we’ve got the
bulge on them. They worked by man power, and that apparatus was
laughably crude when compared with ours, yet their methods were
strikingly similar to those we’re using now or have been using very
recently.”
“For instance?” said Ned, with a lifting of the eyebrows.
“Well, take their springboard arrangement,” replied Tom. “The
cutting tool, or bit, was suspended in the hole by means of a rattan
cable, and the required movement was given to it by a springboard.
When a coolie jumped on the board, it raised the bit; when he
relieved it of his weight the bit fell and cut its way downward. A drum
with a vertical shaft, around which oxen traveled in a circle, coiled
the cable and lifted the drill out of the hole when they wanted to bail
out the hole or change tools. The bailer was made of a section of
bamboo, and that material was also used for tubing and casing and
pipe lines.
“Now, this springboard was very similar in action and function to
the springpole which we’ve used here in America, chiefly at first for
drilling brine wells. It was used, too, in drilling the first oil well of the
California fields.”
“But they’ve given that up now, haven’t they?” asked Ned.
“Sure they have,” was the answer. “The walking beam, which is
the biggest piece of timber in the present-day drilling rig, has taken
its place. And, of course, that’s now operated by steam instead of
manual labor. But my point is that the old springboard process of the
Chinese and the springpole method that we’ve used till recently are
fundamentally based on the same thing—the percussion process.”
“We’ve got a long way from that now, I imagine,” remarked Ned.
“We have and we haven’t,” replied Tom. “Percussion is still in
common use in a great many wells, especially when they’re not
supposed to go very deep and where the rocks are of comparatively
soft stone. But where these conditions don’t exist, the rotary method
is often employed. In that case two strings of pipe are used, one to
wall up the hole, while the other with the drill attached is rotated
inside of it. An important thing in connection with this method is that
a circulation of thick mud pumped through the drill stem will support
the walls of the hole until the well is completed, provided it isn’t too
deep. It’s being used a lot now in the Texas fields, and I’m looking
into it thoroughly. I tell you, old boy, it’s a fascinating study.”
“That’s the way I like to hear you talk,” said Ned, with a smile.
“Once you get interested in a thing, you’ll never stop until you
improve on it. I’ll bet a year’s salary that before a month’s over, you’ll
have invented something that will set the country talking.”
“Don’t risk your money so recklessly,” laughed Tom.
“I’m not rash,” replied Ned. “As a matter of fact, such a wager
wouldn’t be sportsmanlike, for I’d be betting on a sure thing.”
Although Tom’s time had been taken up so fully day and night
with the contract he had on hand and the new invention he was
evolving, he had not forgotten or neglected the unfortunate airman
whom he and his friends had saved from death.
Several times each week he called up the hospital by telephone
to learn how the patient was progressing. And he had requested
Mrs. Baggert, the housekeeper of the Swift home, to send fruit,
jellies and other delicacies to the sufferer, a task which that warm-
hearted woman undertook gladly.
“Come along, Ned,” said Tom one afternoon. “Let’s jump into the
roadster and go up to the hospital. I want to see for myself how the
poor fellow is getting along. Those ’phone calls are usually answered
by the secretary, and she’s rather hazy in her reports. I want to have
a talk with Doctor Sherwood himself. Nothing like going right to
headquarters.”
Ned looked rather dubiously at a pile of papers on his desk.
“I’d like to,” he said, “but——”
Tom laughed, picked up Ned’s hat, jammed it on his friend’s
head, and yanked him out of his office chair.
“You’ve got such winning ways, I can’t resist you,” observed Ned,
surrendering with a grin.
In a few minutes they were at the hospital. In the hall they met Dr.
Sherwood, who was just coming out of one of the wards. He greeted
them heartily.
“I can guess what you’ve come for,” he remarked. “I wish I had
more cheerful news for you about that poor fellow you brought here.
But it’s proved to be a more serious case than I thought at first it
would be. The fractured leg is mending all right, but his head’s in a
bad way. It’s a case of brain concussion. He must have hit his head
pretty hard when he dived into the tree. Most of the time he’s
unconscious or semi-conscious, and his temperature stays high.”
“You don’t think he’ll die, do you?” asked Tom anxiously.
“No-o,” replied the doctor slowly, “I hardly think so. Still, you can’t
tell. He’s a mighty sick man. But come along with me and you can
see him.”
They followed him on tiptoe into one of the rooms. But they did
not need to be so careful, for the young man with flushed face and
disordered hair who lay on the cot was wholly oblivious to their
presence. He was babbling in delirium, and there was no intelligence
in the eyes whose restless glances passed over the visitors as
though they were not there.
It was a saddening sight, and as the boys could be of no service
they quickly took their leave.
“No clue to his identity yet?” asked Tom of the doctor, who had
accompanied them out on the steps of the hospital.
“No,” was the reply. “Lots of people have looked at him without
recognizing him. We’ve had many letters from all parts of the country
from people who had read of the accident and thought the young
