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a black spot. This skiagraph shows the piece of steel or iron, whatever it was. He got some emery in the cornea, but the piece of steel that broke off at the same time, shot through the eyeball, lodged in the scelera, and caused inflammation and loss of sight. The body was located with the ophthalmoscope. Hoping against hope, I cut down over the foreign body and introduced the magnet, but got nothing, because the foreign body was grown fast to the coat of the eye. Then I removed the eye. Here is another instructive skiagraph. The patient was struck with a piece of steel which cut open the eye, causing prolapse of the iris, traumatic cataract, and I could see lying upon the surface of the lens a little sliver of steel. I made a section of the cornea, cut off the prolapsed iris, and lost the piece of steel. I expected to remove that in my operation, but the aqueous humor washed it out. The skiagraph demonstrates it. The eye healed with half normal vision, and it is now eighteen months since the operation, and the eye is a useful one.

Here is another skiagraph which shows a piece of steel in the center of the eye, right in the middle of the vitreous. The patient was sent to me within a few days after the accident. I could see a penetrating wound involving the cornea, iris, and crystalline lens. The lens was so hazy that it was impossible to see the foreign body with the ophthalmoscope. I was told that a skiagraph was made. and showed nothing. But Mr. Fuchs, who is an expert with the X-ray, demonstrated the presence of a foreign body for me at once. The foreign body was extracted with the Haab giant magnet. Here is another skiagraph of a most instructive case. The patient is a bridge-builder for the St. Paul company. He was sent to me with a history of perforating injury of the eyeball, evidently by an infected piece of metal. I saw the case a few days. after the injury, when the eye was violently inflamed. Enucleation was advised. This skiagraph, which I will pass around, shows a minute piece of steel, so situated in the orbit that it was impossible for us to say whether it was in the eye or not. If the eye had not been inflamed, we would have hesitated about removing it, because of the possibility of quieting the eye and finally restoring sight. The man could not stay in Chicago, and the eye was at that time blind. It was acutely inflamed. Time was passing, and we all know that sympathetic inflammation may destroy the fellow-eye in ten days' time, and so at the end of a week we removed the eye. Having the eye in the hand, we wanted to know if we were justified in removing the eye. So Mr. Fuchs made another skiagraph, showing that the piece of steel was in the eye, but just in the outer coat of the eye, or close to the edge, as shown in the skiagraph.

I will pass around two other skiagraphs which illustrate the difficulty we have to contend with sometimes. This man, a skiagraph of whose eye has been passed around, was injured by an explosion of molten metal, and several particles of metal were blown into his face. His eyes were blinded at once. We wanted to know if there were any foreign bodies in these eyes before resorting to iridectomy and cataract extraction for the restoration of sight. If either eye contained a foreign body, even though encysted, an operation on the eye might have excited destructive inflammation. It looks as if there are

two pieces of metal in the eye, but we could not satisfy ourselves whether these pieces of metal were in the eye, in the lids or conjunctiva. The patient was willing to take chances, so we operated and got useful vision in one

eye.

I wish to refer to one point in regard to magnet operations on the eye. We have established this principle: If a foreign body can be located within the eye with the ophthalmoscope, and its location is accessible, without introducing the small magnet deeply into the eye, we may cut down upon it and resort to extraction by placing the point of the magnet in the lips of the wound. If, however, the media are opaque, and we cannot see the foreign body within the eye, the best method is to employ the giant magnet, so-called, and attempt to draw it forward. into the anterior chamber and remove it through the original wound or new section made.

Dr. H. B. Hemenway, Evanston: There is one point I wish to dwell on more fully, and that is the after-treatment of some of these cases. A short time ago I was consulted by a man who had formerly been a fireman on a railroad, and while at work one day he got a hot cinder in his eye. He had to stop in the middle of his run, went to physician and had the cinder removed. What the aftertreatment was I do not know, but he got into such a condition that he had to give up railroad work. He told me that he went to several physicians; that he had seen Dr. Würdemann of Milwaukee, who had advised in favor of enucleation of the eye. In examining him I found that the iris was somewhat adherent to the scar on the cornea; the cicatricial tissue of the cornea included almost the entire cornea, so that there was complete blindness. The blood vessels in the cicatrix were considerably congested. I told him I thought, from the appearance of the eye, the best thing he could do was to have the eye enucleated. He did not want to have it done at that time, and so I recommended that he use a 1-1000 solution of adrenalin, the idea being that this might relieve the congestion somewhat. I have not seen him lately. I believe he is working in another section of the country, but the last time I saw him the cicatrix had practically disappeared. I took no pains to make a careful examination at the time, but the enlargement of the blood vessels had practically disappeared, and what surprised both the patient and myself was that the cicatrix had decreased in size, so that he was getting a little vision in the upper portion of the cornea.

