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OUP CORRECTED AUTOPAGE PROOFS – FINAL, 8/4/2021, SPi
The Meaning of Terrorism

Copyright © 2021. Oxford University Press USA - OSO. All rights reserved.
The Meaning of
Terrorism
C. A. J. COADY
1
3
Great Clarendon Street, Oxford, OX2 6DP,
United Kingdom
Oxford University Press is a department of the University of Oxford.
It furthers the University’s objective of excellence in research, scholarship,
and education by publishing worldwide. Oxford is a registered trade mark of
Oxford University Press in the UK and in certain other countries
© C. A. J. Coady 2021
The moral rights of the author have been asserted
First Edition published in 2021
Impression: 1
All rights reserved. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted
by law, by licence or under terms agreed with the appropriate reprographics
rights organization. Enquiries concerning reproduction outside the scope of the
above should be sent to the Rights Department, Oxford University Press, at the
address above
You must not circulate this work in any other form
and you must impose this same condition on any acquirer
Published in the United States of America by Oxford University Press
198 Madison Avenue, New York, NY 10016, United States of America
British Library Cataloguing in Publication Data

Data available
Library of Congress Control Number: 2021932110
ISBN 978–0–19–960396–1
DOI: 10.1093/oso/9780199603961.001.0001
Printed and bound in the UK by
TJ Books Limited
Links to third party websites are provided by Oxford in good faith and
for information only. Oxford disclaims any responsibility for the materials
contained in any third party website referenced in this work.
For Samuel and Rosa Coady in the hope that their future lies in a world in
which the values of peace and justice are at last genuinely respected.
Contents
Acknowledgments ix
Introduction 1
1. Shaping a Concept of Terrorist Acts: A Clarifying Proposal 10
2. Further Objections: The Tactical Definition Too Broad?
Too Narrow? 33
3. Terrorism and Its Claims to “Distinctive Significance” 54
4. Combatants, Non-Combatants, and the Question of Innocence 81
5. Justifying Terrorism: Four Attempts 110
6. Justifying Terrorism: Three More Attempts 129
7. Counter-Terrorism and Its Ethical Hazards 149
8. Religion, War, and Terrorism 176
References 207
Index 217
Acknowledgments
Philosophers writing on and often discussing together urgent issues related

to war and terrorism form a relatively large, if internationally dispersed,
community of concern. My thinking has profited greatly from both personal
and non-personal interaction with many of its members. Unreliable mem-
ory and space limitation do not permit acknowledgment of all those in the
community to whose stimulation in person or in print I owe intellectual
debts in the matter of discussing terrorism, so what follows is a necessarily
select list (in both the honorific and the choice senses). The References will
indicate other influences.
Such a list should begin with Michael Walzer, of course, whose influence
is pervasive in philosophical discussions and beyond them, and whose visit
to the University of Melbourne for a workshop I had the pleasure of hosting;
Henry Shue, a long-standing friend whom I met back to the 1960s in
Oxford, and with whom I began exchanges on war-related ethics in the
mid-1980s when involved with him in a project on nuclear weapons at the
(then) University of Maryland Institute for Philosophy and Public Policy

(we have had many intensive and helpful discussions of morality and
political violence since, and I later enlisted him in a project on armed
humanitarian intervention at the University of Melbourne); Robert
Fullinwider, David Luban, and Judith Lichtenberg, also colleagues at the
Maryland Institute as well as visitors to the University of Melbourne in the
1990s; my colleagues at the University of Melbourne over many years—Igor
Primoratz, of course, along with Andrew Alexandra, Sagar Sanyal, Ned
Dobos, and Sagar Sanyal, were invaluable; very much has also been learned
in person and in print from Jeff McMahan, Cecile Fabre, Helen Frowe,
David Rodin, Tony Coates, Steven Lee, Christopher Finlay, Seumas Miller,
John Langan S.J., Seth Lazar, Virginia Held, Stephen Nathanson, Cheyney
Ryan, Larry May, and others from that community mentioned above. Kieran
McInerney gave me valuable research assistance and feedback on the book.
Corrections to, and developments of, my thinking on this topic have fol-
lowed from helpful and challenging comments from audiences at papers and
lectures given over the years on the topic. Locales for some of those
audiences have been: University of Melbourne, Australian Catholic
x 
University, University of Sydney, University of Adelaide, University

of Oxford, University of Glasgow, University of Warwick, University of
Bradford, University of Bonn, University of Leipzig, University of
Bielefeld, Mt. Holyoke College, MA, University of Arizona, Georgia State
University, Hiroshima Peace Institute, Rockefeller Center in Bellagio, Italy,
Oxford-Australia-China Summer School on Political Philosophy in Suzhou,
Huazhong University of Science and Technology, and Nanjing University.
My thanks to those institutions and to the Australian Research Council for
an ARC Grant on “Contemporary Terrorism: Ethical and Conceptual
Perspectives,” and also for supporting me for work in this area and others
for five years as an ARC Senior Research Fellow.
I should also acknowledge various permissions to use copyrighted material
in epigraphs in the book and for the painting displayed on its cover:
The painting “Civilised” by New Zealand artist, A. Lois White, repro-
duced courtesy of Sue Disbrowe and other members of the family of
the artist.
Extract from Aileen Kelly, “Aftershock: 1. The city, burning,” repro-
duced courtesy of the Kelly family.
Extract from Algerian Chronicles by Albert Camus, edited and with an
introduction by Alice Kaplan, translated by Arthur Goldhammer,
Cambridge, MA: The Belknap Press of Harvard University Press,

Copyright © 2013 by the President and Fellows of Harvard College.
Extract from Bruce Dawe, “Travelogue,” reproduced courtesy of the
estate of Bruce Dawe.
Extract from John Lahr, column “Questions for John Lahr,” courtesy of
Lahr and The New Yorker.
Extract from The American Heretic’s Dictionary, courtesy of author
Chaz Bufe.
The Earth quakes, the earth

shakes the child. For us
it was bombs. We huddled in shelter.
The earth shook, the air
howled and flamed.
The city burned.
Aileen Kelly, “Aftershock: 1. The city, burning”
Introduction
As witnessed by the arrival and continued presence of the “war on terror,” the
threat of terrorism has been particularly prominent in public consciousness
and in political rhetoric and action during the early years of the twenty-first
century. For the relatively comfortable, economically advanced countries of
what is (somewhat curiously) called “the West,” this attention owes much to
the attacks of September 11, 2001 on New York and Washington, DC. These
attacks, and their aftermaths, even resonated in many less affluent countries
where terrorist attacks were associated more with national disintegration and
civil wars. The 9/11 attacks killed just over 3,000 people and resulted in
military retaliations in Afghanistan and Iraq that killed vastly more thou-
sands and had political and military effects, many of them dire, that continue
still. The arrival of the Covid-19 pandemic in 2020 had the effect of displacing
this apprehension from the foreground of attention in those more affluent
countries, though the hordes of damaged and displaced victims of day-to-day
terrorist acts by state and sub-state agents in parts of the Middle East and
Africa suffered much less of a shift in focus, finding in the pandemic just one
more grave anxiety to besiege them.
The pandemic has indeed been a calamity on a dreadful scale throughout
the world, with deaths in New York City in the early days of the disease’s
spread, for instance, rapidly coming to outstrip the number killed in the 9/11
attacks and then careering beyond. The shift in perspective was not only
imaginatively understandable, but it also had one salutary aspect in suggest-
ing how the threat of terrorism, or some forms of it, can itself too readily
displace attention from other important though less directly dramatic dan-
gers to civil life from multiple diseases and poverty through to environmen-
tal degradation.
Even so, contemporary terrorism certainly poses not only genuine, con-
tinuing threats to lives and expectations, but also important challenges to
our intellectual comprehension, moral understanding, and capacity to
respond and counter the threats without panic or overreaction or damaging
compromise to moral, legal, and political values. It must be added that
Coady.
2 
terrorist acts understandably arouse a particular sort of apprehension