fellow might be a missing son or some other relative. But he doesn’t
answer to any of the descriptions given. And he himself hasn’t been
in a condition to tell us who he is.”
“That young fellow certainly got a rough deal,” remarked Ned, as
he and Tom walked away. “Think of his suffering like that and being
all alone—I mean as far as his folks are concerned.”
“Yes, Ned, and think of his folks, if he has any. How they must be
worrying about him.”
“Queer he didn’t have some sort of tag on his clothing. Most
aviators wear them.”
“So they do. But fellows get careless. I suppose he forgot all
about it.”
The next week was a busy one for Tom. During the evenings he
was engrossed in the study of everything he could find that bore in
the most remote degree on the subject of oil and oil wells. He had
already a very extensive scientific and mechanical library, but in
addition he wrote and wired to learned societies and Government
bureaus for their latest bulletins and reports. These were soon
coming in to him by every mail, and he devoured them with an
insatiable appetite. Any one looking over from the house could see
the light burning in his office till long after midnight.
And every night when Tom at last put out the light and stepped
outside, he saw either a very slight or a very massive figure waiting
to accompany him over the short distance that lay between the office
and the house. One night it would be Rad and the next night Koku.
Those two had had many wrangles on the subject of who should
guard their idolized master, and had finally compromised on taking
turns.
Tom at first had laughed and then scolded, but to no purpose.
“You nebber kin tell, Marse Tom,” Rad had said, shaking his
woolly head, when Tom remonstrated with him, “w’en somebuddy
might cum nosin’ an spifflicatin’ roun’ here w’en you’s busy wid yo’
wuk; an’ ef dey does, dey’s goin’ to fin’ ’Radicate Sampson right on
de job. Nussah, nussah, Marse Tom, dey ain’t no use argifyin’. Ah
stays heah while you stays heah.”
Koku was less voluble, but no less devoted.
“Me sleep when you sleep,” he said simply.
Faced with such loyalty, Tom could do nothing but surrender.
The days were no less busy than the nights, though in another
way. Tom spent hours with Garret Jackson, the manager of the
mechanical department of the works. He was a first-class mechanic,
clear-headed and forward looking, and had been with the Swift
Construction Company for years. Tom had not only the greatest
respect for his ability, but also implicit confidence in his discretion.
Again and again it had been necessary for Tom to entrust him with
secrets of his inventions while he was having special machinery
made, and he had never betrayed his trust. Repeatedly Tom thanked
his stars that he had two such faithful coworkers as Ned Newton in
the financial end and Garret Jackson in the mechanical part of his
business.
As a result of his conferences with Jackson, it was not long
before a high fence began to be constructed in a rather remote
section of the plant. Many curious glances were cast at it as it went
up, enclosing an area of about a hundred feet square. What it was
intended for only a few knew, and the cold stare of Jackson when
any one hinted at a question soon discouraged the inquisitive.
It was just verging on dusk one night, when Tom, coming back
from the post-office, passed the one large confectionery store which
the town of Shopton possessed. He glanced carelessly through the
window and saw that the store contained two customers, a man and
a girl. The latter, who was a trifle out of the direct line of Tom’s vision,
was edging away from the man, who seemed to be annoying her.
The man followed and laid his hand on her arm.
The girl threw it off and faced him indignantly. As she did so, Tom
saw that it was Mary!
In a flash he was in the store.
CHAPTER VIII
THROUGH THE WINDOW
Tom, having so suddenly burst into the store, grabbed the man
by the collar and whirled him about so that the two were face to face.
It was Hankinshaw.
“What do you mean by that?” sputtered Hankinshaw, as he tried
to wrench himself loose from the strangle hold that Tom had on him,
his face fairly apoplectic with rage.
“It’s up to me to ask you what you mean by daring to bother this
young lady,” responded Tom, in a low tense voice while his eyes
glinted like steel. “He was annoying you, wasn’t he, Mary?”
“Yes, he was,” replied Mary excitedly. “And, oh, Tom, I’m so glad
you came! But please, Tom,” she added more calmly, “don’t make a
scene. Let’s get out of here as soon as possible.”
Tom relinquished his hold on Hankinshaw’s collar.
“You’re right, Mary,” he agreed. “His case can wait till another
time. But it’s only your being here that saves him from getting the
thrashing of his life.”
“Huh!” snorted Hankinshaw, who, while not quite as tall as Tom,
was much bulkier and heavier. “That’s easy enough to say. Talk is
cheap. What do you suppose I’d be doing while you were trying to
mess me up?”
“Nothing much,” retorted Tom drily. “That will be enough from
you, Hankinshaw. Give me your parcels, Mary, and I’ll see you
home.”
“The nerve of you to lay your hands on me!” snarled Hankinshaw,
who was getting angrier and angrier. “I’ve a good mind to have you
arrested for assault and battery.”
“Try it,” recommended Tom. “It would be a good chance to show
you up for what you are. Come along, Mary.”
“Gallant knight with his fair lady,” sneered Hankinshaw.
“What’s that?” exclaimed Tom, taking a step toward him.
Before the blaze in the young inventor’s eyes, Hankinshaw
stepped back hastily. As he did so, his foot struck a box on the floor