Dr. C. F. Larson, Crystal Falls, Mich. : I would like to say a word or two in reference to adrenalin in these cases, inasmuch as it has been referred to by the last speaker. Of course, my experience as a general practitioner has not been as extensive in this class of cases as that of many others; but I have found the use of adrenalin chlorid, with chloretone solutions in the after-treatment of irritations of the eye, after a foreign body has been in the eye, of great value. We all know that there is some objection to the use of cocain, even for local anesthesia, and personally, I would like to hear Dr. Wescott's experience in regard to the use of adrenalin, whether it is superior to other agents or astringents in the aftertreatment of these cases.

Dr. A. I. Bouffleur, Chicago: I would like to make some remarks with reference to the question of reporting

these cases. Dr. Wescott referred briefly to the fact that you should report your cases of injuries to the eye. He need not have limited his remarks to the eye, because every case you are called upon to attend on behalf of the railroad company should be reported, it matters not how slight it is. The mere fact that you have been called is sufficient to cause you to make some sort of report. At the present time, the eye is getting to be quite an important factor, for the reason that a number of men are being turned down on promotion after examinations, assigning as the cause that they had received an injury of the eye, that a foreign body had lodged in the eye while on duty, and in looking up the records we have been unable to find any such condition. When the operating department comes back to the claim department or surgical department, we find no reports of any such condition. That is your fault and my fault, as much as it is the individual's fault. If he has not consulted one of us, then it is his own fault. If he has consulted us, we should report the fact, so that it may be recorded.

In the second place, we are not all oculists. Very few of us are experts or specialists in this line. The time has long since passed when we can expect to be specialists in every department of medicine and surgery. Personally, the less I have to do with treating the eye the better I am satisfied, and is does not take me long, after seeing a case, and removing a cinder, if the patient does not improve, to see to it that he gets into the hands of an oculist. But you, gentlemen, who are located away from oculists, have to carry more responsibilities in that respect than I would have to do here in Chicago. But, at the same time, there will come up in the experience of each and every one of you cases in which you are uncertain as to your own ability in handling them. You fell that you are assuming grave responsibilities; you are carrying a heavy load in continuing to care for the case, yet from a professional standpoint you may feel as though you wanted to carry the case through. Man has only two eyes at best, and some of us only have one, and that one may not be a good one. In all railroad work sight is an important thing, as it is in practically all affairs, and for that reason, particularly in railroad work, since there is frequently the matter of damages connected with it, you should keep the claim department very carefully advised as to the progress of such cases. You should do that for their sake, and particularly for your own sake. Many a man's reputation in a community is ruined by the loss of an eye on the part of a patient, for which he really was not to blame, and the company is glad to be forewarned of serious complications that arise, which should be noted and recorded, and if the conditions are favorable for the man to be placed under the care of an oculist, well and good. If they are not, the company will send a good oculist to him, because, if they can save a man's eyesight by expending a little money, they will be glad to do it. But they cannot do it if you wait too long. These reports should be made promptly when complications are developing. This discussion only emphasizes the fact that we can recognize them, and when we do so, if we are unable to handle the cases ourselves properly, we should have someone who is more familiar with these cases than we

are.

Dr. Frank S. Skinner, Marion, Ia.: I would like to report a case that happened about a 'year ago. A coalheaver, in breaking coal, sustained an injury to the eye, a piece of coal flew up, splitting the eye, and opening the anterior chamber. When I saw the case, the lens was sticking out through the hole made by the piece of coal. I took the man at once to Cedar Rapids, placed him under the care of a specialist, and he resorted to cold applications on the eye for a few days, and then, about ten days afterwards, I should judge, he took a scissors, snipped off a portion of the protruding lens, and united the cut with a suture. The case progressed rapidly, and the man to-day has almost normal vision in that eye. It is almost impossible to do that in private practice in a small town the size of Marion, so he was taken at once to the hospital and treated, with the best results. That was about the line of treatment carried out-cold applications kept on day and night for two or three days, the removal of that portion of the lens which was protruding, and closing the incision with sutures, with the best results.