because they make a special impact on us in exhibiting human intentionality
in gross harming. The virus, by contrast, if we ignore fanciful theories about
Chinese malevolence in somehow creating it, sprang from nothing of the
sort, though its spread may well have been helped by human negligence,
incompetence, or stubborn ignorance. To bring out the significance of the
perception of intention in our reaction to terrorist acts, we might consider
how our attitudes to road fatalities and injuries might be affected by adding
an element of intention. Most of us are rightly careful about our driving
because of the real risk of accidental harms on the road, but our caution and
sense of danger would be vastly greater if it was known that there was even a
small percentage of drivers out there who were not merely irresponsibly
negligent, but bent upon killing other drivers.
Philosophy and Terrorism
Although philosophers have eventually devoted a great deal of attention to

terrorism, especially, though not exclusively, since 9/11, there was very little
to consult of philosophical material directly dealing with it when I first came
to concentrate on the topic in the early 1980s. Michael Walzer, whose
Harvard seminar I had attended in 1978, had a brief, stimulating chapter

(of nine pages) in his important book Just and Unjust Wars published the
year before, but he was one of the very few philosophers to address this
question around that time.¹ This is particularly surprising given that there
had been plenty of public focus on terrorist acts in Northern Ireland and in
England throughout the 1970s, as well as on others, including the 1972
Munich Olympic killings of eleven Jewish athletes and a German policeman.
There had also been numerous spectacular hijackings of civilian airplanes in
the 1970s, many of them politically motivated, and a number of them
involving killings or injuries.
Initially, my own stimulus to write on the topic came partly from this
surprising dearth of philosophical treatments and partly from a startling
exchange of views when I was running an Interdisciplinary Programme on
Problems of Peace and Conflict at the University of Melbourne in the late
¹ Carl Wellman and Martin Hughes were notable for doing so, and I discuss some of their
views in this book. See Carl Wellman, “On Terrorism Itself,” Journal of Value Inquiry, vol. 13,
no. 4 (1979); Martin Hughes, “Terrorism and National Security,” Philosophy, vol. 57 (1982).
   3
1970s to early 1980s. At a committee meeting with colleagues in the program

something came up about terrorism, and several of my friends from other
disciplines, notably English, Politics, and History, objected with puzzlement
and a certain degree of scorn to my proposed definition of terrorist acts, and
even more so to the idea of using moral philosophy in the discussion of such
acts. No doubt my early attempt at definition needed refinement, but their
reactions showed two things that had already begun to trouble me. The first
was a fuzziness about what terrorism or terrorist acts could be, a fuzziness
that was a reflection of a state of confusion in the public debate at large about
what was actually being discussed, condemned, excused, or even justified in
talk about terrorism and terrorist acts. This confusion, which is still rampant
today, meant that people were often at cross-purposes in discussions of
terrorism with regard to its moral status, significance, and need for counter-
measures. The second was their scorn about the prospects for philosophical
clarification of the concept and for bringing moral considerations to bear
upon the phenomenon of terrorism, especially moral considerations
informed by philosophical reflection. When this was not cynicism about
philosophical pretensions or politics generally, it seemed a dim reflection of
those political theories and practical policies, known as political realism,
which apparently deny or strongly downplay a role for morality in matters
of the deployment of political violence and much else in politics, insisting
instead on the idea of national interest as the sole or primary relevant

normative consideration.² These things helped prompt my writing the
paper “The Morality of Terrorism,” published in Philosophy in 1985, and
later republished in various places.
In the following years, I have written and spoken frequently on the subject
of terrorism and sought to meet some of the objections to my views and to
heed what other philosophers and theorists have had to say about the subject
in its various aspects. Revising, developing, and integrating my position on
the matter has now produced this book. I have called it The Meaning of
Terrorism partly because I have tried to fashion a concept of terrorism that
reflects to an important extent a semantic core in reports, arguments, and
responses to terrorist acts that will be useful in clearing up the confusions
mentioned above and, moreover, in connecting moral judgment about such
acts with philosophical theory and, to a degree, with what Sidgwick called
“common-sense morality.” But I also have attempted to address questions of
² I have discussed political realism at some length in C. A. J. Coady, Messy Morality: The
Challenge of Politics (Oxford: Oxford University Press, 2008).
4 
the meaning of terrorism, in a sense broader than that of conceptual

analysis, semantics, or even fruitful conceptual tidiness. This is the sense
in which we use the word “meaning” to scrutinize the significance of
activities, policies, connections, institutions, work, and even, at the limit,
life itself. This sense of “meaning” applies to a concern for a focus on bad
things as well as good. In such scrutiny, we are involved both in description
and in normative examination, just as, for instance, in discussing the
meaning of work, we need not only an account of what work (in its manifold
forms) is, but also what it could and should be, and why that matters. By
contrast with a concept like work (assuming that work properly understood
can be considered a good thing), an idea like racism would require in an
exploration of its meaning not only clarification of what it was, but also of
the moral status of its effects on those subject to its operation, effects that
might range from the subtle to the gross, and apart from direct racist acts,
such an exploration would attend to the normative dimensions of the
entrenchment of racist attitudes in social and political institutions.
The Meaning of Terrorism is then a title to indicate a voyage into the
territory of those various dimensions of the idea of meaning. By contrast
with the earlier philosophical neglect of the topic, the amount of ink spilled
on aspects of terrorism, terrorists, and terrorist acts over the past forty years
by philosophers and indeed theorists from many other disciplines and
beyond academia is enormous, and I make no pretense of having heeded

all of it. Nor indeed have I dealt with all the relevant philosophical literature,
though I have concentrated upon a number of prominent authors, and
I have tried to utilize ideas, in both a critical and appreciative spirit, from
selected non-philosophical sources, such as political theory, history, law,
journalism, and even theology.
A Brief Outline of Themes in the Book’s Chapters
Chapter 1 is concerned with bringing some clarity to the widespread con-

ceptual confusion around what terms like “terrorist,” “terrorist act,” and
“terrorism” mean. Without being too rigid about definition, it is important
to operate with some agreed definitional clarity in the area. I defend the
value of such a definitional enterprise and then provide what I call a tactical
definition of a terrorist act that aims to capture a central core involved in
talk about terrorism and opens discussion of terrorist acts to cogent
moral assessment. My definition of a terrorist act is: “A political act,
       ’  5
ordinarily committed or inspired by an organized group, in which violence

is intentionally directed at non-combatants (or ‘innocents’ in a suitable
sense) or their significant property, in order to cause them serious harm.”
The rest of the chapter discusses advantages of the definition and criticizes a
number of objections to it.
In the rest of Chapter 1, I discuss what I see as conspicuous advantages of
the definition, particularly that it treats terrorism as a specific means toward
political goals and hence available to any sort of agent, including states, not
merely to insurgents or other sub-state agents. It also leaves it open whether
revolutionaries, counter-revolutionaries, or other groups can employ polit-
ical violence, whether justified or not, without using terrorist tactics. I then
proffer six clarifications and defenses of the expanded definition’s key terms:
the normative status of the tactical definition with respect to moral neutral-
ity or commitment; the implications of the reference to “serious harm” in it;
whether threats or plans should have been included; the discussion of the
phrase “ordinarily committed or inspired by an organized group” and the
issue of the “lone wolf” terrorist; the scope of the term “political”; and
whether, in philosophical terminology, the object of the intention in the
definition should be read as opaque or transparent, i.e., to what degree is
the determination that an act is terrorist decided by the agent’s belief about
the status of their victim or the objective facts about that status?
In Chapter 2, a number of objections to the definition are discussed that