and he fell backward and went through the confectioner’s window.
There was a crash of splintering glass, and the next instant
Hankinshaw was on the sidewalk, surrounded by a litter of glass and
a score or more of candy boxes that had been flung out with him.
“Oh, I do hope he isn’t hurt!” cried Mary, in a fright.
“I guess not,” replied Tom, as they hurried outside. “You go along,
Mary, before a crowd gathers. I’ll stay behind to help him if
necessary.”
The confectioner had rushed outside with them, in alarm both for
his window and the man who had gone through it. Mary hastened
on, while Tom and the store owner, a Mr. Wilkins, helped
Hankinshaw to his feet.
To their relief, they saw that apart from a few scratches on one of
his hands and the damage to his dignity, no harm had come to the
bulky fellow. But his eyes were baleful as he glared at Tom. If hate
could have killed, Tom would have been a dead man.
“I’ll fix you for this, Swift!” he declared venomously.
“You brought it on yourself,” replied Tom. “I’m glad though that
you weren’t seriously injured. You’d better get back to your hotel
before a crowd gathers. It wouldn’t be pleasant for you to explain just
how you happened to go through the window. Don’t worry about the
glass, Wilkins,” he continued, turning to the confectioner. “If he
doesn’t pay for it, I will. And mind, Wilkins, not a word as to the
young lady who was in the store at the time this happened.”
“You can count on me, Mr. Swift,” replied the storekeeper,
reassured by what Tom had said about the broken window.
“Nobody’ll get anything out of me.”
It was lucky that the accident had occurred at a time when most
of the people of the town were at supper and the streets were almost
deserted. Some had gathered, however, attracted by the crash, and
more were coming, and to avoid questioning Tom went off quickly
toward his home. Hankinshaw after a moment of hesitation started
off for his hotel, not caring to have others see him in his awkward
and humiliating position.
The first thing Tom did on reaching the house was to take up the
telephone and call up Mary. There was a tremor in her musical voice
as she answered.
“Oh, Tom,” she said, “I’m so glad to hear from you. I’ve been
worried to death ever since I left you. Was the man badly hurt?”
“Only a few trifling scratches,” replied Tom. “The fellow got off
better than he deserved. The last I saw of him he was hot-footing it
for his hotel. What he’d like to do to me is a sin and a shame.”
“Do be careful, Tom,” urged Mary anxiously. “He had the look in
his eyes of a sneak. I’m afraid that in some underhand way he may
do you an injury. I’ve been worrying, too, for fear it may affect the
business deal you have with him and his partners.”
“Not a chance,” laughed Tom. “He couldn’t back out now without
being a loser, and he and his crowd are too canny for that. Not that
I’d care a bit if he did. I’m half sorry we took the contract, anyway. If
we hadn’t, this Hankinshaw wouldn’t be hanging around Shopton.
But thank goodness the work is getting pretty well along now, and in
a few weeks the contract will be completed. Then he’ll be nothing but
a bad dream—perhaps I ought to say a nightmare. Don’t worry your
pretty head any more about it.”
“But keep away from him all you can, won’t you?” pleaded Mary.
“I guess he’ll keep away from me,” laughed Tom. “But I’ll promise
you, if that will make you feel better.”
Tom’s prediction proved correct. For several days Hankinshaw
did not appear at all at the works. And even when he resumed his
visits they were brief and less frequent than usual, and he avoided
meeting Tom as much as possible.
In the meantime, the high board fence around a section of the
grounds of the plant had been completed. Material of various kinds
had been carried in and set up by a group of chosen workmen under
the close supervision of Jackson. Gradually a structure arose that
would have seemed strange to the eyes of the people of Shopton,
though familiar enough to dwellers in the oil fields of California,
Oklahoma and Texas.
Tom was building an oil derrick and getting together a full
paraphernalia of cables, drills and other tools necessary in oil-well
digging. Everything was on a miniature scale to save expense, for
the structure was only designed to be temporary and would be
demolished when the need for it had passed.
“Aren’t you going to a good deal of trouble and expense for this
one job?” asked Ned, a little anxiously. “It won’t take much to eat up
all the profit there is on this contract.”
“Don’t worry, old boy,” replied Tom. “If this one contract were the
only thing concerned, this wouldn’t be necessary, for all we have to
do is to follow the specifications of their plan. But I’m doing this for a
different reason. This isn’t for the benefit of Thompson, Bragden and
Hankinshaw, but for trying out something new for the Swift
Construction Company. Do you get me?”
“Do you mean that you’ve hit on a new invention?” asked Ned
eagerly.
“Something like that,” answered Tom with a smile. “Not that I’d
call it an invention—yet. I’ve got a whole lot of things to work out in
connection with it. But the idea I’ve struck seems feasible enough as
far as I’ve gone. I’m getting rid of the technical difficulties one after
the other, and the farther I go, the more convinced I am that I’m on
the right track. But nobody knows better than you that there’s a long
step between theory and practice. The thing that seems perfect in
the study may prove to be a flivver in the field. That’s the reason why
I’m rigging up this miniature oil-well outfit. I want to put my idea to a
