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An imprint of Elsevier Limited
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Notice
Neither the Publisher nor the Author assume any responsibility for any loss or injury and/or damage
to persons or property arising out of or related to any use of the material contained in this book.
It is the responsibility of the treating practitioner, relying on independent expertise and knowledge of
the patient, to determine the best treatment and method of application for the patient.
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 To Jennifer

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painstaking efforts in helping to produce this text
 ix

Preface

Conditions causing spinal pain syndromes are many and thorough physical examination followed, as indicated, by
varied and patients can present with a wide variety of appropriate imaging and laboratory procedures.
symptoms. Therefore, each patient needs to be thoroughly During the last few years of a 37-year career
investigated before treatment commences i.e. diagnosis specializing in spinal pain syndromes, interesting challeng-
must be a prerequisite to treatment. ing spinal pain syndrome cases have been collected, 100 of
It behoves all clinicians dealing with spinal pain syn- which are presented in this text. In some of the cases pre-
dromes to note the following: sented, gross anatomy and pathology, as well as some his-
topathology specimens, obtained from postmortem
 First, do no harm (Hippocrates, Epidemics, Bk. 1, Sect.
material, with changes similar to the clinical cases pre-
XI).
sented, are used to illustrate how such conditions in
 ”If you listen carefully to the patient they will tell you the
patients may cause spinal pain syndromes and provide a
diagnosis” (Quotation of Sir William Osler 1849–1919). This
basis upon which to recommend treatment options.
statement still holds true and emphasizes the great impor-
In some cases patients merely wanted reassurance,
tance of taking a good history.
based upon a thorough evaluation leading to a likely
 Remember that patients may present with more than one
explanation for their chronic pain syndrome(s), rather than
condition, so consider all possibilities.
requesting treatment. The importance of providing ade-
 Get back to the basic principles (Frymoyer JW 1997 Fore-
quate, albeit time consuming, psychological assurance
word. Clinical anatomy and management of low back
should not be underestimated. Obviously, it is important
pain. In: Giles LGF and Singer KP, Butterworth–Heine-
to consider a particular pain syndrome in great detail
mann, Edinburgh) e.g. be conversant with the principles
while not forgetting that psychology must be taken into
of anatomy, physiology, pathology, etc.
account for each patient, as symptoms and signs should
Knowledge is ever increasing on spinal anatomy and histo- not be isolated from the patient as a whole being.
pathology and the possible physiological mechanisms by The cases begin with the most frequently involved spi-
which pain may be generated and experienced. Therefore, nal level (lumbar spine) and conclude with the least fre-
in this text an introductory chapter summarizes possible quently involved spinal level (thoracic spine).
pain sources based on known anatomical principles. The cases represent what actually takes place in day-to-
Because spinal pain syndromes can be complex, there often day clinical practice and illustrate some of the various
is a tendency for clinicians to incorrectly label patients as shortcomings of health care providers.
being ‘neurotic’, or when patients are involved in litigation It should be noted that it is the responsibility of the
they may be considered to have litigation ‘neurosis’ as a treating clinician, relying on independent expertise and
motive. However, it should be remembered that it is not knowledge of the patient, to determine the best treatment
always possible to diagnose a patient’s spinal pain condi- and method of application for their individual patients.
tion because of many factors such as the limitations of Finally, all clinical professionals may make errors of
imaging procedures and the specificity and sensitivity of judgement in the diagnosis and management of patients.
laboratory tests. Therefore, patients should not be consid- Therefore, it is not the intention of this text to criticize
ered as malingerers unless there are very strong grounds any particular profession but rather to draw to the atten-
for doing so. Imaging frequently only provides shadows tion of health practitioners from various backgrounds what
of the truth and laboratory tests can be misleading, so it actually takes place in the health care domain in the hope
is imperative to take a careful history and to perform a that clinicians, and students embarking upon a health care
x PREFACE

career, will glean some insight into the possible difficulties of such syndromes – no one profession has all the answers
that may arise with respect to individual cases. to manage challenging acute and chronic spinal pain syn-
In my opinion, multidisciplinary cooperation is essential if drome patients.
clinicians from different backgrounds are to best serve indivi- L.G.F. Giles
duals with spinal pain syndromes and the possible sequelae
 xi

General introduction

pain unit Giles et al (2003) found that, of the 949 male patients
INTRODUCTION
and 826 female patients (aged 10 to 91 years; average age 43
The diagnosis of spinal pain syndromes is often difficult, as years), all of whom had some form of spinal imaging, 1% of
the anatomy of the spine and its adjacent soft tissue struc- patients had radiologically identifiable life threatening path-
tures is complex. For details of spinal anatomy including his- ological processes. This percentage concurs with the serious
tology and histopathology see Rickenbacher et al (1982), pathology percentage of up to 1% as stated by Waddell
Giles (1989), Von Hagens et al (1991), Rauschning (1997), (2004).
Giles & Singer (1997, 1998, 2000), Cramer & Darby (2005), Pain in any structure requires the release of inflamma-
Moore & Dalley (2006). The purpose of this introduction is tory agents, including bradykinin, prostaglandins and leu-
to provide a synopsis of possible diagnoses based on a sound kotrienes, that stimulate pain receptors and generate a
anatomical foundation as well as on the clinical history, nociceptive response in the tissue; the spine is unique in
physical examination, imaging and laboratory findings. In that it has multiple structures that are innervated by pain
addition, it should be noted that the neurophysiology of pain fibres (Haldeman et al 2002).
is not fully understood at this time. For example, when Slip- Spinal pain syndromes must be viewed in the context of
man et al (1998) studied the mechanical stimulation of cervi- (i) clearly defined pathological conditions, and (ii) the less
cal nerve roots C4 to C8 in patients with cervical radicular well-defined, but much more prevalent, condition of non-
symptoms who were undergoing diagnostic selective nerve specific spinal pain of mechanical origin (Stoddard 1969,
block, to document the distribution of pain and paraesthesiae Kenna & Murtagh 1989). It is imperative to distinguish
that result from stimulation of specific cervical nerve roots, dysfunctional mechanical causes of spinal pain from other
and to compare that distribution to documented sensory der- causes, as patients with mechanical disorders of the spine
matomal maps, they demonstrated a distinct difference are likely to respond dramatically to manual treatment
between dynatomal and dermatomal maps. A dynatome is (Kenna & Murtagh 1989).
the distribution of referred symptoms from root irritation A major difficulty involved in evaluating a patient with
and this is different to the sensory deficit outlined by derma- non-specific spinal pain of mechanical origin, with or with-
tomal maps. Slipman et al (1998) suggest that cervical derma- out root symptoms, is that many causes of pain are possible.
tomal mapping is inaccurate, as the distribution of referred Because the painful structure, or structures, are not amenable
symptoms from cervical root irritation is different than the to direct scrutiny, a tentative diagnosis is usually arrived at
sensory deficit outlined by dermatomal maps. Therefore, it for an individual case by taking a careful case history and
is reasonable to suggest that a similar neurophysiological employing a thorough physical examination, with imaging
finding may occur at other spinal nerve root levels. Thus, and laboratory procedures as indicated. There are several
when considering neurological tests such as pinprick or light main approaches to patient evaluation: (i) history taking;
touch, summarized later in this text, it would be prudent to (ii) assessment of pain (using subjective self-report measures
remember the work of Slipman et al (1998). estimating pain severity, quality and location); (iii) investiga-
Low back pain is experienced by 80–90% of the population tion of personality structure, including the use of appropriate
(Deen 1996), while 34–40% of the population experience neck subjective questionnaires; (iv) clinical identification of signs
and arm pain (Hardin & Halla 1995) compared to 7–14% of and symptoms; (v) the use of appropriate imaging; and
the population that experience thoracic spine pain (Pedersen (v) the use of appropriate laboratory investigations. Evidence
1994, Hinkley & Drysdale 1995). Therefore, musculoskeletal of signs and symptoms deemed excessively, or inappropri-
spinal pain can be a significant health problem. On analysing ately, abnormal (Main & Waddell 1982) should be recorded.
1775 new patients presenting to a multidisciplinary spinal However, caution has to be exercised when making
xii GENERAL INTRODUCTION