criticize it either for being too narrow or too broad. The narrowness criti-
cisms object that (a) there are terrorist acts that target combatants, (b) there
are terrorist acts that do not involve a political motive, e.g., certain criminal
or religious acts, and (c) certain non-intentional violence afflicting non-
combatants, basically some of those covered by the phrase “collateral dam-
age,” should be encompassed by the definition. The “too broad” category of
objections argues that (a) the tactical definition should be restricted by the
inclusion of an ingredient of intentionally provoking fear, and sometimes
add that the inducement of fear should be directed at others than those
attacked, (b) the definition’s extending to states the possibility of committing
terrorist acts is mistaken, (c) the inclusion of non-combatant property in the
definition is mistaken, and (d) my approach simply defines terrorist acts as
murder and loses what is distinctive of such acts. These objections are
criticized and rejected for the most part, though some elicit concessional
comments about their possible ancillary benefits in relation to the preferred
tactical definition.
6 
Chapter 3 addresses four philosophical attempts to show, mostly without

dependence on a definitional account of terrorist acts, that terrorist attacks
have a special moral significance. In doing so, in their very different ways,
these philosophers articulate a concern about terrorism that is widely held
amongst non-specialists. The philosophers who address the idea of special
significance most directly are Samuel Scheffler, Jeremy Waldron, and Lionel
McPherson. Waldron does not use the phrase “special moral significance,”
but the idea of such is pretty clearly at work in his discussion. The fourth is
Karen Jones, who also does not use the language of “special significance,”
but her discussion of “basal security,” the disruption of which “makes a
really efficient” terrorist campaign work, seems to function in the same line
of territory as marking some particularly distinctive feature of terrorism in
addition to its being a tactic distinguished by its commitment to attacking
non-combatants.³ The claim she makes is worth addressing in this context.
I argue that these various attempts fail to make the strong case that they
promise, and that the failure is instructive for the understanding of terrorism
and for policies to deal with it.
Chapter 4 tackles the difficult issues surrounding the concept of comba-
tant/non-combatant, and the related notions of guilt/innocence and the
connection of these to the soldier/civilian distinction. The investigation is
partly conceptual, but it also inevitably raises moral questions and their
significance, since the tactical definition’s reliance upon such concepts

relates immediately to the moral assessments enshrined in the just war
principle of discrimination which prohibits the direction of lethal violence
upon non-combatants, and reflects a wider moral principle that prohibits
violence against the innocent. Whether one or both of these principles
should be rejected, modified, or allow of exceptions are further questions
that are addressed in Chapters 5 and 6. The fact that they need to be so
addressed is why my tactical definition is in a sense morally neutral, though
it points toward the immorality of terrorist acts. The chapter requires
extended discussion of contemporary debates within the complex just war
tradition, particularly between those loosely styled “traditionalist” and “revi-
sionist.” I offer a judgment on the debate, and discuss its relation to my
account of the nature of terrorist acts.
³ Karen Jones, “Trust and Terror,” in Moral Psychology: Feminist Ethics and Social Theory,
edited by Peggy DesAutels and Margaret Urban Walker (Lanham, MD: Rowman and Littlefield
Publishers, 2004).
       ’  7
Chapters 5 and 6 provide an extensive discussion of seven philosophical

positions that attempt to justify terrorist acts in certain circumstances. Each
one, in different ways, reflects less formal and less carefully articulated views
that are proclaimed not only by active terrorists but also many members of
the general public throughout the world, especially when the acts purporting
to be justified are committed by their own people or others with whom they
sympathize. In Chapter 5, four categories of attempted justification are
examined: utilitarian/consequentialist arguments that may reject the prin-
ciple of discrimination outright; the argument from self-defense; the tit-for-
tat argument; and the argument from the need for a fighting chance. In
Chapter 6, three more categories are scrutinized: the argument from collec-
tive responsibility; the argument from redistributive justice; and the argu-
ment from supreme emergency. All seven of these attempted justifications
raise a more general and very challenging issue about the difficulties of
moral philosophizing in the face of absolute moral prohibitions.
Chapter 7 discusses some of the problems posed by contemporary terror-
ism for counter-terrorism measures. The discussion is primarily focused on
reactions of states to sub-state terrorism broadly understood. There is an
initial discussion of issues to do with whether, and if so when, terrorists
should be treated as combatants or criminals, which raises the relations
between military and non-military forms of counter-terrorism. Problems
with military responses connected with the inflammatory slogan “the war on
terror,” including those responses entitled “targeted killing,” are also dis-
cussed. Thereafter, the chapter deals mostly with non-military responses
and their moral and political hazards. These are examined under the three
categories of: (1) domestic and to some extent international legal and
regulatory measures, especially those introduced specifically to deal with
terrorism; (2) diplomatic measures, both internal and external; (3) measures
to remove or deal with the grievance. Under (1), the difficulties connected
with legal definitions of terrorism, and the strong tendencies of legislation to
promote abuses of power and damage to civil liberties, are explored with the
aid of many examples, and the difficulties of the preventive imperative in
legal contexts is analyzed; under (2) and (3) the path of political diplomacy
that takes account of grievances, genuine or purported, is supported, but
obstacles to its success in practice are discussed, including issues of concep-
tual confusion and problems to do with bad faith.
Chapter 8 is concerned with common views, amounting to something like
presuppositions, affirming links between religion and terrorist acts. One
such view is that religion itself has an inherent, distinctive, possibly unique
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Acute Spinal Meningitis.
SYNONYM.—Leptomeningitis spinalis acuta.
By the term spinal meningitis is usually meant inflammation of both

the arachnoid and the pia, the two being, as already stated, in reality
one membrane. In connection with meningitis of the brain it
constitutes a distinct disease which is usually epidemic, and
probably zymotic in its origin. (See EPIDEMIC CEREBRO-SPINAL
MENINGITIS.) Sporadic spinal meningitis is a rare disease. It may be
acute or chronic.
ETIOLOGY.—Among the causes of acute spinal meningitis are injuries

to the vertebral column, such as fracture and dislocation from falls,
blows, etc.; wounds by stabbing or shooting; violent bodily effort, as
in lifting heavy weights, etc. Other causes are local exposure to wet
and cold, as from sleeping on the wet ground or standing long in
water while at work. Like cerebral meningitis, it may complicate
constitutional diseases, as rheumatism, pyæmia, etc., but less
frequently than the former. Syphilitic inflammation of the spinal
membranes is, however, not unfrequently met with, but chiefly of the
chronic form. (See the article on SYPHILIS OF THE BRAIN AND SPINAL
CORD.) In tubercular meningitis of the brain the pia mater of the cord
is often implicated in the disease. Acute spinal meningitis is most
frequently met with in young persons, and is more common in men
than in women.
SYMPTOMS.—The onset of the disease is generally sudden, and it is