practical test. Maybe it’ll work. Maybe it won’t. If it doesn’t, I’ll discard
it and hunt up something better.”
“Go to it, Tom, and good luck to you,” cried Ned enthusiastically.
“I’d have bet my life you’d hit on something new.”
“Hold your horses,” cautioned Tom. “The best laid plans
sometimes ‘gang agley.’ I’m a long way off yet from certainty. But I’m
far enough along to justify this expense to find out whether I’m right
or wrong.”
So the work went on until the structure was complete, and any
one who entered the gates of the carefully guarded enclosure would
have rubbed his eyes and wondered how long it was since Shopton
became an oil field.
The most prominent object was the derrick, or rig, a framework
tower wide at the bottom and tapering off at the top. This was for the
purpose of carrying two pulleys, the crown pulley in the center and
the block through which the sand line ran. Over the crown pulley ran
the cable by which the drilling tools were suspended or lowered or
raised. At one side of the rig was the bull wheel, or windlass, upon
which the cable was wound, and at the other was the walking beam,
a heavy timber hung in the center so that it could undulate up and
down.
Then there was a choice collection of drilling tools, consisting of a
bit, an auger-stem, a sinker bar, a rope socket and jars, all of which
were strung together and suspended from the crown pulley by the
cable. In addition there were the wrought-iron casings for the lining
of the projected experimental well. Nothing essential had been
overlooked, and before long Tom found himself in a position to begin
the tests on which he was counting so much.
Ned in the meantime had been having troubles on the accounting
end. At the expiration of the two weeks when it was stipulated that
the second five thousand dollar payment should be made, the check
was not forthcoming. Ned telegraphed to Thompson and hunted up
Hankinshaw. Both of them put the blame on Bragden, who at the
time, they stated, was on a short vacation from which he would
return in a few days, when the matter would be promptly adjusted.
This, however, did not satisfy Ned, who recognized the familiar tricks
of “shoestring” concerns, and he proceeded at once to “put on the
screws.” But it was only when he threatened immediate stoppage of
work on the contract that the draft he had sent through was finally
honored.
“I told you they were as slippery as eels,” Ned reminded Tom, as
they looked at the cashier’s check whose delay had been so
annoying.
“Yes, and perhaps you wouldn’t have been so far wrong if you
had added that they were as crooked as corkscrews,” replied Tom.
“Bless my premonitions! I’m afraid you’re right,” exclaimed a
voice behind them.
CHAPTER IX
THE MIDNIGHT PROWLER
Tom and Ned looked up, a little startled, and saw their eccentric
friend, Mr. Wakefield Damon.
“Bless my gum shoes!” exclaimed Mr. Damon, wiping his glasses
and settling into the chair that Tom pulled over for him. “I came in on
you like a thief in the night, and by a coincidence I hear you talking
about thieves.”
“Oh, I wouldn’t want to put it as strongly as that,” said Tom, with a
laugh. “But all the same the actions of that oil crowd don’t seem to
be those of responsible business men. We’ve been having no end of
trouble with them, one way and another.”
“I’m afraid perhaps I made a mistake in introducing them to you,”
said Mr. Damon, with a slightly worried look. “Thompson was the
only one of them I knew, and even with him my acquaintance was
slight. By the way, did you get that second payment? Ned, here, was
telling me that they seemed to be trying to sidestep it.”
“It came in to-day,” replied Tom. “But we had a heap of trouble in
getting it. Here it is,” and he handed it over for his friend’s inspection.
Mr. Damon scrutinized it carefully and heaved a sigh of relief.
“Well, that puts you on easy street, anyway,” he said. “They’ll
have to come across with the rest now to save what they’ve already
invested. But I’m afraid somebody else is in for a trimming.”
“What do you mean by that?” inquired Tom, with quickened
interest.
“I heard something when I was on my last trip to New York that
set me thinking,” replied Mr. Damon. “I dropped into one of the clubs
as the guest of a friend of mine who is a member, and among the
people to whom I was introduced was a large Texas oil producer. Of
course, that interested me at once, apart from the fact that he was a
most entertaining talker. He told me a lot about his own experiences
there, and in the course of the conversation got going about the
many “wild-catters” that infest the oil fields.
“You know the wild-catter is to the legitimate oil man very much
what the bucket-shop keeper is to the solid Wall Street broker. He
hates him as he does ivy poison. The shady tricks in which the wild-
catter indulges cast a stigma on the whole oil-producing business.
“Well, this man, in giving me some illustrations of wildcat
methods, happened to mention the name of Thompson. Said he was
one of the most suave and polished individuals that roamed over the
oil fields.
“I didn’t let on that I knew any one of that name, but from the
description he gave me of his personal appearance and manners, I
feel sure that it’s this fellow you’re making this material for. I led him
on to tell me what he knew of him, and if what he said is true, this
Thompson ought to have his picture in the rogues’ gallery. Not that
he ever will probably. He’s too shrewd for that. Always manages
somehow or other to keep just within the law.