judgements on an individual’s behavioural responses to of nuclear anatomy and not for symptomatology, and Schell-
examination as serious misuse and misinterpretation of has et al (1996) showed that significant cervical disc annular
behavioural signs has occurred in medicolegal contexts using tears often escape MRI detection. In addition, Osti & Fraser
such signs (Main & Waddell 1998). These behavioural signs (1992) concluded that lumbar discography is more accurate
have been questioned by Giles (2005). than MRI for the detection of annular pathology. However,
There is still little consensus, either within or among spe- according to Shalen (1989), lumbar discography is a contro-
cialties, on the use of diagnostic tests for patients with spinal versial examination that is regarded by some radiologists
pain syndromes, and the underlying pathology responsible and spine surgeons as barbaric and non-efficacious (Wiley
for various spinal pain problems remains elusive (Videman et al 1968, Clifford 1986, Shapiro 1986). For lumbar spine
et al 1998). Furthermore, in spite of following a thorough CT and MR imaging, Willen et al (1997) showed that the
examination procedure, one often merely eliminates overt diagnostic specificity of spinal stenosis will increase consid-
pathologies and the precise cause of non-specific spinal pain erably when the patient is subjected to an axial load, and
syndromes of mechanical origin often remains obscure Danielson et al (1998) concluded that, for an adequate evalu-
(Turner et al 1998). ation of the cross-sectional area, CT or MR imaging studies
Specifically, diagnostic problems relate to: (a) the limita- should be performed with axial loading in patients who
tions of many diagnostic procedures, including plain film have symptoms of lumbar spinal stenosis. The advantage
radiography, computerized tomography (CT), positron of MRI, which is considered to be the major medical imag-
emission tomography (PET) scan, magnetic resonance imag- ing development of the century (Wong & Transfeldt 2007),
ing (MRI), myelography, discography and bone scans; (b) is that it is a non-invasive procedure, without any recognized
some diagnostic and therapeutic chemical agents being biological hazard, that combines a strong magnetic field
harmful, as can be the case when such chemicals injected and radiofrequency energy to study the distribution and
into intervertebral discs extravasate into the epidural space behaviour of hydrogen protons in fat and water (Weir &
(Weitz 1984, Adams et al 1986, MacMillan et al 1991) caus- Abrahams 2003). More recently, exciting new developments
ing complications due to contact between them and neural have occurred with, for example, upright, dynamic-kinetic
structures (Dyck 1985, Merz 1986, Watts & Dickhaus 1986); i.e. ‘functional’ MRI and its ability to detect load- and
(c) inadequacies in the precise anatomical knowledge of motion-dependent disc herniations, stenosis, instabilities,
the spine including its nociceptive tissues; (d) anatomical and combinations of these pathologies not seen during
complexity of the spine often making roentgenographic recumbent imaging (Jinkins et al 2003, Elsig & Kaech 2006,
interpretation difficult (Le-Breton et al 1993); and (e) there Jinkins JR personal communication 2007). In addition,
sometimes being multifactorial causes of pain at a given 3 Teslar (T) MRI units are becoming available that can pro-
level of the spine (Haldeman 1977, Gross 1979), e.g. injury vide higher-quality images than those obtained at 1.5 T
to the intervertebral disc, the zygapophysial facet joints (Tanenbaum 2006).
and to the segmental soft tissue structures. In addition, there In the thoracic spine, with its particular combination of
may be several types of spinal pain that closely mimic each intervertebral and various synovial joints, the most common
other (Haldeman 1977). A further important point to cause of thoracic spine pain syndromes is dysfunction and
remember is that a central disc herniation may cause spinal degeneration of spinal intervertebral joints and the asso-
pain alone without radiculopathy (Postacchini & Gumina ciated rib articulations (Kenna & Murtagh 1989). Further-
1999) whereas a posterolateral or far lateral disc herniation more, Erwin et al (2000) showed that costo-vertebral joint
will, in all likelihood, cause radicular pain (Keim & anterior capsule and synovial tissues are innervated,
Kirkaldy-Willis 1987). demonstrating that these joints have the requisite innerva-
The nerve root compression that occurs in lumbar disc tion for pain production. Root compression due to postero-
herniation and lumbar canal stenosis often results in a range lateral disc protrusion, with resulting signs and symptoms
of symptoms, including low back pain, sciatic pain, and sen- of intercostal radiculopathy, such as pain, paraesthesiae
sory disturbances and muscle weakness in the legs (Kobaya- and sensory disturbances, has to be differentiated from
shi et al 2005). Summers et al (2005) consider that the degree overt pathological conditions such as neoplasms. Thoracic
of back or leg pain caused by an acute disc prolapse depends, disc protrusion has long been a difficult clinical entity to
in part, on the position, size, and level of the disc prolapse. diagnose (Brown et al 1992) as symptoms can vary dramati-
There often is disagreement on which imaging procedures cally from none at all to motor and sensory deficits resulting
have diagnostic validity for non-specific spinal pain of from spinal cord compression (myelopathy) – pain, muscle
mechanical origin, although it is generally agreed that, for weakness, and spinal cord dysfunction are the most com-
plain film X-ray examinations, two views of the same anato- mon clinical symptoms (Cramer 2005). On the other hand,
mical region at right angles is the minimum requirement thoracic disc protrusion can produce spinal cord compres-
(Henderson et al 1994), and that erect posture radiography sion with bladder incontinence and signs of an upper motor
(Giles & Taylor 1981) and functional views ( Jackson 1977) neuron lesion (Kenna & Murtagh 1989) and occasionally
are more useful. Furthermore, Buirski & Silberstein (1993) paraplegia. As the thoracic cord is immobilized by the
correctly noted that MRI can only be used as an assessment dentate ligaments, the anterior spinal artery may be
 GENERAL INTRODUCTION xiii

significantly compressed by a relatively small central disc for anatomically normal spines and which needs to be con-
protrusion (Pate & Jaeger 1996) and, because there is little sidered during the examination is that the distribution of
extradural space in the thoracic spinal canal, a compara- cutaneous areas supplied with afferent nerve fibres by sin-
tively small disc protrusion may have pronounced effects gle posterior spinal nerve roots, i.e. dermatomes of the
on the neurology (Hoppenfeld 1977). Thoracic cord com- human body (Dorland’s Illustrated Medical Dictionary 1974,
pression can also be caused by ossified ligamenta flava in Barr & Kiernan 1983), has been fairly well established
Caucasians (van Oostenbrugge et al 1999) as well as in Jap- (Fig. i). Myotomes, a group of muscles innervated from a
anese people (Otan et al 1986, Yonenobu et al 1987, Kojima single spinal segment (Dorland’s Illustrated Medical Dictio-
et al 1992). nary 1974), likewise, have been fairly well established.
As it is still only rarely possible to validate a diagnosis According to Keim & Kirkaldy-Willis (1987), dermatomes
in cases where pain arises from the spine (White & Gordon enable deficits of a specific nerve root to be accurately loca-
1982) and, because it is not possible to establish the patho- lized during sensory examination. However, it is important
logical basis of spinal pain in 80–90% of cases (Chila et al to note that Jinkins (1993) and Slipman et al (1998) question
1990, Spratt et al 1990, Pope & Novotny 1993), this leads this concept and suggest that there is, in fact, some overlap
to diagnostic uncertainty and suspicion that some patients of sensation.
have a ‘compensation neurosis’ or other psychological
problem. It is also appropriate at this time to recognize the
role of psychosocial factors in spinal pain. Although the
complex interaction of psyche and soma in the aetiology of
spinal pain is not well understood, a psychogenic compo-
nent may be primary (conversion disorder), secondary
(depression caused by chronic pain), contributory (myofas-
cial dysfunction), or absent (Keim & Kirkaldy-Willis 1987).
Nonetheless, clinicians must have a good understanding of
possible causes of symptoms and a high suspicion of possi-
ble underlying pathology, e.g. patients presenting with
symptoms of tethered cord syndrome (Yamada 1996, Giles
2003, Yamada et al 2004), or patients presenting with symp-
toms of arteriovenous malformations (Criscuolo & Rothbart
1992), i.e. an abnormal communication between an artery
and a vein (Beers et al 2006), should not be overlooked.
It is reasonable to broadly classify acute spinal pain as
being of 7–28 days or less duration, which may be followed
by a sub-acute stage of up to 12 weeks; after this the pain
can be considered chronic (Skoven et al 2002).

HISTORY OF SPINAL PAIN

The importance of an exhaustive case history cannot be over-
emphasized and it should take into account facts such as the
patient’s age, occupation, onset of pain, previous injuries,
medication, recreational activities, pain aggravation and
characteristics, location, distribution, and any related neuro-
logical symptoms (numbness, paraesthesiae, muscle weak-
ness) and whether compensation is involved regarding an
injury. Some conditions provide reasonably characteristic
patterns, while others do not. For example, pain that occurs
at night, and which is relieved by aspirin, may be associated
with an osteoid osteoma, that is a benign tumour of bone
(Keim & Kirkaldy-Willis 1987). Night pain per se should be
considered as being of probable serious pathological change.
Likewise, night sweats may suggest a serious underlying
pathology. Figure i Dermatomes on the anterior and posterior surfaces of the
Taking into consideration the abovementioned issue of body. Axial lines, where there is numerical discontinuity, are drawn
dermatomes and dynatomes (Slipman et al 1998), an thickly. (Modified from Wilkinson, JL 1986 Neuroanatomy for
important neurological concept that has been recognized medical students. John Wright & Sons, Bristol, p 29.)
xiv GENERAL INTRODUCTION

Until a thorough history has been taken and a complete

physical examination and any appropriate imaging or labo-
ratory tests have been performed, as considered necessary
for a particular patient, to rule out organic disease, it is not
wise to label a patient as being neurotic or a malingerer, par-
ticularly as it is thought that such patients form only a small
minority of cases (Teasell 1997). Furthermore, there has long
been a misconception that all injuries should heal after 6
weeks; however, clinical experience and follow-up studies
(Mendelson 1982, Radanov et al 1994) clearly demonstrate
that not all patients necessarily get better and that there is a
significant subset who continue to suffer from chronic symp-
toms (Teasell 1997).
It is worth noting the sobering comment of orthopaedic
Professor Ruth Jackson in her classic textbook The Cervical
Syndrome (1977) in which she wrote:
‘When one who is not completely versed in the symptom-
atology of disorders of the cervical spine has completed this
portion of the examination, he may have drawn the conclu-
sion that the patient is psychoneurotic. However, to draw
such a conclusion is a reflection on the examiner’s diagnostic Figure ii A schematic diagram showing part of the lower lumbar
ability and not on the patient, until proven otherwise.’ (i.e. L3 to S1 levels) spinal innervation (lateral view). 1 ¼ anterior
primary ramus of the spinal nerve; 2 ¼ anterior primary ramus branch
This comment applies equally well to all regions of the
to the intervertebral disc; 3 ¼ posterior primary ramus of the spinal
complex human spine. nerve; 4 ¼ medial branch of the posterior primary ramus with an
adjacent zygapophysial joint capsule (articular) branch, and a
BRIEF SUMMARY OF SPINAL INNERVATION descending articular branch to the zygapophysial joint capsule one
joint lower; 5 ¼ lateral branch of the posterior primary ramus;
The overall basic pattern of innervation of the spine can GRC ¼ grey ramus communicans; TVP ¼ transverse process;
briefly be outlined by looking at the anatomy of the lower ZJC ¼ zygapophysial joint capsule; arrow ¼ mamillo-accessory
lumbosacral spine as shown schematically in Figures ii and iii. ligament. (Reproduced with permission from Giles L G F 1989
The segmental innervation of the lumbar, cervical and Anatomical basis of low back pain. Baltimore, Williams & Wilkins, p 60).
thoracic spines is extremely complex as partly shown in
Figures iv, v and vi, respectively. Although part of the usually formed by the fourth lumbar root (Izci et al 2005).
innervation of the anterior and posterior elements of the Occasionally, two furcal nerves may be present, i.e. L3 and
lumbar spine is shown schematically in Fig. iv, the inner- L4 or L4 and L5; sometimes only one L5 furcal nerve is pres-
vation shown for the cervical and thoracic spines is less ent. The dorsal root of the furcal nerve has a ganglion
detailed in order to simplify the diagrams. However, the situated, as for the normal dorsal roots, at the level of the
basic neuroanatomical principles shown for the lumbar intervertebral foramen; once the nerve has left the interver-
spine are largely the same for each spinal level, bearing tebral foramen with the roots proper of that level, with
in mind the different osteological and soft tissue structures which it constitutes a single radicular nerve, it gives off
for the three levels of the spine; full details of spinal inner- three branches, contributing to form, respectively, the femo-
vation can be found in standard textbooks such as Gray’s ral nerve, the obturator nerve, and the lumbosacral trunk
Anatomy and Moore’s Clinically Oriented Anatomy, or in (Postacchini & Rauschning 1999). The clinical relevance of
anatomy texts specifically related to the spine (Cramer & the furcal nerve is that disc herniation, or other pathological
Darby 2005). conditions, may impinge upon both the radicular nerve
Possible anatomical variations in nerves should be kept proper of that level and on the furcal nerve, thus causing
in mind in view of their associated clinical importance. atypical bi-radicular syndromes (Kikuchi et al 1986; Postac-
For example, in the lumbar spine the furcal nerve, i.e. an chini & Rauschning 1999). According to Haijiao et al (2001),
accessory spinal nerve originating from the cord indepen- MRI provides accurate information on lumbosacral nerve
dently of other lumbar nerve roots that, like the latter, root anomalies.
includes a ventral and a dorsal component; the furcal The thoraco-lumbar junction gives rise to the cluneal
nerve can be found in all subjects, is generally single and, nerves providing innervation of the lower lumbar region,
in most cases, its roots emerge from the spinal cord and below the iliac crest, i.e. by sensory nerves coming from the
run within the thecal sac beside the L4 roots (Kikuchi et al T11, T12, L1 and L2 roots; these roots give rise to a short dorsal
1986; Postacchini & Rauschning 1999) with the furcal nerve ramus that divides into two branches – a medial branch and a
 GENERAL INTRODUCTION xv