Dr. Ira K. Gardner, New Hampton, Ia.: Dr. Skinner has told us that the protruding portion of the lens was clipped off with scissors and the other portion left. I would like to ask him if he knows what happened to the other part of the lens? He said the man had good vision afterwards. I wish Dr. Skinner would give us a little more information in that direction. What he has said has aroused my curiosity, and I have no doubt he can give us a little more information concerning that eye. Dr. Skinner: I stated that the man had almost normal vision.

Dr. Gardner: I don't know how the man can see at all.

Dr. Skinner: But he does; and I can't explain it. Dr. C. D. Wescott, Chicago: I rise a second time, at Dr. Plumbe's request, to speak of some technical points. in regard to the treatment of these cases.

First, in regard to the after-treatment of injuries of the eye. That all depends. But we are talking now presumably to Dr. Plumbe's paper, in regard to the more ordinary or simpler traumatisms of the eyeball from foreign bodies. The first point is to get the foreign body out with as little damage to the eye as possible, and in a cleanly manner, leaving the eye as clean as possible after operation. Then, until healing is complete and the eye free from redness, the eye should be under observation. It should be flushed once or twice a day with boric acid. solution by the physician who is responsible for the case. A warm saturated solution of boric acid is as good mechanical disinfectant as you can use in the eye, and is a safe one in such cases. The eye should not be bandaged unless the injury is sufficiently great to cause photophobia. If the patient says that light hurts him, and he is inclined to close the eye, there is your indication. Nature closes the eye to keep the light out, and you can help the patient by putting on a light sterile dressing. You do not want to confine the discharges and thus increase the danger of multiplication of the micro-organisms which are always in the conjunctival sac, and which you cannot wash out thoroughly.

A word or two with reference to the use of atropin. It is the anodyne par excellence in all diseases of the eye,

except in glaucoma. You know that we have a disease which is characterized by increased tension or hardness of the eyeball, and it produces blindness by pressure upon the optic nerve. That disease is glaucoma. It is very painful. We should never use atropin in the eye of a man who is past middle life without asking ourselves the question, Is there any danger of doing damage to the eye? But in the presence of injury, we must keep the eyes quiet. The after-treatment in most cases consists in cleanliness, atropin, as long as there is pain, a light dressing as long as there is photophobia.

In regard to the use of adrenalin, the evidence to-day is that adrenalin is not directly a therapeutic agent in the sense of really changing or altering the pathologic conditions. Adrenalin quiets the eye by limiting the amount of blood in the anterior and superficial parts of it. It makes the patient more comfortable; it makes the eye more comfortable; it limits the blood supply until nature can bring about that change which we call a cure, or until the daily application of antiseptics or other agents can effect a cure. The best effect of adrenalin is in facilitating anesthesia of the eyeball in hyperemic eyes. Take an eye that is recently injured or is inflamed, you know how impossible it is almost to get cocain, helocain, or eucain to take hold and do any service whatever, but if you will first blanch the conjunctiva with adrenalin you may use a local anesthetic just as you would in a normal

eye.

Dr. Donald Macrea, Jr., Council Bluffs, Ia.: It seems to me that some of us who live in larger towns than the smallest towns, are in a position more to be regarded than those men to live in smaller towns, so far as eye work is concerned. In the smaller cities and towns there is no question at all but what the general practitioner has to do all of his own work, and does more than I would care to do. Personally, I never touch an eye at home, because we have an excellent oculist there, and I turn my eye cases over to him, unless it is a case of cinder in the eye or something of that kind, then I remove it. But the more severe cases of eye injuries, I, like Dr. Bouffleur, prefer to refer to oculists.

When it comes to railroad work, I would like to have the Chief Surgeon (Dr. Bouffleur) instruct us what to do with cases like this. (Of course, we have certain instruction for the severe cases, but not the ordinary cases.) For instance, we see a case in which a little inflammation of the eye is progressing, and we feel our inability and inefficiency to cope with the case. Shall we send such cases to Chicago at once? Of course, some of these patients may refuse to go. I have in mind the case of a man who came to me with his cornea in a handkerchief, the vitreous, aqueous humor and everything else, and I had him taken at once to the hispital. Our local oculist removed the eye. I would like to know what to do in such a case, whether to take the patient away to an oculist, or whether it is safe to wait in case he did have to go away.