rarely preceded by the usual inflammatory symptoms of chilly
sensations, restlessness, headache, etc. A sharp rigor is the first
indication of disease in most cases. This is followed by fever, with
high temperature and a quick, full, hard pulse. Pain in the back
follows, either confined to a limited region or extending throughout
the whole extent of the spine, soon becoming acute, and aggravated
by any movement of the trunk or even of the limbs. There is usually
but little tenderness on pressure upon the spinous processes, and
often none at all. The pain extends around the body and throughout
the limbs. In the course of a few hours muscular contraction in the
region of the back, and also of the limbs, is observed. When the
disease is situated in the cervical region, the head is drawn
backward, and cannot be moved without severe pain. If it occupies a
considerable extent of the spine, the dorsal muscles become rigidly
contracted and the body is arched forward (opisthotonos), as in
tetanus, so that the patient may even rest upon his occiput and
sacrum. Owing to the implication of the muscles of respiration, more
or less dyspnœa is common, and may even cause death by
asphyxia. There is no paralysis of the limbs, unless there be
complication of myelitis, but the patient abstains as far as possible
from any movement from dread of pain. Reflex irritability is
exaggerated. Retention of urine and constipation are common,
probably for the same reason. Hyperæsthesia of the surface of the
body in limited areas is sometimes noticed, owing to the irritation of
the posterior spinal roots. Provided the extent of the inflammation be
comparatively limited, recovery is possible, though rare, at this stage
of the disease.
When the course of the disease is unfavorable, symptoms of

paralysis appear, from compression of the cord by the products of
inflammation. The hyperæsthesia of the skin gives place to
insensibility; the muscles lose their reflex function and their reaction
to electricity; the bladder and rectum become paralyzed. The
invasion of the medulla by the disease, which is announced by
paralysis of the muscles of the œsophagus and of the tongue, is a
fatal complication. The pulse and the respiration become rapid and
irregular from compression of the vagus, the temperature rises to
106° or 108° F., and death ensues through asphyxia or failure of the
heart.
The course of acute spinal meningitis is rapid. It sometimes

terminates fatally within two or three days, and the average duration
of fatal cases is about a week, but exceptionally the disease may last
for several weeks or even months. Even then complete recovery
may take place, though permanent effects are usually left behind,
such as paresis or paralysis of the lower extremities, muscular
contractions, muscular atrophy, etc., from injury to the nerve-roots or
the cord.
The mind is generally clear in the early stage; afterward there may
be delirium, especially along with cerebral complication.
MORBID ANATOMY.—It is rarely that the pia mater is the only tissue
involved in the inflammation. Frequently the inner surface of the dura
is the seat of a fine injection, with delicate false membranes, and the
cord itself—at least its exterior portions—probably always
participates more or less in the congestion. The pia is reddened and
thickened, the surface showing small bloody extravasations, and the
space between its two layers is the seat of a fibro-purulent deposit.
The spinal fluid is turbid and flocculent. The seat and extent of the
morbid appearances vary in different cases; they are always more
abundant in the posterior than the anterior part of the cord, and may
be confined to a limited space or extend throughout its whole length.
It is remarkable that the region of the medulla oblongata is generally
free or only slightly affected; but since bulbar symptoms are often
prominent in grave cases, Leyden6 accounts for it by supposing that
the exudation is washed away by the constant movement of the
cerebro-spinal fluid. If the cord be involved in the inflammation, it is
softened and injected, the nerve-sheaths are destroyed, and the
axis-cylinders swollen in places. The nerve-roots show hyperæmia,
infiltration of the interstitial tissue with round cells, and destruction of
the nerve-sheaths.
6 Klinik der Rückenmarks-krankheiten, von E. Leyden, Berlin, 1874, vol. i. p. 407.
DIAGNOSIS.—Spinal meningitis is easily recognized in most cases by

its sudden onset and the severity of its symptoms. The distinguishing
symptoms are sudden and acute pain in the back, extending around
the body and into the limbs, which is increased by every movement
of the trunk, rigidity of the back, hyperæsthesia of the skin, retraction
of the head, with difficulty of breathing and of swallowing. The
diseases from which it must be distinguished are muscular
rheumatism (so called), tetanus, and myelitis. In rheumatism of the
dorsal muscles the pain is confined to the back, does not extend to
the limbs, and is only excited by movement. The fever is moderate or
absent; there are no symptoms of spinal complication, such as
cutaneous hyperæsthesia, retraction of the head, paresis of the
limbs, etc.; and the result is uniformly favorable. Tetanus is almost
always due to some well-marked traumatic cause; the muscles of the
jaw are usually first implicated (trismus); and the attacks of general
muscular spasm are easily excited by peripheral irritation. Myelitis
can be distinguished by the absence of pain in the limbs and by
paraplegia, but it must be borne in mind that myelitis and spinal
meningitis may coexist.
PROGNOSIS.—Acute spinal meningitis is always a grave disease,

hence a guarded opinion should be given even in apparently
favorable cases. General mildness of the symptoms, with no
indication of extension to the medulla oblongata, would afford ground
for encouragement. The unfavorable symptoms are those showing
compression or inflammation of the cord, such as paresis, paralysis,
twitching of the limbs, muscular contractions, cutaneous anæsthesia,
etc. The extension of the disease to the medulla, as shown by
difficulty of swallowing, speaking, or breathing, is almost necessarily
fatal.
TREATMENT.—During the first stage of the disease an effort should be

made to reduce the hyperæmia of the membranes by the local
abstraction of blood. This is best effected by cupping along each
side of the spine and by the application of leeches to the anus; the
bleeding should be promoted by poultices. Free purging is likely to
be of service, and is best obtained by means of ten grains each of
calomel and jalap (for an adult), followed by saline laxatives.
Counter-irritation to the back may be induced by the application of
blisters or by painting the skin with a strong tincture of iodine (one or
two drachms of iodine to an ounce of sulphuric ether). After the
effusion of lymph and pus, as shown by symptoms of compression of
the nerve-roots and cord, absorbents should be tried, of which the
iodide of potassium, in doses of five to ten grains, four times daily, is
most likely to be of benefit. Pain must be relieved by opium or
morphia and chloral hydrate. The latter, either alone or combined
with hyoscyamus and bromide of potassium, will be useful to allay
spasmodic twitching, opisthotonos, or muscular contraction. The
patient should be enjoined to lie on each side alternately, or on the
face if possible, in order to equalize the hyperæmia of the
membranes and cord. Liquid nourishment must be freely
administered, such as milk, broths, gruel, etc., together with wine
and other stimulants in case of exhaustion and threatening of
collapse. During convalescence the patient should be carefully
protected against cold and fatigue, and the strength must be
supported by quinine and iron with suitable diet.
Chronic Spinal Meningitis.
SYNONYMS.—Chronic inflammation of the pia mater of the spinal cord,

Chronic spinal leptomeningitis.
Chronic spinal meningitis may follow the acute form, or it may arise
from chronic disease of the vertebræ or of the cord, especially
myelitis and sclerosis. It is most apt to accompany sclerosis of the
posterior columns, and it is often difficult to say in any particular case
whether the meningeal affection preceded or followed that of the
cord. Probably some cases of chronic myelitis, especially of the
disseminated form, owe their origin to chronic meningitis.7 It has
been thought to follow blows on the back, and also to arise from
general concussion without traumatism, and has been considered as
a frequent result of accidents from railroad collisions, etc. This view
has been disputed by Herbert W. Page,8 who says: “Of the
exceeding rarity of spinal meningitis as an immediate result of
localized injury to the vertebral column we are well assured.... And
we know of no one case, either in our own experience or in the
experience of others, in which meningeal inflammation has been
indisputably caused by injury to some part of the body remote from
the vertebral column.” Chronic alcoholism and syphilis, especially the
latter, predispose to the disease. In many cases no adequate cause
can be assigned.
7 Leyden, op. cit., vol. i. p. 442.
8 Injuries of the Spine and Spinal Cord, without Apparent Mechanical Lesion and
Nervous Shock, in their Medico-legal Aspects, London, 1883, p. 128.
SYMPTOMS.—Gowers9 remarks that a large number of symptoms