Figure iv A schematic diagram showing basic lumbar vertebral

anatomy and part of the innervation of the anterior and posterior
structures of the vertebral column: 1 ¼ nucleus pulposus;
2 ¼ annulus fibrosus; 3 ¼ anterior longitudinal ligament/
periosteum; 4 ¼ posterior longitudinal ligament/periosteum;
5 ¼ dural tube; 6 ¼ epidural vasculature; 7 ¼ filum terminale;
8 ¼ intrathecal lumbosacral nerve root; 9 ¼ ventral (anterior) root;
Figure iii A schematic diagram showing part of the lower lumbar 10 ¼ dorsal (posterior) root; 11 ¼ dorsal root ganglion (spinal
spinal innervation (posterior view). 3 ¼ posterior primary ramus of ganglion); 12 ¼ dorsal ramus of spinal nerve; 13 ¼ ventral ramus
the spinal nerve; 4 ¼ medial branch of the posterior primary ramus of spinal nerve; 14 ¼ recurrent meningeal nerve (sinuvertebral
with an adjacent zygapophysial joint capsule (articular) branch nerve of von Luschka); 15 ¼ autonomic (sympathetic) branch to
(arrow), and a descending articular branch to the zygapophysial joint recurrent meningeal nerve; 16 ¼ direct somatic branch from
capsule one joint lower (bisected arrow); 5 ¼ lateral branch of the ventral ramus of spinal nerve to lateral disc; 17 ¼ white ramus
posterior primary ramus; MP ¼ mammillary process with mamillo- communicans (not found caudal to L2); 18 ¼ grey ramus
accessory ligament; ZJC ¼ zygapophysial joint capsule. (Reproduced communicans (multilevel irregular lumbosacral distribution);
with permission from Giles LGF 1989 Anatomical basis of low back 19 ¼ lateral sympathetic efferent branches projecting from grey
pain. Baltimore, Williams & Wilkins, p 61.) ramus communicans; 20 ¼ paraspinal sympathetic ganglion (PSG);
21 ¼ paraspinal sympathetic chain; 22 ¼ anterior paraspinal
afferent sympathetic ramus projecting to PSG; 23 ¼ anterior
lateral branch that innervate the skin and are known as the sympathetic efferent branches projecting from PSG; 24 ¼ lateral
superior cluneal nerve (Maigne 1980; Maigne & Maigne paraspinal afferent sympathetic ramus projecting to PSG. (Note:
1991). The cluneal nerves can be associated with low back afferent and efferent sympathetic paraspinous branches/rami may
pain in the region of the posterior iliac crest (Maigne 1980, be partially combined in vivo.) A ¼ neural fibres from main trunk of
Maigne 2000) and with pain projecting into the buttock spinal nerve (N); B ¼ neural fibres from ventral ramus (13) of spinal
nerve; C ¼ neural fibres from dorsal ramus (12) of spinal nerve;
(Maigne & Doursounian 1997).
E ¼ neural fibres from medial branch (D) of dorsal ramus (12);
In the neck, the vertebral nerve that originates from near F ¼ neural fibres from lateral branch of dorsal ramus (12) of the
the superior pole of the stellate ganglion, and rarely from spinal nerve. (Modified from: Jinkins JR et al 1989 American
the inferior cervical ganglion, is usually a single filament Journal of Neuroradiology 10: 219–251, American Journal of
and, in essence, is a deeply placed long gray ramus commu- Roentgenology 152: 1277–1279; Jinkins JR 1997 Clinical anatomy
nicans from the 6th or 7th cervical nerves that connects the and management of low back pain, p 255–272; Auteroche P 1983
stellate or inferior cervical ganglia to the lower cervical spi- Anatomia Clinica 5: 17–28.)
nal nerves (Tubbs et al 2007). Many of the fibres from this
ramus (C6) become incorporated in the sympathetic plexus et al (2007) emanating from the stellate ganglion; Tubbs et al
surrounding the vertebral artery (Axford 1928) and (2007) concluded that this may be important in treating
branches from the vertebral nerve join the perivertebral medically intractable neck pain by allowing neural blockade
nerve plexus that accompanies the basilar and superior cer- of the vertebral nerve.
ebellar arteries intracranially (Lang 1993). Articular and Among various other structures that may be involved in
meningeal branches were sometimes identified by Tubbs a patient’s symptoms are the transforaminal ligaments
xvi GENERAL INTRODUCTION

Figure v A schematic diagram of a typical cervical vertebra showing basic cervical vertebral anatomy and part of the neuroanatomy within
the spinal and intervertebral foramen canals. The long arrow points to the origin of the recurrent spinal meningeal nerve and the insert shows
this nerve in detail. The short arrow points to the anterior spinal artery. The diagram does not show the peripheral innervation of the
intervertebral disc or of the zygapophysial (facet) joints. 1 ¼ intervertebral disc; 2 ¼ posterior longitudinal ligament; 3 ¼ uncovertebral joint;
4 ¼ deep sympathetic chain; 5 ¼ vertebral artery and spinal branch; 6 ¼ anterior nerve root; 7 ¼ anterior primary ramus; 8 ¼ posterior
primary ramus; 9 ¼ posterior nerve root and ganglion of C5; 10 ¼ posterior spinal arteries; 11 ¼ spinal canal; 12 ¼ subdural space;
13 ¼ dura; 14 ¼ arachnoid; 15 ¼ dentate ligament; 16 ¼ epidural space; CN ¼ cervical nerve; RSMN ¼ recurrent spinal meningeal nerve;
SG ¼ sympathetic ganglion; PGF ¼ post ganglionic fibres. (Modified and reproduced with permission from: Jackson R 1977 The cervical
syndrome, 4th edn. Charles C Thomas, Springfield.)

(TFLs) (Amonoo-Kuofi et al 1988, Giles 1992a, Cramer et al paresis; pain may be present in various forms and may take
2002) that reduce the space available for the spinal nerve the form of low back pain or neurogenic claudication or, if
root within the intervertebral foramen (Min et al 2005) subarachnoid haemorrhage occurs, then severe headaches,
and thus may play a role in giving rise to severe pain photophobia, and meningism may be present (Rothbart et al
and paraesthesiae along the distribution of a nerve due 1997). A spinal dural arteriovenous fistula, where a direct
to direct mechanical pressure on the neural complex connection between the radicular branch of a radicular artery
(Amonoo-Kuofi & El-Badawi 1997). TFLs can successfully and the corresponding radicular vein at the dorsal root sleeve,
be imaged with low-field-strength MRI; if a trained radiol- results in signs of a progressive myelopathy (van der Meulen
ogist identifies a TFL, there is an 87% chance that one is et al 1999, Jellema et al 2007).
present and, if a trained radiologist does not identify a MRI of the spinal cord plays a very important role in the
TFL in an intervertebral foramen, there remains a 51% diagnosis of AVMs. For example, high T2 signal MRI of the
chance that one is present (Cramer et al 2002). spinal cord is the most sensitive imaging finding in spinal
Another structure to be considered, and alluded to above, dural arteriovenous fistula (Gilbertson et al 1995).
is that of spinal arteriovenous malformations (AVMs) i.e. Because of the lack of pathognomonic symptoms and signs
dural arteriovenous fistulas, intradural arteriovenous mal- associated with spinal arteriovenous malformations, the dif-
formations, and extradural venous varices (Criscuolo & ferential diagnosis is extremely important because the asso-
Rothbart 1992, Mascalchi et al 2001) that, although rare, ciated progressive myelopathy may be confused with other,
may occur in any region of the spine (Royston 2007) includ- more common, neurological conditions (Rothbart et al 1997).
ing the sacrum (Schaat et al 2002). The spinal level of the arte- For a full appreciation of the various types of AVMs, their
riovenous malformation will determine the symptoms in a symptoms, signs and a differential diagnosis work-up, see
particular patient. Symptoms associated with AVMs include Rothbart et al (1997). Essentially, neuroradiological studies
pain, sensory abnormalities, sphincter disturbances and should demonstrate the presence and precise location of the
 GENERAL INTRODUCTION xvii

IMAGING
Routine radiographs of the spine, and when indicated by
the history and symptoms, the chest, should be taken to
establish a baseline and to rule out metabolic, inflamma-
tory, and malignant conditions (Keim & Kirkaldy-Willis
1987), bearing in mind the limitations of plain X-ray exam-
inations. As long as proper coning of the X-ray beam is
used in conjunction with high speed screens and films,
and appropriate filtration of the X-ray beam, there is mini-
mal X-radiation to the patient while obtaining maximum
quality X-ray films. These radiographs should be taken in
the erect posture, whenever possible, using carefully stan-
dardized procedures; for example, to accurately determine
whether possibly significant leg length inequality is pres-
ent with corresponding pelvic obliquity causing postural
(compensatory) scoliosis in the spine (Giles & Taylor 1981,
Giles 1984, 1989). In the cervical spine, functional flexion
and extension views may show instability; sagittal plane dis-
placement between two adjacent cervical vertebrae of more
than 3.5 mm, or relative sagittal plane angulation greater
than 11 , is considered to represent cervical segmental insta-
bility (White et al 1975) – that is, horizontal or angular
instability (Dai 1998).
Bogduk’s (1999) ‘modified criteria for the use of plain
Figure vi A schematic diagram showing basic thoracic vertebral films in low back pain’ which are based on the work of
anatomy and the nerve supply of the thoracic ventral compartment Deyo & Diehl (1986) are of concern when viewed in the
at the level of the vertebral body (c) and at the level of the light of some of the following cases from over 37 years
intervertebral disc (d). The ventral and dorsal roots of the spinal experience in the diagnosis of spinal pain syndromes. Bog-
nerve are retracted dorsally (arrow). Bundles of nerve fibres duk (1999) states ‘plain films may be used as a screening
originating from rami communicantes (3) pass cranial and caudal to test for "red flag" conditions if a patient presents with
the spinal nerve and the dorsal root ganglion (G) towards the dorsal
any of the following features’: history of cancer, significant
ramus of the spinal nerve (5). Large and small sinuvertebral nerves
(6) derive from the rami communicantes. 1 ¼ anterior longitudinal trauma, weight loss, temperature >37.6  C, risk factors for
ligament nerve plexus; 2 ¼ paraspinal sympathetic ganglion; infection, neurological deficit, minor trauma in patients
3 ¼ rami communicantes; 4 ¼ ventral ramus of the spinal nerve; (over 50 years of age, known to be osteoporotic or taking
5 ¼ dorsal ramus of the spinal nerve; 6 ¼ sinuvertebral nerves; corticosteroids), and no improvement over a 1 month
7 ¼ posterior longitudinal ligament nerve plexus. The diagram does period. Clearly, it is better for a patient to undergo plain
not show the innervation of the intervertebral disc or the film radiography when indicated by the history (unless
zygapophysial (facet) joints and other structures. (Reproduced with there is a contraindication such as pregnancy) at the onset
permission from Groen G J et al 1990 Nerves and nerve plexuses of of symptoms, rather than to risk misdiagnosis and mis-
the human vertebral column. Am J Anatomy 188(3): 282–296, management, both of which would be disadvantageous to
Wiley-Liss, Inc., a subsidiary of John Wiley & Sons, Inc.) patients. This is particularly important when treatment by
spinal manipulation is considered, as the application of
mechanical forces to a spine that may have degenerative
vascular nidus of the AVM, define the angioarchitecture, changes, or overt pathological changes, could be dangerous.
determine the operability of the malformation, and aid in In my opinion, not looking at the spine and pelvis in all cases
the safe obliteration of the lesion by defining the vascular prior to using mechanical treatment may well explain the
anatomy of the malformation and the normal spinal cord occurrence of some adverse events, even though most
(Rothbart et al 1997). According to Xia et al (2007), intraopera- authors have reported a low rate of adverse events asso-
tive angiography for AVMs has been found to result in ciated with spinal manipulation.
favourable clinical results by ensuring safe and accurate Further imaging procedures may be necessary. These
occlusion of the fistula. include (i) magnetic resonance imaging, which can provide
From the above, it is clear that clinicians need to be very good detail of soft tissue structures in and about the
familiar with both normal and abnormal anatomy in order spinal column without the need of radiation or of contrast,
for them to think laterally when confronted with challeng- (ii) CT scans, which are particularly good at showing bony
ing spinal pain syndromes. structures and are useful for some neural problems,
xviii GENERAL INTRODUCTION