“Among other things, this new acquaintance of mine said that
he’d heard that Thompson and his partners were trying to put
something over on an old blind man who owns a likely property at
Goby, I think it was, close to one of the big gushers that has come in
recently. The old man didn’t want to sell or lease, and the Thompson
crowd were determined to make him. Just how they were going to
bamboozle him or coerce him, my informant didn’t know, but he had
heard enough before he left to be sure that some shenanigan was
on foot. Said he’d bet a hundred dollars to a plugged nickel that
before many moons had passed the gang would have the property
and the blind man would find himself buncoed.”
“So that’s the kind of fellows they are!” exclaimed Tom hotly. “If I
weren’t held by my contract I wouldn’t do another jot of work for
them.”
“Oh, well, it isn’t a dead certainty that that Thompson and our
Thompson are the same man,” said Mr. Damon. “It’s a common
enough name, as far as that goes.”
“Still, I think they’re identical,” insisted Tom.
“At any rate, you’ll be through with the job soon and then you’ll be
rid of them for good and all. By the way, how’s the work coming on?”
“All right,” replied Tom. “Unless something unforeseen happens
we’ll be through on schedule time.”
“What’s that thing on the grounds that looks like a derrick?” asked
Mr. Damon. “It wasn’t there when I went away. Seems to have gone
up almost over night, like Jonah’s gourd.”
“Oh, it’s a contrivance that I had built to test an idea of mine,”
answered Tom.
At once Mr. Damon was after the hint like a terrier after a rat.
“Invented something new?” he asked eagerly.
“Not quite yet,” replied Tom, with a smile. “But I’ve hit on an idea
that may amount to something when I’ve worked it out more
thoroughly.”
“Good for you!” cried Mr. Damon enthusiastically. “I knew you
wouldn’t be at this thing long before you struck something that would
make anything that had gone before look like thirty cents. More
power to you, my boy. What does your father think of it?”
“It hits him hard,” replied Tom. “I’ve gone into the thing pretty
thoroughly with him and I’ve benefited a lot by his suggestions. He
thinks it will mean an immense saving in time, expense and man
power. So far, we haven’t run up against any obstacle that seems
insurmountable. Still, you never can tell till it actually gets to working.
It may turn out to be a flivver after all.”
“Bless my modesty!” snorted Mr. Damon unbelievingly. “Hear
Tom Swift talk about flivvering! That’s one thing he’s never done yet.”
“There’s got to be a first time for everything,” bantered Tom.
“It’ll be a long time coming,” retorted Mr. Damon. “One thing I’m
certain of,” he went on; “and that is you’ll have a mighty fine market
for your invention when you get it perfected. You’ll have all the big
companies bidding against each other to get hold of it. I tell you, my
boy, there’ll be a fortune in it.”
“Let’s hope so,” said Tom. “But the pot of gold is still at the foot of
the rainbow and it may be a long tramp until I reach it.”
Although Tom expressed himself in this cautious way, he felt
quite certain in his own heart that he had hit upon a great invention.
This concerned itself with the drill with its sharp cutting edge, or bit.
Up to that time dependence had been placed upon having a hard
tempered edge that cut into and splintered the rock by its sharpness,
its weight and the distance from which it fell.
This was much. But Tom’s theory was that where there was much
there could always be added more. Suppose a circular motion could
be given to the bit at the moment of contact and the bit itself so
shaped that in addition to the crushing power given by the weight
and fall there would be a grinding, scooping movement that would
eat into the very heart of the soil or rock, making each stroke vastly
more efficient. If he could double its effectiveness, he would wipe out
at once half the time required, half the wear and tear on the
machinery, half the man power required, and vastly reduce the
overhead expense. It would mean an incalculable saving to the oil
industry, and to Tom himself it would mean a fortune.
His father agreed with him that he had hit upon an idea that went
to the core of the matter. Then followed long days and nights of
experimenting, until at last just as the dawn was lighting up the sky
on one memorable morning Tom leaped from his seat in wild
exultation and fairly shouted:
“I’ve got it! I’ve got it!”
After the first few minutes of jubilation, he went over his figures
and diagrams again. Yes, if there was anything in mathematics, he
had proved that the new drill and bit would do what was expected of
them.
But the invention had first to be demonstrated in actual working,
and he pushed forward energetically the work in his experimental
plant.
About a week later he was working alone in the office, when,
shortly after midnight, there was a knock at the door and Koku,
whose night it was for self-imposed duty, entered. His eyes were
rolling in agitation, and he had his fingers on his lips as though to
impose silence.
“What is it, Koku?” asked Tom, somewhat startled by the air of
mystery.
“S-sh,” warned Koku. “Man down at fence. Saw light.”
Instantly Tom was outside. He looked down toward the stockade
that enclosed the experimental plant, but could see nothing.
“Guess you must have been dreaming, Koku,” he whispered.
“No,” said Koku. “Light come. Light go. There is now.”
Tom, too, saw a sudden gleam, as suddenly extinguished, that
evidently came from a flashlight.
“Come, Koku,” he commanded, and moved down stealthily
toward the fence.