formerly assigned to chronic spinal meningitis have nothing to do
with that pathological state, but are now known to be owing to
alterations within the cord which are frequently associated with it.
The symptoms which are really due to the meningeal inflammation—
namely, those arising from interference with the nerve-roots in their
passage through the thickened membranes—do not differ essentially
from those of chronic pachymeningitis of the spine; the principal are
pain in the back, especially on movement, extending to the trunk and
limbs, hyperæsthesia of the skin in various regions within the domain
of the irritated sensory roots, with diminution or loss of the knee-jerk,
and areas of anæsthesia due to their more complete compression.
The compression of the motor roots gives rise to symptoms which
are similar to those of disease of the anterior cornua, consisting
chiefly of muscular wasting, with impairment of motion in
corresponding regions, without fever.
9 The Diagnosis and Diseases of the Spinal Cord, by W. R. Gowers, M.D., 2d ed.,
Philada., 1881, p. 73.
The anatomical appearances, which are most pronounced in the

posterior aspect of the cord, and diminish from below upward, are
often of considerable extent. The membrane is thickened, opaque,
and often adherent to the cord. On the inner surface are seen
numerous small bodies composed of proliferating connective
tissue.10 These, according to Vulpian, are chiefly found in the lower
dorsal and lumbar region and on the cauda equina. The dura is very
frequently involved in the inflammation; it is thickened, and its inner
surface is adherent to the pia, often showing numerous miliary
bodies similar to those found in the pia.
10 Leyden, op. cit., vol. i. p. 144; A. Vulpian, Mal. du Syst. nerv., Paris, 1879, p. 126.
DIAGNOSIS.—Chronic spinal meningitis so rarely exists apart from
disease of the dura or of the cord that its separate diagnosis must be
mainly a matter of conjecture. Leyden justly says we must usually be
content to diagnosticate chronic meningitis without attempting any
further distinction, except in cases which originate in disease of the
vertebræ or of their neighborhood, and afterward penetrate into the
spinal canal, and which would probably give rise to pachymeningitis.
The diseases with which chronic meningitis of the spine is most likely
to be confounded are posterior sclerosis (locomotor ataxia) and
chronic degeneration of the anterior cornua (progressive muscular
atrophy).11 From the former it is distinguished by the absence of
ataxia; from the latter, by the irregular distribution of the symptoms;
and from both, by the existence of limited areas of anæsthesia and
of extensive spinal pain. It must be remembered that inflammation of
the cord complicating that of the meninges, or pressure upon the
cord by the thickened membranes may give rise to mixed symptoms.
The latter is especially observed in syphilitic cases.
11 Gowers, op. cit., p. 74.
PROGNOSIS.—Simple chronic spinal meningitis is rarely if ever fatal.

How far it is capable of amelioration or of cure is not, in the present
state of our knowledge, known. When complicated with disease of
the cord the prognosis will depend upon that of the latter. Syphilitic
chronic meningitis is to a certain extent amenable to appropriate
medication.
TREATMENT.—The treatment should have for its object (1st) to relieve

pain; (2d) to arrest the progress of the inflammation, and especially
to prevent it from extending to the cord; (3d) to promote the
absorption of the exudation. For the first object the internal or
hypodermic employment of morphia should be combined with
external applications, such as fomentations, liniments, ice, etc.
Counter-irritation by means of dry cupping, blisters, iodine, etc., with
leeches, shampooing, and douches of hot water, may be of some
use in retarding the progress of the inflammation, and should be
aided by the administration of mercurials and the preparations of
iodine. The biniodide of mercury would be useful for this purpose in
the dose of one-sixteenth to one-eighth of a grain three times daily,
its effect being carefully watched in order to prevent salivation. The
same means will also aid in favoring the absorption of lymph. In
syphilitic cases an appropriate specific treatment is indicated.
Spinal Meningeal Hemorrhage.
SYNONYMS.—Spinal meningeal apoplexy, Hæmatorrhachis.
Spinal meningeal hemorrhage may take place between the dura

mater and the walls of the vertebral canal, or between the dura and
the pia mater—i.e. into the arachnoid space.
ETIOLOGY.—Penetrating wounds, injuries to the vertebræ, fractures

and dislocations, and violent blows are apt to give rise to more or
less hemorrhage into the spinal canal. Violent convulsions, as in
tetanus, epilepsy, uræmic eclampsia, hydrophobia, may be followed
by meningeal hemorrhage, owing to the disturbance of the
circulation from asphyxia; and excessive muscular effort, as in lifting
heavy weights, etc., has been said to cause it. In cerebral meningeal
hemorrhage and in effusion into the substance of the brain the blood
sometimes escapes into the spinal canal. An aneurism of the aorta
has been known to communicate with the canal; such a case was
reported by Laennec.12 In certain diseases with hemorrhagic
tendency, as purpura and scurvy, spinal extravasation is occasionally
observed.13
12 Traité d'Auscultation médiate, 4th ed., Paris, 1837, vol. iii. p. 443.
13 A case of scorbutic spinal hemorrhage is reported in the British Med. Journal, Nov.
19, 1881.
SYMPTOMS.—These vary according to the conditions under which the

hemorrhage is produced and to the amount of bleeding. In traumatic
cases the signs of hemorrhage are often completely overshadowed
by those of the injury of the vertebræ, the membranes, or the cord,
and are undistinguishable. When a large amount of blood is
suddenly introduced into the spinal canal, it usually gives rise, by
pressure on the cord, to paraplegia, which, however, is sometimes of
only short duration. Thus in Laennec's case the bursting of an
aneurism into the spinal cavity was signalized by a sudden
paraplegia, but in half an hour the power of movement returned,
though sensation did not. The patient died in a few hours from
hemorrhage into the left pleural cavity. The amount of blood in the
spinal cavity is not stated, and, in fact, it would appear that the spine
was not opened. When the amount of blood is smaller the symptoms
indicate irritation of the spinal nerves and of the cord. Pain in the
back is always present, extending into the limbs, and is sometimes
severe. Its seat corresponds to that of the effusion. There may be a
feeling of tingling and numbness in the lower extremities, with
anæsthesia or hyperæsthesia of the skin and more or less paresis. A
feeling of constriction around the waist or the chest is sometimes
complained of. In slight effusions the symptoms may be limited to
numbness and formication of the extremities, with slight paresis.
There is rarely fever in the early stages, unless the amount of blood
is sufficient to give rise to inflammatory conditions of the cord or
membranes. If the extravasation be moderate it is generally
absorbed, with relief to the symptoms, although slight numbness and
paresis of the extremities may continue for a long time.
PATHOLOGICAL ANATOMY.—In hemorrhage outside the dura the loose

cellular tissue between the membrane and the bony canal contains
more or less coagulated blood according to the circumstances of the
case, especially in the posterior region of the canal and covering the
nerve-roots. The dura is reddened by imbibition of the coloring
matter of the blood. When the amount of the effusion is large, as in
traumatic and aneurismal cases, or where cerebral hemorrhage has
extended into the spine, the cord may be compressed by it.
Hemorrhage into the arachnoid sac, except in cases of violence,
etc., is usually of limited amount, sometimes only in the form of
drops of blood upon the surface of the dura or pia. When more
abundant it may surround the cord more or less completely, but in
most cases it is limited in longitudinal extent, being confined to the
space of one or two vertebræ. The cord may be more or less
compressed, reddened, and softened. In all cases the spinal fluid is
discolored and reddened in proportion to the amount of the
hemorrhage.
DIAGNOSIS.—When the complications are such that symptoms