(iii) myelography or post-myelography CT scans for agree, stating that even the most severe degenerative changes
demonstrating lesions of the spinal cord and canal such can occur in the absence of symptomatology, but back pain is
as neoplasm and other space occupying lesions, for exam- more common in individuals who demonstrate these degen-
ple disc herniation, (iv) bone scans when tumour, infection erative changes. The specificity difficulties encountered with
or small fracture(s) are suspected, and (v) discography MRI studies to date may relate to the fact that recumbent
when indicated, to show tears in the intervertebral disc MRI technology was used; new technology allowing for com-
with internal disc disruption. The usefulness of a positron parisons between upright, weight-bearing, dynamic, posi-
emission tomography (PET) scan, used heavily in clinical tional MRI and traditional supine MRI has shown that there
oncology, should not be underestimated. When invasive is a very significant difference between the pathology visua-
imaging is being considered, the possible complications lized between the two MRI procedures; therefore, the diag-
of such a procedure should always be considered. nostic information that can be derived from routine supine
Unfortunately, all the preceding procedures have some MRI studies is extremely limited (Jinkins JR, personal com-
limitations, for example plain film radiographs will not munication, 2007).
show an osseous erosion until approximately 40% decrease It should be noted that another limitation of MR imag-
in bone density has occurred (Michel et al 1990, Perry ing is the resolving power (i.e. ability to distinguish small
1995), and Schellhas et al (1996) and Osti & Fraser (1992) or closely adjacent structures) of the MRI machine; this
found that discography is more accurate than MRI for the has to be taken into account when considering what cannot
detection of annular pathology in the cervical and lumbar be seen. I am advised that the latest MRI scanners have a
spines respectively. Therefore, these limitations show, as resolving power of 100 to 250 microns i.e. 1/10th to 1/4
stated above, that imaging procedures may only give a of a millimetre, so any lesion smaller than this would not
‘shadow of the truth’; this important fact should be remem- be seen. For this reason, it is not uncommon for imaging
bered. This is particularly true when a patient’s physical reports to fail to indicate injuries that may be the cause of
examination and imaging studies are not remarkable and pain.
do not pinpoint the cause of symptoms, as imaging cannot It is of interest to note that cervical spine investigations
show all tissue changes (Giles & Crawford 1997a). The lim- with plain radiography, myelography, and computed
itations of present diagnostic imaging procedures (Finch tomography have shown that degenerative disease fre-
2006) in not being able to show all soft tissues are an unfor- quently occurs in the absence of clinical symptoms (Boden
tunate but obvious fact. The following comments are of et al 1990b) while Gore (1999) stated that degenerative
interest with respect to some limitations of imaging changes of the cervical spine, as seen on plain roentgen-
procedures. ograms and more sophisticated studies, are common in
With respect to the lumbar spine, and with the same both symptomatic and asymptomatic patients.
principle applying to the cervical and thoracic regions, Nonetheless, various studies have shown a significant
Vernon-Roberts (1980) wrote: ‘It may be a minor consola- association between some structural abnormalities and
tion to clinicians and others who have to deal with the the presence (Parkkola et al 1993, van Tulder et al 1997,
problem of low back pain to know that even clinically Paajanen et al 1997, Luoma et al 2000), frequency (Vide-
and radiologically ‘normal’ spines can have pathological man et al 2003, Videman & Nurminen 2004) or severity
changes which, until proved otherwise, could be a cause (Videman et al 2003, Peterson et al 2000) of low back pain.
of much stress to both doctor and patient’. Using flexible fibrescopes (external diameter of 0.6–1.5 mm)
According to Osti & Fraser (1992), a normal MRI does not Tobita et al (2003) stated, with respect to the entire spine:
exclude significant changes in the peripheral structure of the ‘Although the diagnosis of spinal disease has been greatly
intervertebral disc that can produce spinal pain. Further- improved by computed tomography (CT) and magnetic
more, Schellhas et al (1996) demonstrated that ‘significant resonance imaging (MRI), there are still many conditions
cervical disc annular tears often escape magnetic resonance that are difficult to diagnose by these means as patho-
imaging detection, and magnetic resonance imaging cannot logical changes were seen by fibrescopic examinations in
reliably identify the source(s) of cervical discogenic pain’. patients in whom no abnormal changes were found by
The same principle is likely to apply to all spinal disc levels. MRI or CT’.
Several MRI studies have shown that 20–76% of asymp- The abovementioned findings raise questions about the
tomatic adults exhibit abnormalities of lumbar discs morphology-based understanding of pain pathogenesis in
(Boden et al 1990a; Buirski & Silberstein 1993, Jensen et al patients with disc abnormalities (Boos et al 2000). Further-
1994, Deyo 1994, Boos et al 1995, Jarvik et al 2001) in other more, Karppinen et al (2001) found that MRI scans from
words, 24–80% of symptomatic adults exhibit abnormalities 180 patients with unilateral sciatic pain suggested that a
of lumbar discs on MRI. Kleinstuk et al’s (2006) lumbar discogenic pain mechanism other than nerve root entrap-
spine MRI study showed that symptomatic adults with ment generates the subjective symptoms among sciatic
chronic, non-specific low back pain appear to have an overall patients.
higher prevalence of structural abnormalities than previously A further difficulty is that the nomenclature and classifi-
reported for asymptomatic individuals. Haldeman et al (2002) cation of lumbar disc pathology is not standardized
 GENERAL INTRODUCTION xix

(Fardon & Milette 2001), although Pfirrmann et al (2001) intestine, and placenta (Brabson 2001). Evaluation of
have suggested a method for grading disc degeneration enzymes more specific to the liver, 50 -nucleotidase or g-glu-
on T2-weighted MRI. tamyltranspeptidase (GGT), can differentiate hepatic from
When nerve root dysfunction is suspected, electromyog- extra-hepatic sources of alkaline phosphatase (Beers et al
raphy (EMG) and nerve root conduction studies can be 2006). Early inflammatory changes may be detected by an
helpful (Hoppenfeld 1977). increase in C-reactive protein (CRP) and/or an increase in
It is important to note the following comments regard- the erythrocyte sedimentation rate (ESR). A full blood count
ing imaging shown in this text: can be helpful, for example, in cases where there is suspi-
cion of primary haematological disorders and for some
 Most plain film anteroposterior radiographic images of the infections (Henderson et al 1994). Immunoelectrophoresis
spine and or pelvis are printed as if the clinician were look- of serum and urinary proteins may also be useful diagnostic
ing at the patient’s back; i.e. a marker showing ‘R’ indicates procedures in the diagnosis of multiple myeloma (Brown
the patient’s right side. 1975, Beers et al 2006). Examples of other tests that should
 Spinal axial CT scans are viewed, as usual, from ‘below’; be considered, when indicated, are: (i) latex flocculation
i.e. remember that the clinician ‘looks up’ the patient’s for rheumatoid spondylitis; (ii) serum and urine amylase
spinal canal with the patient supine, so the patient’s right and lipase for chronic pancreatitis (Collins 1968, Schroeder
side is marked ‘R’ on the left side of the axial CT scan fig- et al 1992); and (iii) blood culture and sensitivity, and for
ure(s). genitourinary tract infections urine culture and sensitivity.
 For spinal axial MRI scans, the same principle as for CT In addition, it may be necessary to assess bone density using
axial scans is applied; i.e. the patient’s right side is on a dual energy X-ray absorption (DEXA) bone densitometer
the left side of the figure(s). in osteoporotic patients. In males, prostate-specific antigen
 MRI T1-weighted images produce essentially a fat image in (PSA) should be considered if there is any suspicion of pros-
which structures containing fat (bone marrow, subcutaneous tate malignancy (Kingswood & Packham 1996).
fat) appear bright, while structures containing water In this book it is not necessary to list every spine-related
(oedema, neoplasm, inflammation, cerebrospinal fluid, scle- condition with its possible abnormalities in serology, haema-
rosis, large amounts of iron) appear dark (Yochum & Barry tology, urinalysis and other laboratory tests, as these have
1996). been well documented in numerous clinical diagnosis texts.
 MRI T2-weighted images produce essentially a water In some publications, particular reference to spinal patholog-
image in which structures containing predominantly free ical conditions and related pathology tests have been sum-
or loosely bound water molecules (neoplasm, oedema, marised (Haldeman et al 1993, Henderson et al 1994).
inflammation, healthy nucleus pulposus, cerebrospinal A large range of laboratory evaluations are important
fluid) appear bright, while substances with tightly bound when the clinician suspects metabolic disturbance, malig-
water (ligaments, menisci, tendons, calcification, sclerosis nancy, infection or one of the arthritides such as ankylosing
or large amounts of iron) appear dark (hypointense) spondylitis or rheumatoid arthritis. Nonetheless, it should
(Yochum & Barry 1996). be noted that various tests have different levels of accuracy,
 Patient identification details have been blacked out to as calculated from their sensitivity (proportion of individuals
maintain patient confidentiality. with the condition whose tests are positive) and specificity
(proportion of individuals without the condition whose tests
are negative (Bloch 1987, Nachemson 1992, Henderson et al
LABORATORY TESTS 1994)).
When bony pathology is suspected, useful laboratory tests
that may be helpful in detecting bone disease include serum
CONDITIONS ASSOCIATED WITH SPINAL PAIN
calcium, phosphorus, acid phosphatase, and alkaline phos-
SYNDROMES
phatase (particularly alkaline phosphatase isoenzyme deter-
mination by electrophoresis, which differentiates alkaline A summary of the chief conditions causing spinal tender-
phosphatase of osteoblastic origin from alkaline phosphatase ness is shown in Table i. In addition, it is necessary to list
from other sources) (Brown 1975). On electrophoresis, liver some possible causes of non-specific spinal pain of
isoenzyme levels usually range from 20 to 130 U/L; bone iso- mechanical origin, with or without radicular pain, as
enzyme levels from 20 to 120 U/L; and intestinal isoenzyme briefly summarized in Table ii, which provides a summary
levels (which occur almost exclusively in individuals with of some literature references over the years in order to give
blood group B or O and are markedly elevated 8 hours after a historical background to the complex issue of non-spe-
a fatty meal) from undetectable to 18 U/L (Brabson 2001). cific spinal pain of mechanical origin. As Waddell (2004)
The five alkaline phosphatase isoenzymes of greatest clini- stated, most back pain is ‘ordinary backache’. This often
cal significance originate in the liver (includes kidney and is referred to as ‘mechanical’, ‘non-specific’ or ‘idiopathic’
bile fractions), bone (may also include bile fraction), spinal pain. In a large number of these cases, it may not
xx GENERAL INTRODUCTION