Dr. Bouffleur: In reference to the remarks of Dr. Macrea, in such cases it is better to wire the special agent for instructions. If he does not understand the telegram, or its import, he will get me on the wire, and if he does that, you need not be afraid, as the matter will be explained to him and you will receive satisfactory instruc

tions in short order. This has occurred several times within the past year, in which cases would come up, and concerning which messages have been sent to Mr. Inge, and they should all be sent to him. He gives instructions, and in cases in which he has not clearly understood the situation from the telegram, he has called me up, or my assistant, in regard to something about the eye, and I in turn have called up Dr. Wescott and obtained instructions from him. The company is anxious to do everything it can, and the mere spending of a few dollars in order to save a man's eye or part of his sight will not be a barrier. On the other hand, if you should take the case to a competent oculist, I am sure the company would stand a reasonable expense for services rendered. However, I would advise you to use the wire freely in such cases. The answers are reasonably prompt, and particularly if you get a rush message. If necessary you can use Western Union, pay for it, send a bill in for it, and it will be honored. It is an easy matter for you to communicate with the company, and in an emergency you are allowed a certain latitude. I am not authorized to give you positive instructions to spend the company's money, but if there is anybody in this hall who is on the staff of surgeons of the Milwaukee road, who spends any money or incurs any expense in saving life or a limb of any employe, and has not been recompensed for it, I would like to know all the details, and I will do all I can toward securing for him a refund of the money he has advanced.

Dr. Plumbe (closing the discussion): I have nothing in particular to add to what I have already said, and what has been said by Dr. Wescott. I will say a word or two, however, in regard to my experience with cocain in the eye. I think it was along in the late seventies that I saw cocain mentioned as a local eye enesthetic in the medical journals. I wrote to Chicago and St. Paul, but could not get it. I then wrote to Merck & Co., and they sent me a five-grain vial, and charged me 75 cents for it. They sent me half an ounce of a 5 per cent solution of cocain and charged me $1.50 for it. Not long after this, a child was brought to me with a foreign body of some kind (I don't remember what it was) in the eye. As usual, in this case the parents tried to extract the foreign body, but the child would not let them do it. I thought this was a good opportunity to try cocain, so I instilled, with considerable trepidation, a little into the eye, and in five minutes the child allowed me to examine the eye, and I extracted the foreign body without any difficulty. It was simply on the cornea, and since that time I have never been without cocain.

SURGICAL SERVICE FOR THE RUTLAND RAILWAY.

Dr. M. L. Bingham of Burlington, Vt., has been appointed chief surgeon of this line, and is organizing a staff of division and local surgeons.

Remember that the "facies" of tubercle may not be noticable in urinary tuberculosis, and that the cachexia of malignant disease only appears in the last stage of cancer of the bladder.-Fenwick.

INTERNAL INJURIES THE RESULT OF SEVERE TRAUMATISM.*

BY D. W. FINLAYSON, M. D., OF DES MOINES, IOWA.

In no case of injury is the attending surgeon certain that he can be safe or discreet in making a definite prognosis, and especially is this true if a favorable issue is announced and given to the friends of the injured person and to the public. This uncertainty of results, while present in all cases of surgery to a certain degree, is intensified if the injury occur to one or more of the body cavities or to any organ or important tissue that is concealed from the view and inspection of the surgeon. In almost all cases of railroad surgery, the injuries received arise from unusually severe and disastrous causes, such as result from the wreck of trains, falls from cars and injuries attendant upon switching, track work, etc., in all cases representing such severity that no injury can safely be called simple and uncomplicated when first seen and inspected by the attendant.

The head when traumatized is at all times a source of great anxiety to the surgical attendant, for time alone, in some instances, will solve the problem as to the character of danger encountered and eliminate or involve the dreaded complications that may or may not develop. An ever to be feared sequence of blows on the head, as is well known, is fracture of the skull, and this fear is present not only in large or severe blows, but in the small and apparently trivial ones, as well. An accident occurs to the head with or without abrasion of the scalp, and the appearance of the wound does not indicate cause for especial alarm; but they are at the disposal of the surgeon for diagnoses and prognoses. Most of this class of accidents do recover without unusual or unlooked for complications, and all goes well with the patient and his attendant. But not infrequently the results are not satisfactory, and what indicated a simple affair at the beginning of the case, with small responsibility, really was a fracture of the skull accompanied by bone depression on the brain, a lesion that unless seen and corrected early, becomes in many cases a serious matter throughout future life to the patient, as manifested clearly in epilepsy, partial or complete paralysis, or even mental deterioration. In the life work of every one of us, we can readily recall some instance or instances where such a lesion, or lesions, arose from a cause that was easily corrected at the time of receiving the injury, but through neglect, lack of skill, or from some other cause of procrastination, was permitted to go on to final destructive impairment mentally or physically of a once healthy fellow being.