attributable to hemorrhage are not observed, the diagnosis of spinal
hemorrhage is impossible. This may happen in the case of wounds
and injuries of the vertebræ and of the passage into the spinal canal
of blood from an apoplectic effusion of the brain. In the convulsions
of tetanus, epilepsy, etc. the amount of the hemorrhage is rarely
sufficient to give rise to distinctive symptoms. In idiopathic and
uncomplicated cases the chief diagnostic marks are suddenness of
the attack; pain in the back, usually at the lowest part; disturbances
of sensation in the extremities (anæsthesia, formication, etc.);
paresis or paralysis of the legs; the absence of cerebral or spinal
inflammatory symptoms; and, in many cases, the favorable course of
the disease. Sometimes an ostensible cause, such as scurvy,
purpura, suppressed menstruation, or hemorrhoidal flux, will aid in
the diagnosis. The disease for which spinal hemorrhage is most
likely to be mistaken is acute myelitis, but this is not sudden in its
onset, is accompanied with fever, and gives rise to paralysis both of
motion and sensation, and to loss of control over the sphincters, to
bed-sores, etc. Hemorrhage of the cord would be accompanied by
paraplegia and loss of sensation in the lower extremities and slight
tendency to spasmodic manifestations; it is fatal in the majority of
cases, or else is followed by permanent paralysis. Hysteria might be
confounded with spinal hemorrhage, but the history of the case and
the transient duration of the symptoms would clear up all obscurity.
PROGNOSIS.—In traumatic cases the hemorrhage is usually only one

element in the gravity of the situation, which depends chiefly upon
the character and extent of the original injury. In idiopathic and
uncomplicated cases the prognosis, which must always be doubtful,
will vary according to the severity of the symptoms as corresponding
to the amount of the effusion. The danger is greatest during the first
few days; if there should then be diminution of the more important
symptoms, an encouraging opinion may be given. The immediate
effects may, however, be less grave than the remote, such as bed-
sores, cystitis, etc. Except in the very mildest cases the patient is
likely to be confined to bed for several weeks. In more severe ones
the convalescence may be very protracted, and permanent
lameness, etc. may result.
TREATMENT.—In the early stage absolute rest in bed, with cold

applications to the back and moderate purging, should be employed.
Large doses of ergot are recommended, but there is little evidence of
benefit from this medicine. In traumatic cases no rules for treatment
of the hemorrhage can be laid down. If the extravasation evidently
depends upon a constitutional diathesis, as in purpura, scurvy, etc.,
the remedies appropriate for these diseases should be employed,
especially tonics and astringents, such as the tincture of the chloride
of iron, in doses of from fifteen to thirty drops three times daily,
quinine, and the vegetable acids. Should there be evidence of blood-
pressure from suppressed discharge, as in amenorrhœa, arrested
hemorrhoidal flow, etc., leeches should be applied to the anus, and
blood may be taken from the region of the spine by cupping. In the
later stages an attempt may be made to aid the absorption of the
effused blood by the administration of the iodide of potassium or the
protiodide of mercury, and by the application of blisters or strong
tincture of iodine to each side of the spine. Pain must be relieved
and sleep obtained, when necessary, by means of opium, chloral
hydrate, or other anodynes. Electricity, rubbing, bathing, etc. will be
useful for combating the paralytic symptoms which may remain after
the disease itself is relieved.
SPINA BIFIDA.
BY JOHN ASHHURST, JR., M.D.
DEFINITION.—By the term spina bifida is meant a congenital

malformation of the vertebral column, consisting in the absence of a
part—commonly the spinous processes and laminæ—of one or more
of the vertebræ, and thus permitting a protrusion of the spinal
meninges, which, with their contents, form a tumor of variable size
and shape, usually in the lumbo-sacral region.
SYNONYMS, ETC.—Of the various names which have been proposed

for this affection, most are objectionable, as not expressing with
sufficient definiteness what is meant. Thus, hydrorachis (the term
generally employed by French writers), hydrorachitis, spinal
hydrocele, etc., convey merely the notion of an accumulation of fluid
within the spinal canal, and are as applicable to simple serous
effusions in that part, whether occurring as a complication of
hydrocephalus or as the result of injury, as to the special affection
under consideration. Again, myelochysis—pouring out or protrusion
of the spinal marrow—would imply that the cord itself was
necessarily involved in the tumor, which is certainly not always the
case. The terms schistorachis (cleft spine) and atelorachidia
(defective spine—a name suggested by Béclard) would be
preferable, and are really more accurate than the name spina bifida,
since, as a matter of fact, the spinous processes are, as a rule, not
bifid, but totally deficient. The latter term, however, has the
advantage of being more familiar, and may be retained simply as a
matter of convenience. It is said by Itard to have been first employed
by the Arabian physicians.
HISTORY.—Spina bifida does not appear to have been known to the
ancients, the earliest recorded observations of the affection being
found in the writings of Bauhinus (1560-1624), of Tulpius (1593-
1674), of Bonetus (1620-89), and of Ruysch (1638-1731). Good
accounts of the affection may be found in the Dictionnaire des
Sciences médicales (tome xxii., Paris, 1818), and particularly in
Holmes's Surgical Treatment of the Diseases of Infancy and
Childhood (2d ed., London, 1869), in Follin and Duplay's Traité de
Pathologie externe (tome iii.), and in Treves's article on
“Malformations and Injuries of the Spine” in the International
Encyclopædia of Surgery (vol. iv., New York, 1884).
ETIOLOGY.—There are two conditions essential to the formation of a

spina bifida: (1) an arrest of development, or at least a defective
closure, of the vertebral arches; and (2) a dropsical condition either
of the central canal of the spinal cord or of the subarachnoid spaces;
but which of these is the antecedent condition it is, as justly
remarked by Erb, impossible to decide. Spina bifida often occurs as
a complication of hydrocephalus, and is itself often complicated with
an atrophic and deformed condition of the lower extremities—a
circumstance which led Tulpius to suggest that the malformation was
caused by a malposition of the fœtus in utero, an explanation which
it seems hardly necessary to waste time in considering. Salzmann
observed spina bifida in two children born of the same mother, and
Camper noticed it in twins.
SYMPTOMATOLOGY.—Spina bifida forms a tumor—or, more rarely,

several tumors—in the region of the vertebral column, usually
discovered at birth, but occasionally not noticed until a later period.
Thus, Lancisi mentions a case in which the tumor first made its
appearance in a hydrocephalic child at the age of five years, and J.
L. Apin one in which the patient reached the age of twenty before
any swelling was manifested. If these records are accepted as
authentic, the only satisfactory explanation is that of Itard—viz. that
the bony deficiency existed from the time of birth, and that the
dropsical protrusion did not occur until afterward: this seems to me
more reasonable than the suggestion of the younger Andral, that the
vertebræ underwent a process of secondary softening and
absorption. The part most frequently affected is the lumbar region,
but cases are not wanting of the occurrence of spina bifida in the
cervical, dorsal, and sacral regions, and even, in at least one case
(Genga's), in the coccyx. The tumor almost invariably occupies the
median line, and projects directly backward: in at least four cases,
however, recorded by Bryant, Emmet, and Thomas, the tumor
protruded anteriorly from deficiency of the vertebral bodies.
The size of a spina bifida varies from that of a walnut to that of a

child's head, or even larger: in some rare instances, such as those
recorded by Lezelius and Richard, the whole spinal column has been
cleft, and the tumor has extended from nucha to sacrum; but cases
of this kind seldom come under the surgeon's observation, as
children with such extensive deformity usually perish shortly after
birth. The shape of the swelling is rounded, or more often oval; it is
commonly sessile, but occasionally pedunculated; and it is
sometimes lobulated, the lobules being separated by more or less
distinct sulci. The skin covering the tumor is in some cases normal,
with more or less fat in the subcutaneous connective tissue, but
more often thin, tightly stretched, red, shining, and occasionally
ulcerated; more rarely it is thickened and leathery, as in a case
referred to by Sir Prescott Hewett. Sometimes a navel-like
depression is found at some part of the surface, corresponding, as
pointed out by Follin and Duplay, and by Erb, to the place of
attachment, on the interior of the sac, of the terminal extremity of the
spinal cord. The cutaneous investment is sometimes altogether
wanting, the spinal dura mater itself forming the external covering of
the tumor. It is in these cases especially that ulceration and rupture
are apt to occur.
Spinæ bifidæ are usually soft and fluctuating, and occasionally