Table i Summary of chief conditions causing spinal tenderness Table ii Some possible causes of non-specific spinal pain
of mechanical origin with or without radicular pain
1. Diseases of the overlying skin and subcutaneous tissue.
These are usually clinically obvious and include poten- Nerve root conditions
tially serious conditions such as melanoma  Adhesions between dural sleeves and (a) the joint cap-
2. Diseases of the vertebral column sule with nerve root fibrosis (Sunderland 1968, Jackson
Inflammatory 1977, Wilkinson 1986) and (b) intervertebral disc hernia-
Pott’s disease tion (Wilkinson 1986).
Staphylococcal spondylitis  Intervertebral disc degeneration and fragmentation
Typhoid spine (Schiotz & Cyriax 1975), or nucleus pulposus extru-
Spondylitis ankylopoietica (Spondylitis Ossificans sion (Mixter & Ayer 1935) causing nerve root com-
Ligamentosa/ankylosing spondylitis) pression (Kobayashi et al 2005), or nerve root
Actinomycosis ‘chemical radiculitis’ (Marshall & Trethewie 1973).
Hydatid cyst Zygapophysial joint conditions
Paget’s disease  Joint derangement (subluxation) due to ligamentous
Degenerative and capsular instability (Hadley 1964, Cailliet 1968,
Spondylosis Jackson 1977, Macnab 1977, van Norel & Verhagen
Osteochondritis (rare) 1996).
Nucleus pulposus herniation and other soft tissue  Joint capsule tension with encroachment upon the inter-
injuries vertebral foramen lumen (Jackson 1977).
Neoplastic  Joint degenerative changes, e.g. ‘meniscal’ incarceration
Primary tumour (Schmorl & Junghanns 1971), traumatic synovitis due to
Secondary deposit ‘pinching’ of synovial folds (Giles 1986, Giles 1987, Giles
Myelomatosis & Harvey 1987, Giles & Taylor 1987a & b), synovial fold
Leukaemic deposits tractioning against the pain-sensitive joint capsule
Traumatic (Hadley 1964), and osteoarthrosis (Jackson 1977).
Fracture  Joint effusion with capsular distension which may
Dislocation (a) exert pressure on a nerve root (Jackson 1977),
Nucleus pulposus herniation (b) cause capsular pain (Jackson 1966), or (c) cause
Erosion by aortic aneurysm nerve root pain by direct diffusion (Haldeman 1977).
3. Diseases of the spinal cord and meninges  Joint capsule adhesions (Jackson 1977, Farfan 1980,
Metastatic epidural abscess or tumour Giles 1989).
Meningioma Intervertebral disc conditions
Neurofibroma  Disc protrusion into the spinal and intervertebral
Herpes zoster canals.
Meningitis serosa circumscripta  Disc/dural adhesions (Parke & Watanabe 1990)
Tumour of the spinal cord  Spondylosis (Young 1967, Jackson 1977).
Syringomyelia Miscellaneous conditions
Arachnoid calcifications (Wijdicks and Williams 2007)  Spinal and intervertebral canal (foramen) stenosis
4. Hysteria and malingering: compensation neurosis (Young 1967, Jackson 1977, Epstein & Epstein 1987,
5. Metabolic disorders: osteoporosis, osteomalacia, Rauschning 1992).
hyperparathyroidism  Intervertebral canal (foramen) venous stasis (Giles
1973, Sunderland 1975).
Modified from Mackenzie I 1985 Spine, tenderness of. In: Hart FD (ed) French’s  Myofascial genesis of pain (trigger areas) (Travell &
index of differential diagnosis, 12th edn. Butterworth & Co. Ltd, p 788. Rinzler 1952, Bonica 1957, Simons & Travell 1983).
 Baastrup’s syndrome (Reinhardt 1951, Bland 1987)
 Osseous spinal anomalies, e.g. bilateral cervical ribs,
be possible to identify the precise pain generator. How- block vertebra (Jackson 1977).
ever, an orthopaedic surgeon well versed in spinal pain  Idiopathic scoliosis (Ramirez al 1997)
syndromes, Emeritus Professor Ruth Jackson, stated that
the word idiopathic is used by defeatists to signify ‘I don’t
know the cause’ and that, if one searches diligently for the provided from human postmortem material to illustrate
cause of any painful or abnormal condition, the answer can some possible causes of such pain (Figures vii.1–32). Most
usually be found (Jackson 1977). examples are from the lumbosacral spine as low back pain
As there are many putative causes of such spinal pain, is experienced by the majority of spinal pain syndrome
some gross anatomical and histopathology examples are patients.
 Another Random Document on
Scribd Without Any Related Topics
ate. No, it can’t be little Miss Elizabeth,—it’s more likely some one
that has hired or bought the place and goin’ to upset and change it
all.”
“I didn’t say the lady was old, grandma; she has lots of soft,
silvery, wavy hair with big gray eyes to match, and such a pretty
colour in her cheeks, and her dress was soft and fluffy too and the
colour as if purple and white violets and silver popple leaves were all
mixed together,” said Sarah, moving her hands before her, a little
way she had when talking, as if in describing what she had seen she
was touching the real object, for Sarah, though only a little girl from
a bare hillside farm and taught at the school below at Foxes Corners,
had a keen eye for colour and loved beautiful things, so that ugliness
or unkindness of any sort really hurt her if she could have explained
her feelings.
“My Gray Lady’s first name is Elizabeth, though, and she knows
you and your molasses cakes,” continued Sarah, after a moment’s
pause, “for she said, ‘When you go home say to your grandmother
that Elizabeth who rode the black pony sends her love, and that she
will go to see her soon, and that she hopes that she will give the
little Elizabeth some of the cookies of which she has often heard.’
Elizabeth is the little girl, but I’m going to call her Goldilocks,
because the name matches her hair and she looks as if she was
meant to—

“ ‘Sit on a cushion and sew a fine seam

And feast upon strawberries, sugar, and cream.’ ”