Handbook of Spinal Cord Injuries and Related Disorders A Guide To Evaluation and Management 1st Edition Hyun Yoon Ko Sungchul Huh

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Handbook of Spinal Cord Injuries and Related Disorders A Guide To Evaluation and Management 1st Edition Hyun Yoon Ko Sungchul Huh

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Handbook of Spinal Cord Injuries and

Related Disorders A Guide to

Handbook of Spinal Cord Injuries and Related Disorders

MANAGEMENT AND REHABILITATION OF SPINAL CORD INJURIES

Management and Rehabilitation of Spinal Cord Injuries

Diagnosis and Treatment of Spinal Cord Injury 1st

Color Atlas of Spinal Cord Surgery Jörg Klekamp

Spinal Cord Injury and the Family A New Guide 1st

The Cambridge Handbook of Anxiety and Related Disorders

Fluid, Electrolyte and Acid-Base Disorders: Clinical

ISBN 978-981-16-3678-3 e-ISBN 978-981-16-3679-0

© The Editor(s) (if applicable) and The Author(s), under exclusive

The use of general descriptive names, registered names, trademarks,

This Springer imprint is published by the registered company Springer

1. Clinical and Functional Anatomy of the

Keywords Spinal cord – Development – Metamerism – Myotome –

1.1 Development of the Spinal Cord

Vertebral body Corresponding spinal cord segment

1.4 Anatomy of the Spinal Cord

1.4.1 Overview of Anatomy of the Spinal Cord

1.4.2 White Matter and Tracts

Ned stopped in his work of gathering up his papers and looked

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