Hemorrhage from blows on the head forms an interesting and important study from the viewpoint of the surgeon. These may be extradural, or in the substance of the brain tissue-intradural, and in any instance must not be permitted to pass unnoticed, but must be arrested, if possible, before coma or possibly fatality ensues, but these hemorrhages may even escape notice until proven to exist by an autopsy.

Cranial topography and anatomic familiarity with the brain, and the skull case, can materially help us to make

* Read at the ninth annual meeting Iowa State Association of Railway Surgeons, October 22 23, 1902.

a correct diagnosis and prognosis in these injuries, much to the interest of the patient and the accuracy of the attendant. The anterior branch of the middle meningeal artery has caused more extradural hemorrhage, perhaps, than all other causes about or in the head. Frequent agents of hemorrhage also are the sinuses-superior longitudinal, lateral, and the superior and inferior petrosal. The optic nerves, and as a sequence vision also, frequently suffer from head traumatism, first affecting the brain, then transmitting the result forward to the optic nerves and finally to the eyeball.

In the thorax, the home of the heart and lungs, these organs are the chief sufferers directly or indirectly from severe cavity injury, and especially is this the fact with the lungs and the surrounding pleuræ, from great contusion and compression, as well as from the sharp spiculæ of broken ribs cutting through the pleura and into the ung. The heart so actively resents any injury to its tissue and integrity that wounds of this organ are seldom known unless of fatal issue, and that inmediately.

In the abdominal and pelvic cavities, the many contained organs there escape frequent injury, much of the time owing to their great motility and the elasticity of their surroundings, the parietal structures. Any viscus, wherever found, is more in danger when full than when empty, as has been so often observed in injuries to the bladder, from great traumatism of the pelvis involving its

contents.

Contusions received on the stomach, when fatal, seldom cause death from the injury to that organ per se, as in rupture, subsequent peritonitis, etc., although they do occur; but directly and suddenly from fatal contusion of the solar plexus, and consequent paralysis of the heart. The duodenum, because of the absence of a mesentery and its fixation, and because of its position lying upon or across the spinal column, receives more direct fatal injuries than any other segment of the alimentary tract; these accidents frequently resulting in rupture because of its fixity and unusual immobility. The remaining small, and all the large, intestines are not in nearly so much danger as the duodenum. In any traumatism of the abdominal contents, peritonitis plays an important part in the gravity of the situation, and must be constantly kept in mind when dealing with this class of injuries. Traumatic peritonitis from abdominal bruises is one of the frequent sequences of all injuries that occur from severe casualties. When the many folds, recesses and duplications of the peritoenum are recalled and considered, it can be the cause of little surprise that violation of its integrity is apt to ensue, and that fatality may mark the termination of such an injury.

There can be no more distressing and annoying class of accidents than those that afflict the pelvis and its contents. Primarily the pelvis is one of the strongest of the body cavities, but when it becomes crushed the mutilation is likely to engage any or all contained organs and tissues. The iliac vessels as they cross its ramus are in great danger, the numerous large nerves, members of the sacral and lumbar plexuses and the anterior direct branches of the sacral nerves, involving as they do the bladder by partial or complete paralysis and the rectum, are all concomitants of pelvic traumatism. The anterior

crural nerve as it is transmitted over the ramus may be injured, resulting in more or less complete obliteration of extension of the legs. The great sciatic nerve through impairment will produce paralysis of the leg flexors, the obturator injury made manifest by loss of adduction, and the internal pubic nerve, well marked as it is by innervation of the perineal muscles, will seriously cripple all the cerebro-spinal innervation of the sexual organs as well. Added to these as nerve lesions in or about the pelvis may be noted injury of the lower hypogastric or pelvic plexus of the sympathetic system, which added to the internal pudic potentiality, completely destroys the nerve supply to the pelvic organs.