“Elizabeth Wentworth and her daughter back here and I never

knew it!” cried Grandma Barnes, rising as if to take immediate
action. “Your Aunt Jane might well say, as she did on her last visit,
that this hill farm is as far out o’ the world as livin’ in a lighthouse
that had no stairs or boat to it, and the only way to get anywhere
was to take a dive and swim. But see here, Sarah Barnes, how did
you come to meet the General’s folks? It’s near a mile from the road
up from the Centre to their front gate; mebbe you ran across them
in the village, and if so, how came you to speak?”
 Sarah opened her lips to answer and then stammered and grew
red under her grandmother’s keen gaze. “I didn’t pass their gate and
I didn’t meet them in the village. I was—I was just taking a bunch of
field flowers, that I got along the road, up to the cemetery to
mother, and then when I go there, I usually take some to the
General’s mound too, ’cause nobody took anything, except a little
flag Memorial Day, and it’s usually all faded by now. This year,
though, the lot was planted with flowers, and I was wondering why.
I was sittin’ there watching a gray squirrel that lives in one of the old
cannons that stand at the plot corners. You see the squirrel knows
me because I’ve taken him nuts two winters whenever we’ve gone
to Pine Hill coasting, and he comes up real close. To-day when he
came up, I only had some cracker crumbs in my pocket, but he
acted real pleased to see me, and I was so busy talking to him that I
didn’t hear anybody coming up until somebody said, ‘Who is this
little girl that brings flowers to an old soldier’s grave, and has a
squirrel for a friend?’ ”
“A nice way of wasting your time, I must say, of a week-day
afternoon, and so much to be done at home,” broke in Mrs. Barnes,
rather crossly.
But Sarah, not minding the interruption, continued: “Then I
jumped up, and there was Gray Lady and Goldilocks sitting in a nice
big straw chair, like those on Judge Jones’ porch, only it had wheels
and a handle behind like a baby wagon, and a fattish woman with a
pleasant face was pushing it.”
“Well, what happened next?” asked grandma. “I wonder she
didn’t tell you not to trespass and feed animals in a cemetery!”
“Oh, no, she liked it, and we got acquainted right away. She
asked me what put it in my head to bring the flowers, and told her
that it was because nobody else did and that I loved the General
because my mother told me that though he lived through a lot of
battles, he got the wound that made him die long after, in trying to
get back a little black child that had been sold away from its mother,
for it’s an awful thing to take children away from their mothers, and
only God should do it, and I know He must be always sorry when He
has to. And I said I knew how it hurt because He took my mother
away from me.
“Goldilocks said she wished that she had a tame squirrel down in
her garden, and I said there were plenty of squirrels there, and she
could begin to tame ’em as soon as food gets scarce. Then she
asked how I knew, and then it all came out that Dave and Tommy
Todd, Mary, and I often take a cross-cut through the General’s
orchard, when we go over to Aunt Jane’s. Then they asked me to
walk down home with them.
“There was a new high fence all round the orchard, with a gate
by the old house in the corner that has the big stone chimney, where
the Swallows live, so we can’t cut across any more, and before I
thought, I said so; but Gray Lady said, ‘I think, Sarah, it will be quite
as pleasant for you to come in at the front gate, and go out at the
back, as to crawl through a hole in the brush like a fox or a
woodchuck,’ and I guess it will, for she doesn’t want us to stop
coming.
“Then I asked her if the house had lovely pictures in it and birds
with real eyes sitting on perches, and more books than the Sunday-
school library, and she laughed and asked who told me that, and I
said it was Jake Gorham that went up there to set new glass in the
roof light after the hail-storm last summer.”
“Sarah Barnes! such gall as to make free and talk to General
Wentworth’s daughter like that! I just wonder what she thinks of
you!”
“She didn’t tell me, grandma; but, oh, what do you suppose, she
said that if I came down some afternoon, she’d show me all the
pictures and then I could tell Goldilocks how to begin to make
friends with the squirrels, and that she would show me their tree
with a lunch-counter on it for birds, where there is something for
every kind to eat. Do you suppose she will ask me for this Saturday,
grandma, and may I wear my pink lawn, if it stays warm? My
Sunday dress for fall shows where the hem was let down.”
“She may and then again mayhap ’twill be the last you’ll ever
hear of it. Come to think of it, in those days my ginger cookies were
mixed with butter instead of lard, and they had currants in them. I
guess I’ll risk it to make a batch to-morrow, lest Mrs. John should
come up—that is if I finish all this mending, for there is only one
more Saturday and Labor Day, and then school opens, and all you
girls and boys will be making excuses for shirking your chores. Five
o’clock already! Sarah Barnes, do you go straight out and feed the
chickens and then rinse those milk-pans,—that comes first before all
the fine talk of seein’ pictures and making pies and cakes for birds.”
Sarah went slowly toward the barnyard and fed the greedy fowls
in an absent-minded sort of way, all the while looking across the
field where the birds were beginning to gather in flocks, wishing she
knew them all by name and thinking of Gray Lady and Goldilocks.
Would they remember the invitation or would she never perhaps see
them again? School would soon begin, and that meant no spare time
until after four, and it is so often rainy on Saturday.
Rain did not wait for Saturday this time, for a heavy drizzle set in
that night, and Sarah went to sleep wondering exactly what a bird
lunch-counter was and what became of it when it rained.
Then school began, and her new friend made no sign, and Sarah
began to wonder if her meeting with Gray Lady had been one of the
dreams she so often had when she sat on the orchard fence in June
watching the bobolinks fly over the clover and waiting for things to
happen.
 II
A RAINY DAY
It was the first Friday of the fall term and there were only fifteen
scholars at the weather-beaten shingled schoolhouse at Foxes
Corners. The usual number in winter was twenty-five, but some of
the older pupils did not return until late in October, for these boys
and girls helped their fathers and mothers either about the farm
work or in the house, and as this school district was located in pretty
rolling hill country, with woods and a river close by, city people came
to board at the farm-houses and often did not go away until they
had seen the leaves redden and fall.
Miss Wilde, the teacher, was very glad to begin with only fifteen
scholars. She was not very strong; the children were always restless
during the first month after their vacation. Then, too, it is more
difficult for a teacher to interest scholars that range from five to
fifteen than where she has children all of an age.
Miss Wilde was very patient, for she loved outdoors and liberty
herself, and she knew just how hard it was in these first shut-in days
for the children to look out the open windows and see the broad
fields stretching out to the woods, and hear the water rushing over
the dam at Hull’s Mill, and then take any interest in bounding the
Philippine Islands and remembering why they are of special value to
the United States.
Tommy Todd was what is usually called the “bad boy” of the
school. He was thirteen, keen-witted and restless. He learned his
lessons quickly, and then when Miss Wilde was hearing the little
ones drone out their “twice one is two,” “twice two is four,” he often
sat idle in his seat devising mischief that he sometimes put in motion
before school was over.
Then there were some days when it seemed as if Tommy would
leave his desk and fly out of the window in spite of himself. Poor
Miss Wilde had been obliged to make him change desks twice
already. From his first place he could look at a pasture, where a
family of woodchucks had their burrows, and he had caused several
stampedes, not only among the boys, but girls also, by calling out:
“Hi! there goes a buster! I bet its hide’s worth more’n a quarter!
Now Jones’ yaller dog is after him! Hi! there! good work! he’s headin’
of it off! Gee, Hog’s reared and give him a bite! There they go round
the hill! If the hole back t’other side I stuffed Saturday’s got loosed
out, I bet on the hog!” (Ground-hog being the familiar name for the
woodchuck in this region.)
Order being restored, Tommy was moved to the east side of the
room. Here the view was downhill over the lowlands, ending at a
great corn-field that belonged to Tommy’s grandfather. The corn was
yellow in the ear, but still standing. A flock of crows that had a roost
in the swampy millwoods knew all about this corn-field and
considered it as their own property, for had they not superintended
its planting, helped thin out the seed lest it should grow too thick,
and croaked and quavered directions to old man Todd and his horses
every time they ploughed and hoed? Now, guided by a careful old
leader who sat on a dead sycamore top and gave warning (for all
crow flocks have such a chief), they were beginning to attack the
ripened ears, the scarecrows placed at intervals that had been of
some use in the early season having now lost the little influence they
possessed and fallen into limp heaps, like unfortunate tramps asleep
by the wayside.
So every time the crows came over, Tommy would stretch up in
his seat and finally slip out of it entirely and, hanging half out of the
window, shake his fist at them, all the time uttering dire threats of
what he would do if he only had his father’s shot-gun.
For these reasons, Friday morning saw him seated in the middle
of the room with the older girls and sharing the double desk with
Sarah Barnes. Now Sarah thought that Tommy was the cleverest boy
she had ever seen, and Sarah had visited in Centre Village in
Hattertown, and Bridgeton, been twice to the Oldtown County Fair,
and would have gone to New York once with her Aunt Jane if
measles had not prevented; so that her friends thought, for thirteen,
she was quite a travelled lady.
Tommy also considered her favourably and had been heard to
say that she was not bad for a girl; yet, to be put in the middle seats
with the girls he considered an insult to his years, and he was sulky
and brooded mischief all the morning.
In reality Tommy was not a bad boy in any way. What he wanted
was plenty of occupation for his mind and body to work at. Miss
Wilde knew this and tried to give him as many little things to do as
possible. It was Tommy who had charge of the new cage rat-trap of
shiny copper wire, in which it was hoped the field rats might be
caught, that, as soon as cool weather came, gnawed their way in
through the loose floor boards and sometimes destroyed the books,
and, as Sarah Barnes declared (whose duty it was to keep the wells
filled), drank the ink. Tommy also kept the water-pail full and tended
the big wood-stove in winter; but none of these tasks seemed to
touch the restless spot and he could think out more puzzling
questions in a day than the whole school board could have answered
in a week, and then, as Sarah Barnes once said, “Tommy Todd’s
questions never seem to stay answered.”
Miss Wilde had taught, at first, in the school of a large town
where there were plenty of pictures and maps on the walls, and
charts of different kinds and reference books for the children to use,
and where people who loved children would often drop in and tell
them about birds and flowers or their journeys to interesting places.
She had taken the country school because the doctor thought it
would be better for her health, and oh, how she wished that she
could have brought some of the pictures and books with her, or that
some of the summer boarders who stayed until almost winter would
come in and talk to her pupils. She told the children stories or read
to them on Friday afternoons. She also knew that there were some
travelling libraries of books that she might borrow that the children
could have themselves, but reading is a habit; the children needed
to be interested first. So it came about that, when the second year
of her school life on the hillside began, Miss Wilde felt rather
discouraged.
 On this particular rainy Friday she was feeling worried about her
mother, who boarded at the Centre Village and with whom she spent
every week-end, going down with the mail-carrier on his return trip
Friday evening and usually walking back on Sunday afternoon if no
one chanced to be driving that way. Mrs. Wilde had been ill the
Sunday before and Miss Wilde had not heard a word all the week.
Everything had gone awry that morning, and when the last child had
filed out for the dinner-hour and gone splish-splashing up the muddy
road, before straightening out the room as usual, Miss Wilde sat
down at the desk, her head in her hands, and two big tears splashed
down on the inky blotting-paper before her. Presently she wiped her
eyes, opened all the windows that the rain did not enter, took her
box of luncheon from her desk, and walked slowly down the side
aisle to the little porch, which also acted as the cloak-room, the
place where she usually ate her luncheon when it was too cool or
wet to go outdoors.
As she passed Tommy Todd’s desk she thought she heard a
noise, and glanced sideways, half expecting to see him crouching
under it, bent upon some prank. No one was there, and still there
was a scratching sound in that vicinity. Opening the desk lid, Miss