partially reducible; their tension and elasticity are increased when the
child is in the upright position or during the acts of expiration and
crying, and are diminished during inspiration or when the child is laid
upon its face. When the part is relaxed a bony prominence can be
felt on either side, and the aperture in the vertebral column can be
more or less distinctly outlined. The swelling is apt to be painful on
pressure. If the tumor is of moderate size and covered with healthy
skin, there are usually no constitutional symptoms, and, even where
ulceration and rupture occur, the opening may heal and a
spontaneous cure may possibly ensue. More often, as the tumor
increases in bulk—or at any time if pressure be made upon it—
various nervous symptoms are observed: drowsiness, muscular
twitchings, convulsions, and often paraplegia and paralysis of the
sphincters. Rupture is usually followed by the development of spinal
meningitis, or may prove directly the cause of death by the loss of
cerebro-spinal fluid which it causes; in other instances, however, if
the rupture be a small one, healing may occur (as already
mentioned) or a fistulous opening may persist; in rare cases the fluid
may escape by a process of transudation without rupture, as in an
example recorded by Laborie.
As may be inferred from what has already been said, the course of
spina bifida is usually rapid and toward a fatal termination. In some
instances, however, as in cases observed by Holmes, and more
recently by Lithgow, spontaneous recovery has followed the
obliteration of the channel which unites the sac with the cavity of the
spinal membranes; and in other instances, without a cure having
been effected, life has been prolonged for very many years. Thus,
Behrend reports a case in which a patient with spina bifida lived to
the age of fifty, and Holmes refers to another in which death resulted
from an independent disease at the age of forty-three. But a still
more remarkable case was recorded by Callender, the patient in this
instance having reached the age of seventy-four.
PATHOLOGY AND MORBID ANATOMY.—The most important points for

consideration in respect to the anatomy of spina bifida are the
relations which the spinal cord and spinal nerves bear to the sac,
and the nature of the contained fluid. It is ordinarily said that the
spinal cord itself commonly enters the sac of a spina bifida—the
report of the London Clinical Society's committee gives the
proportion of cases in which it does so at 63 per cent.—and Holmes
figures a specimen from the museum of St. George's Hospital,
London, in which this condition is obviously present; on the other
hand, Mayo-Robson in eight operations only once found the cord
implicated; and the late John B. S. Jackson of Boston—whose name
will be recognized as one of high authority in regard to all questions
of morbid anatomy—once assured me that he had made very many
dissections of spinæ bifidæ, and that he had invariably found that the
cord stopped short of the sac, and that only the nerves entered the
latter: this, as negative evidence, cannot of course contravene such
positive evidence as that of the specimen referred to by Holmes, but
it would seem to show that the condition was a less common one
than is generally supposed, and that in at least a fair proportion of
cases the cord itself did not form part of the sac contents. This
remark applies especially to those cases in which the fluid is
accumulated in the subarachnoid space, and in which, as pointed
out by Sir P. Hewett, the cauda equina or spinal nerves are pushed
by the vis a tergo into the sac; but when the dropsical effusion
occupies the central canal of the cord, this is apt to be flattened and
spread out like a thin lining to the sac, just as the brain is spread
over the inner wall of the skull in cases of internal hydrocephalus;
and, on the other hand, when the accumulated fluid fills the cavity of
the arachnoid the cord is apt to be pushed forward, and the sac may
be entirely devoid of all nerve-structures. Such, too, according to
Giraldès, is the case in spina bifida of the cervico-dorsal region.
The committee of the London Clinical Society classify cases of spina

bifida in three divisions: (1) Those in which the membranes only
protrude (spinal meningocele); (2) those in which the protrusion
involves both the cord and membranes (meningo-myelocele); and
(3) those in which the central canal of the cord itself forms the cavity
of the sac (syringo-myelocele). The last variety is the rarest, as the
second is the most common. In meningo-myeloceles the spinal cord
with its central canal is continued within the median, vertical portion
of the sac, and at this part there is no covering of true skin; the
nerve-roots which traverse the sac arise from this intramural portion
of the central nervous system.
Humphry of Cambridge, England, makes a somewhat similar
classification of spinæ bifidæ, recognizing as the most common
variety the hydrorachis externa anterior, in which the fluid occupies
the subarachnoid space in front of the spinal cord, and in which “the
cord and the nerves are stretched backwards and outwards upon the
sac, and are there confluent, together with the arachnoid, pia mater,
and dura mater, or their representatives, in the thin membrane which
forms the hindmost part of the wall of the sac;” rarer forms are the
hydro-meningocele, or hydrorachis externa posterior, in which the
fluid accumulates behind the cord, which does not enter the sac, and
the hydro-myelocele or hydrorachis interna, in which the fluid
occupies the central spinal canal.
The theory which, according to the Clinical Society's committee, best

explains the pathological anatomy of spina bifida is that which
assumes a primary defect of development of the mesoblast from
which the structures closing in the vertebral furrow are developed.
The fluid of spina bifida appears to be identical in character with the

cerebro-spinal fluid. Bostock found that it was very slightly clouded
by the application of heat, and that it contained, in 100 parts, 97.8 of
water, 1.0 of chloride of sodium, 0.5 of albumen, 0.5 of mucus, 0.2 of
gelatin, and some traces of lime. Five specimens more recently
analyzed by Hoppe-Seyler gave an average of 98.8 parts water, 0.15
parts proteids, and 1.06 extractives and salts. Turner found a
reaction somewhat similar to that of grape-sugar, as had been
previously found by Bussy and Deschamps in cerebro-spinal fluid
itself, but in two specimens analyzed by Noad for Holmes it was at
least very doubtful whether sugar was actually present. “The first
specimen was found to be completely neutral; its specific gravity was
1.0077; it contained phosphates, but no reaction could be obtained
resembling that of sugar. The second specimen ... did give a reaction
with copper like that of sugar, but no trace of fermentation could be
obtained.” Three analyses, however, made by Halliburton for the
London Clinical Society's committee showed uniformly a decided
trace of sugar, with a diminution in the quantity of proteids, which
appeared to consist entirely of globulin.
In some cases the sac of a spina bifida contains, besides nerve-
structures and cerebro-spinal fluid, both fibrous and fatty tissues.
DIAGNOSIS.—Ordinary fatty tumors have been mistaken for spinæ

bifidæ, but such an error could only be committed through
carelessness: more difficult is the diagnosis from certain forms of
congenital cyst, occupying the median line of the back, and still more
difficult the diagnosis from the several affections known as false
spina bifida. In the former case the distinction might be made by
noting the irreducibility, constant shape, and unchanging tenseness
of the cyst, and perhaps, as suggested by T. Smith, by tracing the
line of spinous processes beneath it; some information, too, might
perhaps be gained by chemical examination of the fluid obtained by
puncture. Under the name of false spina bifida Holmes includes
three distinct conditions: these are—(1) a true spina bifida, in which
the connection with the spinal membranes has in some way been
obliterated, the sac then communicating with the vertebral canal, but
not with the theca; (2) a congenital, cystic, or fatty tumor, taking its
origin within the vertebral canal, and projecting through an opening
caused by a gap in the laminæ; and (3) a tumor containing fœtal
remains, and properly regarded as an example of included fœtation.
In any of these cases a positive diagnosis might be impossible, and
the probable nature of the tumor could only be inferred by noting the
absence of one or more of the characteristic symptoms of true spina
bifida.
PROGNOSIS.—The prognosis of spina bifida is without question