While any one of these is subject to the force of pelvic traumatism, it must be clearly remembered that two or even all of these great nerves are subject to associate casualty. So long as the bladder and rectum are not seriously impaired, life may possibly be prolonged with some measure of comfort, but the bladder and the rectum when ennervated are certain to wear out the sufferer's life, and that before long. Then the bladder, particularly when full, is very subject to injury, much more so than when empty. When the pelvis is crushed on a full bladder, extra- or intraperitoneal laceration of that reservoir is an accident by no means rare, but the diagnosis of this accident is easily proven and repair at once should be instituted. The urethra in either sex, but especially the male, is one of the common sufferers from traumatism, due to crushing injuries of the bony pelvis or to direct crushing of the canal against the pelvic arch, and when seriously traumatized presents one of the most pitiable conditions in the entire domain of surgery. Particularly Particularly is this true if the prostatic and membranous portions are the subjects of crushing or lacerating injuries, for their situation is so deep and inaccessible to effectual catheterization of the bladder that toxemia from infiltrated urine and catheter fever are almost certain to be some of the associate results of such an injury. The ureters are subject to accidents and extensive lacerations are fatal.

Thus we see that the internal injuries of the body are always a matter of serious moment in railroad accidents as in any other class of casualties where bodily injuries are received. Many times no definite internal organ can be absolutely known to be a sufferer from traumatism at the time, or even until the necropsy, which, like an open book, lays clearly before us the secrets of a closed cavity with its injured organs. In this great domain, like any other field of surgery, large responsibility continually rests on the surgeon's shoulders at all times and in all cases. He is responsible directly to his patient and to his employer, the railroad company, both at the same time and on the same case. In the first, the jeopardy of human life is placed in his keeping for repair; in the second, grave responsibility in finance is the peril of the company. To-day, more than ever in the past, because of improved methods of diagnosis, the judgment of the surgeons employed by the railroads is paramount, and if not wisely directed the company becomes the immediate sufferer, owing to its employe's inaccuracy of diagnosis, prognosis and misapplied treatment.

In any case, therefore, let us be careful and painstaking, and never mislead the hopes of our patient or the com

pany that employs us by forgetting the internal organs of the patient on the one side, and the statements we give to the company on the other as to the outcome and final results of the patient in our charge.

DISCUSSION.

Dr. Gardner: There are only a couple of points I want to touch on. The first is with reference to head injuries. I know that we are often rewarded with most brilliant results by a careful examination and consideration of the symptoms as they present themselves.

I had a case three or four years ago of a man who received a fall while riding horseback. He was not thought to be very much injured, but in about twelve hours slight coma commenced, with a slight amount of paralysis in one arm, and he finally became unconscious. There was a slight abrasion of the scalp, hardly any lesion could be detected to the skull cap. The conditions were such that we believed we were justified in trephining at the point where the trauma had taken place. After removing the button of bone, we did not find anything wrong with the dura at the point where the injury was received, but by carefully searching and pressing down, we succeeded in finding a semi-solid clot of blood, about the size of a small hen's egg. We believed then we had found the source of trouble and after removing the clot, closed up the wound, and were rewarded by the patient regaining consciousness and recovering. If that clot had remained there, I believe it would have destroyed his life. While it is not always that we are so fortunate, I think we are nearly always justified in making a most thorough investigation and search in order to locate the trouble or cause of trouble. Slight traumatism, on the other hand, often causes such a pathologic change on structure or function of internal organs or tissue as to result in the gravest consequences to the patient.

By the sudden stopping of a freight train, a healthy, robust stockman was thrown from a low chair to the floor of the caboose. He got up unaided, sat on the seat and said at first that he was not hurt. But in a few minutes he complained of severe pain in the lumbar region and was carried from the car to a hotel near by. On a most careful examination, no external marks of injury could be detected. Yet this man was paralyzed from the region of the umbilicus to the toes, and remained in such condition for about a year. Several expert neurologists made repeated examinations of the man to make out the pathology, or to eliminate malingering, without arriving at positive conclusions. This patient seemed to improve after securing a settlement with the railway company whereby he received $3,000.

The next case was a man falling from a haystack; he was paralyzed from the neck down; no discoloring of the skin, and the spinal process intact. The particular point the man wanted to know about was as to the prognosis. I gave him a rather favorable prognosis, and believed the man would ultimately be able to walk and use his legs and arms in a fair degree. But this all goes to show what severe results may follow even slight traumatism.

Always tie both ends of a divided artery in a wound.— Fenwick.

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