Wilde gave a scream, for inside was the new trap and inside the trap
two wicked-looking old rats whose whiskers had evidently grown
gray with experience.
“I wonder what he would have done with them if I had not found
him out?” she said to herself, as she lifted the cage, by hooking the
crook of her umbrella into the handle on the top, and carrying it with
the greatest care, put it into the empty wood-box in the porch. Then
she seated herself on the bench by the outer door and unstrapped
her box. But it evidently was not intended that the poor teacher
should lunch that day, for suddenly the door flew open and the
weather-beaten face of Joel Hanks, the carrier who had the
forenoon mail-route, peered anxiously in.
“You here, Miss Wilde?” he called anxiously. “I’m glad yer hain’t
gone up to the house for your nooning, cause I clean fergot when I
come by up, but yer Ma’s feelin’ extra poorly and uneasy, and she
thought mebbe you could come back along with me instead of
waiting till night. I’m goin’ to eat over to Todd’s and I can stop back
for you close to one if you can arrange to go.”
“Oh, I wish I had known it before the children went to dinner,”
she cried, clasping her hands together nervously and dropping the
box, out of which her lunch rolled to the floor, amid the damp that
had been made by wet coats, overshoes, and dripping umbrellas.
“As it is, when the children come back, I cannot send them right
home again, for some have a long walk. If it wasn’t for Tommy Todd,
I could leave Sarah Barnes for monitor; but there are those rats, and
the school board does not like me to shorten hours so soon after
vacation. It’s too late for me to go over for Mrs. Bradford, or I know
that she would help me by coming as she did several times last
spring.”
“Sorry I couldn’t stop this morning, but I come by the lower road.
Wall, mebbe you’ll think out some way and I’ll stop back a bit a’ter
one,” Joel said cheerfully, going back to his covered cart and chirping
to his wise old horse, who, though he was gaunt and had only one
good eye, knew every letter-box on the route and solemnly zig-
zagged across the road from one to the other on his way up to
Foxes Corners, but as surely passed them by without notice on the
return trip.
Miss Wilde had barely swept away the scattered lunch through
the open door when again she heard wheels, and looking up saw
that which made her stand stock-still in surprise, broom in hand,—a
trim, glass-windowed depot wagon, such as she had seldom seen
out of Bridgeton, drawn by a handsome pair of gray horses, whose
long, flowing tails were neatly braided and fastened up from the
mud with leather bands, instead of being cruelly docked short as
sometimes happens. The driver, a pleasant-looking, rosy-cheeked
man, was well protected by coat and boot of rubber; but before Miss
Wilde could more than glance at the outfit the door opened and a
lady stepped lightly out, reaching the school porch so quickly that
she had no need of an umbrella.
Spying Miss Wilde, she said in a voice clear as a bell, and yet so
well modulated and sweet that no one who heard her speak ever
forgot its sound—“Are you the teacher here?”
 “Yes.”
“And your name?”
“Rosamond Wilde,” replied the astonished girl, hastily hanging up
the broom, unconsciously leading the way into the stuffy schoolroom
and placing the best chair by the side of her desk, as she did when
the minister, Dr. Gibbs, from Centre Village, who was president of
the school board, came to hold a spelling-match.
“Thank you,” said the silvery voice, as its owner took the
proffered seat, turning so that she could look out of the window.
“I have heard from Dr. Gibbs that you sometimes use part of
Friday afternoon for telling the children stories, or reading something
that may amuse as well as teach them, and I thought that perhaps,
as the board does not object, you might sometimes be willing to
have me come in and talk to them. I am very fond of children, and
have one little girl of my own, so that I know very well what they
enjoy. I’ve travelled for several years, and I have a great many
interesting pictures I could show them. Then, too, I have always
loved birds and flowers, and with my father I used to tramp about
and learned to know all those of this neighbourhood. I well
remember that when I was a child and studied at home, rainy Friday
afternoons were always pleasant, because mother, my cousins, and I
had fancy-work or some other sewing and stories; so I thought to-
day perhaps would be a good time for a beginning.”
If the sky had opened and an angel come directly to her aid, Miss
Wilde could not have been more overcome. She pulled herself
together and began to frame a polite answer, when looking at the
guest, who had thrown off her light raincoat, she caught the
sympathetic glance that shot from a lovely pair of gray eyes with
black lashes, and saw that the fluffy gray hair belonged to a really
young woman, but a little older than herself. Forgetting that a
teacher is supposed never to lose control of herself, before she
realized that she had said a word she had told this friend in need
about her school, Tommy Todd, her mother’s sickness, and all.
In less time than it takes to tell of it, the coachman had been told
to go down to the blacksmith’s shop and wait under cover until three
o’clock, and Miss Wilde was helped to make her preparation for
leaving.
When the children came trooping back, they found the door
between cloak-room and schoolroom closed, and teacher waiting for
them in the outer room with very rosy cheeks and a happier
expression than her face usually wore.
Tommy Todd looked relieved, for, he reasoned, if teacher knew
there were two rats in his desk, she would not have looked pleased.
In a few words Miss Wilde explained the happenings, cautioned
them to be very good, and saying, “Right, left, right, left,” was about
to open the door for the children to march in, when Sarah Barnes
asked, “Teacher, what is her name, so we can call her by it?” Then
teacher realized that she didn’t know. But as the door opened Sarah
said, in a very loud whisper, as whispers are apt to sound louder
than the natural voice, “Why, it’s my Gray Lady!” and so in truth it
was.
Teacher watched them until they took their seats, and then
gently closed the door behind her. For a moment no one spoke.
Tommy Todd peeped cautiously into his desk to be sure the rats
were safe, and found to his dismay that they were gone. Inwardly
he hoped they wouldn’t get loose, for Gray Lady didn’t look as if she
would like rats, which showed that after only one glance he wished
to please her, while at the same time the name by which they first
knew her became fixed in the mind of every child.
 III
GRAY LADY AT SCHOOL
The silence inside the school continued a full minute, that
seemed like an hour, and the dripping of the rain from the gutter
was so plain that Sarah found herself counting the drops—“One—
two—three—four—splash!”
Fifteen pairs of eyes were fastened upon the newcomer, and, as
she caught the various questions in them, the colour in her cheeks
deepened. Suddenly she recognized her little friend whom she had
met on the hillside the week before. “Sarah Barnes,” said Gray Lady,
“will you not tell me the names of your schoolmates and introduce
me to them? It is always so much more pleasant when we are
looking at people, places, or things to know what they are called.”
Then Sarah, delighted at being remembered when she had
begun to be quite sure that all her hopes were in vain, guided by an
inborn instinct of politeness that told her it would not be civil to
stand at her desk and call out the various names, marched solemnly
up to the teacher’s desk and, beginning in the front row with her
own little sister Mary, repeated the fifteen names in full, with the
greatest care and distinctness, and each child, not knowing what
else to do, bobbed up and answered, “Present,” the same as if
teacher had been calling the roll. When Sarah had finished, she was
quite out of breath, for some of the names were very long; the last,
that of the one little Slav in the school, Zella Francesca Mowralski,
being also hard to pronounce.
“Thank you,” said Gray Lady; “I think that I can remember the
first names at least. But now that you have presented your friends to
me, won’t you kindly present me to them? You know who I am and
where I live, do you not?”
“Of course I do!” cried Sarah, glad to be in smooth water again.
“You are Goldilocks’ mother, Gray Lady, and you are our General’s
daughter and you live in his house!” Then, realizing that she had
given play to her own fancy rather than stated the facts expected,
she fled to her desk and hid her face behind its lid.
No reproof followed her as she expected, but instead the
pleasant voice again said: “Thank you, Sarah; I like the name you
have given me better than my very own, and if you all know where
to find the General’s house, you know where to find me,” and when
Sarah, gaining courage, looked up again, she saw, what the others
did not notice, that the gray eyes were brimming, though there was
a smile on her lips.
“Now, children, what would you like to hear about this afternoon?
Miss Wilde told me that she had intended giving you a spelling
review and writing exercise of some kind, but that we might finish
the day as we choose. Shall I read you a story, or would you like to
ask questions and talk best?—one at a time, of course!”
“Talk—you talk,” shouted a vigorous chorus.
“By the way, Tommy Todd,” said Gray Lady, “why do you sit in the
middle with the girls instead of on the outer row with the boys,
where there is more room?”
Tommy, placed between Sarah Barnes and his own sister, started
half up in his seat and looked all round the room as if seeking a way
of escape, and finding none, dropped his gaze to his desk and sat
mute with a very red face.
The question was repeated—still no answer. A hand flew up. “I
know,” piped the voice of one of the little ones in front; “it’s ’cause
Tommy can’t keep his eyes inside the winder if he’s by it; he’s always
spying out at ground-hogs and crows and askin’ teacher questions
about the birds setting on the wires, so he don’t mind his books and
teacher don’t know the answers to all he asks, an’ it gives her the
headache!”
“Well, Tommy,” said Gray Lady, who had learned that at least one
of the children before her cared for out-of-doors, which was
precisely what she wanted to know, “as long as this is a sort of
holiday, suppose you take that empty seat by the east window and
tell us what you see. You may open the window and the others on
that side also, for I think the rain is over; yes, the clouds are
breaking away.”
How fresh and sweet the air was that rushed into the close room!
Tommy stuck his head out and took a great breath as he looked
down over the corn-fields,—his enemies the crows were not there.
“There isn’t much to see now, it’s too wet yet,” he said; “but
pretty soon there will be, for most birds and things get hungry right
after a rain!”
“Olit—olit—olit—che-wiss-ch-wiss-war,” sang a little bird in a low
bush by the roadside.
“What bird is that,” asked Gray Lady; “do any of you know?”
“It’s just the usually little brown bird that stays around here most
all the time, but I love the tune it sings,” said Sarah Barnes. “Teacher
says it’s some kind of a sparrow.”
“It is a Song Sparrow,” said Gray Lady, “and you are right in
saying it stays with us almost all the year.”
“Now,” called Tommy, “the birds are beginning to come out;
some Barn Swallows are flying over the low meadow and there’s a
lot of ’em, and another kind strung along the wires on the turnpike.
They always sit close and act that way all this month and some fly
away, and ’long the first part of next month, when the corn’s all
husked, they’ll be gone! Please, ma’am, why do some birds never go
away, and some do, and what makes ’em come back?” Then Tommy
began one of the volley of questions that Miss Wilde so dreaded.
“Yes, an’ please, ma’am,” asked Dave, “why are some birds that
mate together such different colours?” “An’ what becomes of
Bobolinks after Fourth of July?” asked another. “An’ what makes
birds have so many kind of feet?” queried a third.
Then questions flew so thick and fast that Gray Lady could not
even hear herself think, and presently, when every one had laughed
at the confusion, order was restored.
“I asked you a moment ago what you would like to hear about. I
think I know. You would like to hear about birds! Are there any other
boys here besides Tommy and Dave who care about birds?” asked
Gray Lady, who wished to have each child feel that he or she had a
part in what was going on.
 “I know about birds’ eggs!” cried Bobby Bates, a boy who, from
being undersized, looked much younger than he really was; “I’ve got
a pint fruit-jar of robins’ eggs.”
“But I’ve got a quart jar of mixed eggs,” said Dave, “and they’re
mostly little ones, Wrens and Chippy birds and such like, so’s I’ve
really got more’n Bobby!” he added boastfully.
Gray Lady opened her lips to speak sharply and her eyes flashed,
for nest-robbing was one of the things she most detested. Then she
remembered that perhaps these children had not only never even
dreamed that there was any harm in it, but had never heard of the
laws that wise people had made to protect the eggs of wild birds, as
well as the birds themselves, from harm. So she hesitated a moment
while she thought how she might best make the matter understood.
“Why do you like to collect eggs?” she asked. “Because they are
pretty?”
“Yes’m, partly,” drawled Dave, “and then to see how many I can
get in a spring.”
“But do you never think how you worry the mother birds by
stealing their eggs, and how many more birds there would be if you
let the eggs hatch out? What the rhyme says is true,—