unfavorable; at the same time the affection is by no means to be
considered, as it was formerly, one of an invariably fatal character,
for, apart from the fact already mentioned that several cases are on
record in which patients with untreated spina bifida have reached
adult life, and even old age, the modern method of treatment has
proved so much more successful than those formerly employed that
in favorable cases surgical interference affords at least a reasonable
prospect of recovery. The circumstances which especially furnish
grounds for an unfavorable prognosis are the rapid growth of the
tumor, the thinning or ulceration of its coverings, and the occurrence
of nervous symptoms, and particularly of paralysis or convulsions.
TREATMENT.—This may be either palliative or radical. If the tumor be

not increasing materially in size, the surgeon may properly content
himself with palliative measures—applying equable support and
perhaps slight pressure by the use of a well-padded cap of gutta-
percha or leather, an air-pad, or, as advised by Treves, a simple pad
of cotton smeared with vaseline, and a bandage; if the tumor be
small and covered with healthy integument, painting its surface with
collodion may be of service through the contractile property of that
substance. Radical measures are only indicated when the child,
otherwise healthy, seems to have his life threatened by the rapid
growth of the tumor, causing risk of ulceration and rupture, or giving
rise to convulsions or paralysis. The principal modes of treatment to
be considered under this heading are—(1) simple tapping or
paracentesis; (2) injection of iodine; (3) ligation of the neck of the
sac; and (4) excision.
(1) Paracentesis, a simple evacuation of the fluid contents of the sac,

is the only operation ordinarily justifiable in cases attended by
paralysis or other grave nervous manifestations. The puncture
should be made in the lower part of the sac and at a distance from
the median line (in the course of which the nerve-structures are
particularly distributed), and only a small quantity of fluid—a few
drachms or at most one or two ounces—should be removed at a
time, the instrument being at once withdrawn if convulsions follow,
and the wound being instantly closed with lint dipped in compound
tincture of benzoin. Either an aspirator-tube or a small trocar may be
used, and the operation may be repeated if necessary, pressure
being maintained during the intervals. Paracentesis has occasionally
though not often proved curative.
(2) Injection of Iodine.—This mode of treatment was introduced

about the same time by Velpeau and by Brainard of Chicago. The
latter surgeon's method consists in injecting, after only partially
emptying the tumor, a solution of iodine with iodide of potassium
(iodine, 5 grs.; iodide of potassium, 15 grs.; water, 1 fl. oz.), allowing
it to flow out again, washing out the sac with water, and finally
reinjecting a portion of the cerebro-spinal fluid originally evacuated;
and the former's, in completely evacuating the tumor, and then
injecting a mixture of iodine and iodide of potassium, each one part
to ten parts of water. Each of these plans has met with a fair
measure of success;1 but the modification introduced by James
Morton of Glasgow is a great improvement, and affords what is
actually the most successful mode yet devised for dealing with spina
bifida. Morton employs a solution of iodine in glycerin (iodine, 10
grs.; iodide of potassium, 30 grs.; glycerin, 1 fl. oz.), which has the
advantage of being less diffusible than the aqueous solution, and
therefore less liable to enter the spinal canal. The tumor is about half
emptied, and a small quantity—from fluid drachm ss to fluid drachm
iij of the solution—is then slowly injected, and allowed to remain. The
operation is repeated after a few days if necessary. Of 50 cases
known to Morton as having been treated in this way up to May, 1885,
41 were regarded as successful; but of 71 cases collected by the
London Clinical Society's committee, only 39 had been benefited by
the operation.
1 In a case recently recorded by Woltering, however, iodine injection was followed by
death within half an hour.
The introduction of iodine into the sac of a spina bifida is, according
to Morton, only justifiable in cases unattended by paralysis; under
opposite circumstances I should be disposed to try a plan recently
employed with success by Noble Smith in a case of meningocele—
viz. injecting the iodo-glycerin solution into the coverings of the sac,
and as close to it as possible without perforating it.
(3) and (4). Ligation and excision have each occasionally effected a
cure, but more often have but helped to precipitate a fatal issue. A
successful case of ligation followed by excision has been recently
recorded by Löbker. The elastic ligature, applied around the neck of
the sac (if this be pedunculated), has been employed by Laroyenne,
Ball, Colognese, Baldossare, Mouchet, and other surgeons, and of 6

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The Meaning of Terrorism Cecil

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The Meaning of Terrorism

British Library Cataloguing in Publication Data

Philosophers writing on and often discussing together urgent issues related

(then) University of Maryland Institute for Philosophy and Public Policy

University, University of Sydney, University of Adelaide, University

Cambridge, MA: The Belknap Press of Harvard University Press,

The Earth quakes, the earth

terrorist acts understandably arouse a particular sort of apprehension

Philosophy and Terrorism

Although philosophers have eventually devoted a great deal of attention to

Harvard seminar I had attended in 1978, had a brief, stimulating chapter

   3

1970s to early 1980s. At a committee meeting with colleagues in the program

instead on the idea of national interest as the sole or primary relevant

the meaning of terrorism, in a sense broader than that of conceptual

beyond academia is enormous, and I make no pretense of having heeded

A Brief Outline of Themes in the Book’s Chapters

Chapter 1 is concerned with bringing some clarity to the widespread con-

       ’  5

ordinarily committed or inspired by an organized group, in which violence

In Chapter 2, a number of objections to the deﬁnition are discussed that

Chapter 3 addresses four philosophical attempts to show, mostly without

signiﬁcance, since the tactical deﬁnition’s reliance upon such concepts

       ’  7

Chapters 5 and 6 provide an extensive discussion of seven philosophical

SYNONYM.—Leptomeningitis spinalis acuta.

By the term spinal meningitis is usually meant inflammation of both

ETIOLOGY.—Among the causes of acute spinal meningitis are injuries

SYMPTOMS.—The onset of the disease is generally sudden, and it is

When the course of the disease is unfavorable, symptoms of

The course of acute spinal meningitis is rapid. It sometimes

DIAGNOSIS.—Spinal meningitis is easily recognized in most cases by

PROGNOSIS.—Acute spinal meningitis is always a grave disease,

TREATMENT.—During the first stage of the disease an effort should be

Chronic Spinal Meningitis.

SYNONYMS.—Chronic inflammation of the pia mater of the spinal cord,

SYMPTOMS.—Gowers9 remarks that a large number of symptoms

The anatomical appearances, which are most pronounced in the

PROGNOSIS.—Simple chronic spinal meningitis is rarely if ever fatal.

TREATMENT.—The treatment should have for its object (1st) to relieve

Spinal Meningeal Hemorrhage.

SYNONYMS.—Spinal meningeal apoplexy, Hæmatorrhachis.

Spinal meningeal hemorrhage may take place between the dura

ETIOLOGY.—Penetrating wounds, injuries to the vertebræ, fractures

SYMPTOMS.—These vary according to the conditions under which the

PATHOLOGICAL ANATOMY.—In hemorrhage outside the dura the loose

DIAGNOSIS.—When the complications are such that symptoms

PROGNOSIS.—In traumatic cases the hemorrhage is usually only one

TREATMENT.—In the early stage absolute rest in bed, with cold

BY JOHN ASHHURST, JR., M.D.

DEFINITION.—By the term spina bifida is meant a congenital

SYNONYMS, ETC.—Of the various names which have been proposed

ETIOLOGY.—There are two conditions essential to the formation of a

SYMPTOMATOLOGY.—Spina bifida forms a tumor—or, more rarely,