“ ‘The blue eggs in the Robin’s nest

Will soon have beak and wings and breast,
And flutter and fly away!’

Only think, if all those robins’ eggs of yours, Bobby, and all your little
eggs, Dave, should suddenly turn into birds and fly about the room,
how many there would be! But now they will never have wings and
swell their throats to sing to us and use their beaks to eat up insects
that make the apples wormy and curl up the leaves of the great
shade trees.”
“Robins don’t do any good; they just spoil our berries and
grapes; dad says so, and he shoots ’em whenever he can, and he
likes me to take the eggs,” said Dave, stubbornly, while Sarah Barnes
exclaimed, “Yes, an’ my father says he ought to be ashamed of
himself!” almost out loud.
 “I know that Robins sometimes eat fruit,” said Gray Lady, firmly,
“but they do so much more good by destroying bugs that the Wise
Men say that neither they nor their eggs shall be taken or destroyed,
and what they say is now a law. So that it is not for any one to do as
he pleases in the matter. To kill song-birds or destroy their eggs is as
much breaking the law as if you stole a man’s horse or cow, for
these birds are not yours; they belong to the state in which you live.”
Bobby and Dave looked surprised, but Tommy and Sarah nodded
to one another, as much as to say, “We knew that, didn’t we?”
“Some day, if you are clever with your lessons so that Miss Wilde
can spare the time for it, I will tell you all about the reasons for
these laws, and what the wild birds do for us, and what we should
do for them. But first you must learn to know the names of some of
the birds that live and visit hereabout, as I am now learning yours,
and make friends of some of them as I hope to make friends of
you.”
“Yes, yes, oh, yes!”
“You can’t make friends of birds; they won’t let you,” said Dave
Drake, who was a sickly, lanky boy of fourteen with a whining voice;
“they always fly away. That is, I mean tree birds, not chickens nor
pigeons.”
“Chickens aren’t birds, they’re only young hens,” put in Eliza
Clausen, with an expression of withering contempt. She was one of
the big fourteen-year-old girls, and not being a good scholar was apt
to use opposition in the place of information.
“We can make friends of at least some birds,” said Gray Lady, “if
we are kind to them. When we have human visitors come to stay
with us, what do we do for them?”
“We let them sleep in the best bedroom, and we get out the best
china and have awful good things to eat, and give ’em a good time,”
said Ruth Barnes, all in one breath.
“Yes, and we should do much the same with our bird friends.
They do not need to have a bedroom prepared; they can generally
find that for themselves, though even this is sometimes necessary in
bad weather; but they often need food, and in order that they
should have what Ruth calls ‘a good time,’ we must let them alone
and not interfere with their comings and goings.
“Go softly to the west window and look out,” continued Gray
Lady, raising a finger to caution silence, for from her seat on the
little platform she could see over the children’s heads and out both
door and windows, “and see the hungry visitors that a little food has
brought to the very door.”
The children tiptoed to one side of the room, and there, lo and
behold, was a great Blue Jay, a Robin, a Downy Woodpecker with his
clean black-and-white-striped coat and red neck bow, and a saucy
Chickadee, with his jaunty black cap and white tie, all feasting on
the broken bits of Miss Wilde’s ham sandwich, while a pair of Robins
were industriously picking the fruit from a remnant of huckleberry
pie. Unfortunately, before the children had taken more than a good
look, the door banged to and the birds flew away, the Woodpecker
giving his wild sort of laugh, the Robins crying, “Quick! quick!” in
great alarm, while the Jay and Chickadee told their own names
plainly as they flew.
“As we have agreed to talk and ask questions, I will ask the first
one,” said Gray Lady, as they all settled down, feeling very good-
natured and eager to listen.
“Eliza said a few minutes ago that a chicken isn’t a bird. Now a
chicken is a bird, though of course all birds are not chickens.

The Bird
“Who can tell me exactly what a bird is? You all may think you
know, but can you put it in words?”
“A bird isn’t a plant; it is an animal,” said Tommy Todd.
“Yes, but a cat is an animal, and a snake, and a horse; and we
are animals ourselves.”
“A bird is a flying animal,” returned Sarah.
“Very true, but so is a bat, and, as you know, a bat has fur and
looks very like a mouse, and a bird does not.
 “Ah, you give it up. Very well, listen and remember. A bird is the
only animal which has feathers! With his hollow bones filled with
buoyant, warm air, and covered with these strong pinions, he rows
through the air, as we row a boat through the water with the oars,
balancing himself with these wings, also steering himself with them
and with his tail made of stiff feathers and shaped to his particular
need, while with small feathers laid close, overlapping each other
like shingles, and bedded on an under-coat of down, he is clothed
and protected from heat, cold, and wet.
“The eye of the bird is different from ours, for it magnifies and
makes objects appear much larger to it than they do to us. Also,
while with other animals each group has practically the same kind of
feet or beaks, birds have these two features built on widely different
plans, so that when you have learned to know the common birds by
name and are really studying bird-life, you will find that you must be
guided to the orders in which they belong often by their beaks and
feet.
“Barnyard Ducks, as you know, have webbed toes for swimming,
and flat bills to aid them in shovelling their natural food from the
mud.
“Birds of prey, like the Hawks and Owls, have strong hooked
beaks and powerful talons or claws, for seizing and tearing the small
animals upon which they feed.
“The Woodpeckers (all but one) have two front and two hind
toes; these help them grasp the tree bark firmly as they rest, while
they have strong-cutting, chisel-like beaks, which they also use for
tapping or drumming their rolling love-songs.
 CHICKADEE

“While the insect-eating song-birds have more or less slender

bills and four toes, three in front and one behind, for perching
crosswise on small branches, the seed-eating songsters, such as
Sparrows, have similar feet, but short, stout, cone-shaped bills for
cracking seeds and small nuts.
 “By this you can see that in spite of the fact that all birds wear
feathers, and have wings, a tail, beak, and a pair of legs, they may
still be very different from each other.
“A Turkey Gobbler doesn’t look much like a Robin, nor a Goose
like a Swallow, yet they are all four birds! They all four bring forth
their young from eggs; but the little Turkeys and Goslings are
covered with feathers when they peep out of the shell and are able
to walk, while the young Robins and Swallows are at first blind,
naked, and helpless; so here again you can see that there is
something special to be learned about every bird that flies or
swims.”
“Chickadee-dee-dee! Can’t you tell them something about me?”
said this dear little bird, flitting about one of the open windows and
clinging upside down to the blind slats that were bare of paint, like
either a Woodpecker, or, as Tommy Todd remarked, “the man in the
circus.”
“The little bird peeping in the window and calling his name
reminds me of a pretty poem about him,” said Gray Lady. “I will
repeat it to you and write it on the board so that you can copy it in
your books, and then some of you may like to learn it to surprise
Miss Wilde on another rainy Friday.”

A LITTLE MINISTER
I know a little minister who has a big degree;
Just like a long-tailed kite he flies his D.D.D.D.D.
His pulpit is old-fashioned, though made out of growing pine;
His great-grandfather preached in it, in days of Auld lang syne.

Sometimes this little minister forgets his parson’s airs:

I saw him turn a somersault right on the pulpit stairs;
And once, in his old meeting-house, he flew into the steeple,
And rang a merry chime of bells, to call the feathered people.
 He has a tiny helpmeet, too, who wears a gown and cap,
And is so very wide-awake, she seldom takes a nap.
She preaches, also, sermonettes, with headlets one, two, three,
In singing monosyllables beginning each with D.

But O her little minister, she does almost adore:

I’ve heard her call her sweet D.D. full twenty times or more.
And his pet polysyllable—why, did you hear it never?
He calls her Phe-be B, so dear, I’d listen on forever.

Now if there is a Bright Eyes small who’d like to go with me,

And on his cautious tiptoes ten, creep softly to a tree,
I’ll coax this little minister to quit his leafy perch,
And show this little boy or girl the way to go to church;

And where his cosy parsonage is hidden in the trees,

And how in summer it is full of little D.D.D.’s.
And if Bright Eyes will prick his ears, he’ll hear the titmice say,
“Good morning,” which, in Chickadese is always “Day, day, day.”

—Ella Gilbert Ives.

“Now that I have answered my own question, there was another

that one of you asked, or rather a pair of questions. Why do some
birds go away in autumn, and why do they come back? It is very
important to know the answers to these, if we want to really
understand about the lives of birds and the trials and dangers they
undergo.

The Bird Year and the Migration

“People who think of birds at all know that they are not equally
plentiful at all times of the year, but that they have their seasons of
coming and disappearing, as the flowers have, though not for
exactly the same reason.
 “We are accustomed to see the plants send up shoots through
the bare ground every spring, unfold their leaves and blossoms, and,
finally, after perfecting seed, wither away again at the touch of frost.
“Of these plants, as well as some large trees, a few are more
hardy than others, like the ground-pine, laurel, and wintergreen, and
are able to hold their leaves through very cold weather, and we call
them evergreens.
“You notice that the birds appear in spring even before the
pussy-willows bud out, and that every morning when you wake, the
music outside the window and down among the alders on the
meadow border is growing louder, until by the time the apple trees
are in bloom there seems to be a bird for every tree, bush, and tuft
of sedgegrass.
“By the time the timothy is cut and rye harvested, you do not
hear so great a variety of song. The Robin, Song Sparrow, House
Wren, and Meadowlark are still in good voice, and an occasional
Catbird, but the Bobolink has dropped out, and the Brown Thrasher
no longer tells the farmer how to plant his corn: ‘Drop it, drop it,
cover it up, hoe it, hoe it;’ and very wise he is, too, for the corn is all
planted.
“Later still, when the stacked cornstalks fill the fields with their
wigwams, like Indian encampments, the pumpkins are gathered in
golden heaps, and the smoke of burning leaves and brush pervades
the air, you hear very few bird songs, for many birds have either
dropped silently out of sight or collected in huge flocks, like the
Swallow, swept by, and disappeared in the clouds, while others, like
the Purple Grackle or Common Crow-Blackbird,—walk over the
stubble and cover the trees, making such a creaking, crackling noise
that one would surely think that their wings as well as voices were
rusty and needed oiling.
“What has become of the birds? Where do they go when they
disappear?
“Being warm-blooded animals they cannot dive into the mud and
hide, like fishes, or crawl into cracks of tree bark and wrap
themselves up in cocoons, like insects. Neither do they drop their
feathers and die away as tender plants drop their leaves and
disappear.
“People once believed that Swallows dived through the water into
the mud, where they rolled themselves into balls and slept all winter.
They thought this because Swallows are seen in early autumn in
flocks about ponds and marshes, where they feed upon the insects
that abound in such places. People thought that as Swallows were
last seen in these places before they disappeared they must have
gone under the water; but this was merely guessing, which is a very
dangerous thing to do when trying to find out the plans that Nature
makes for her great family.
“Later yet, when the snow begins to fall, there is little or no bird
music, only the hoot of an Owl, the shrill cry of the Hawks, the
‘quank, quank’ of the Nuthatch, that runs up and down the tree-
trunks like a mouse in gray-and-white feathers, the jeer of the Jay,
and the soft voice of the Chickadee that, as you have just heard,
tells you his name so prettily as he peers at you from beneath his
little black cap.
“But the Catbird, Wren, Bobolink, Oriole, the Cuckoo that helped
clear the tent caterpillars from the orchard, the Chat that puzzled the
dogs by whistling like their master, the beautiful Barn Swallow, with
the swift wings, that had his plaster nest in the hayloft, the Phœbe
that built in the cowshed, and the dainty Humming-bird that haunted
the honeysuckle on the porch and hummed an ancient spinning-
song to us with his wings,—where are they all?
“And why is it that while those have disappeared, some few birds
still remain with us in spite of cold and snow?”

THE FLIGHT OF THE BIRDS

 Whither away, Robin,
Whither away?
Is it through envy of the maple leaf,
Whose blushes mock the crimson of thy breast,
Thou wilt not stay?
The summer days were long, yet all too brief
The happy season thou hast been our guest.
Whither away?

Wither away, Bluebird,

Whither away?
The blast is chill, yet in the upper sky
Thou still canst find the colour of thy wing,
The hue of May.
Warbler, why speed thy southern flight? Ah, why,
Thou, too, whose song first told us of the spring,
Whither away?

Whither away, Swallow,

Whither away?
Canst thou no longer tarry in the North,
Here where our roof so well hath screened thy nest?
Not one short day?
Wilt thou—as if thou human wert—go forth
And wander far from them who love thee best?
Whither away?

—Edmund Clarence Stedman.

The Fall Migration

“If you watch the birds, you will soon notice that some eat only
animal food, in the shape of various bugs, worms, and lice, while
others eat seeds of various weeds, and grasses, and also berries.
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