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tion or auto-suggestion, to which the subject is susceptible by reason of the pain or tenderness of back, and weakness and paresthesia of limbs incident to the shock, as well as of the general muscular soreness-the "stiff and strained feeling" described by Erichsen.

These otherwise temporary peripheral sensations, especially when acompanied by unfavorable suggestions of physician and friends, lead to introspection, expectant attention and apprehension, which cause erethism and hyperesthesia of the cerebral neurones, intensifying the local conditions present and bringing into full consciousness the ever present normal subconscious organic sensations, which are misinterpreted as evidences of disease.

Prolonged emotional excitement or stress alone, by reason of the continuous cerebral activity and insufficient rest with its resulting auto-intoxication from accumulation of waste products within the brain, may cause cerebral irritation and produce local peripheral sensations. These local sensations of cerebral origin, being misinterpreted as evidences of disease, intensify the psychic irritation, thus is developed a vicious cycle of action and reaction, which, prolonged and aggravated by the suspense of legal proceedings easily brings on a state of functional perversion. This may eventuate in organic disease; hence the fact that a claimant does not recover from his condition when he "recovers from a corporation," is not prima facie evidence that his condition resulted from trauma.

Because a disease is produced by abnormally prolonged or intensified psychic activity, is no reason for expecting recovery upon the removal of the exciting cause any more than with any other class of diseases.

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of external injury," but "one of the most remarkable phenomena * is, that at the time of the occurrence of the injury the sufferer is usually quite unconscious that any serious accident has happened, though the next day he complains of feeling shaken and bruised all over, as if he had been beaten, or had violently strained himself by exertion of an unusual kind. After a time, which varies much in different cases, from a day or two to a week or more, he finds that he is unfit for exertion and unable to attend to business.

"In other cases, the symptoms do not develop until several weeks or perhaps months have elapsed."

How else could we account for "a trifling accident" being more serious than a severe one, than through the influence of the mind? Erichsen and his followers do not explain this physical paradox.

In such a dissertation, it is proper to refer to non-polemic authors, so that I shall quote from writers on practice, general surgery, diseases of the nervous system, diseases of the spinal cord and medical diagnosis.

Da Costa1 writes: "Many cases of so-called 'railway spine' are really examples of traumatic hysteria." Continuing, the author says: "The accident plays a double part in producing traumatic hysteria; first by its effects on the mind (psychic traumatism); second, by its effects on the body, which anchors the attention to one point. An area of pain or stiffness often serves as an auto-suggestion which undergoes morbid magnification through the distorted medium of hysteria."

He might have added, with equal truth, that a third, and probably greatest factor, is the unfavorable influence of physician, lawyer and

We are justified in inferring such are the friends-those to whom one naturally anchors cases Mr. Erichsen thus describes:

"One of the most remarkable circumstances connected with injuries of the spine is the disproportion that exists between the apparently trifling accident that the patient has sustained and the real and serious mischief that has occurred; not only do symptoms of concussion of the spine of the most serious, progressive and persistent character often develop themselves after what are apparently slight injuries but frequently when there is no sign whatever

his hope. Da Costa says the teaching "that the symptoms of what Erichsen named 'railway spine,' arose from inflammation of the cord and its membranes, is now abandoned," and that "the term 'concussion of the spinal cord' has no pathologic meaning."

Under "Injuries of the Spinal Ligaments and Muscles," he writes: "Injuries of the back, even without cord injury are frequently linked with very deceptive nervous symptoms. 1. Modern Surgery, third edition, 1900.

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The three marked symptoms are pain, tenderness and stiffness of the back." * * Firm pressure on a spot of real tenderness causes rapid pulse (Mannkopf).

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** Moullin tells us that the extremities feel weak because they are deprived of proper support on account of the immobility of the muscles of the back. For the same reason the action of the abdominal muscles is interfered with and the power of micturition and of defecation is impaired," all cardinal symptoms described by the adherents of "railway spine" as evidence of injury to the cord, yet which Da Costa gives as symptoms of injury to the spinal ligaments and muscles "by wrenches, twists and violent muscular efforts (as in lifting)."

Anders writes that the "irritable neurasthenic condition of the cerebro-spinal axis so common among the employes of railroads and known as 'railway spine' is now acknowledged as the type of traumatic hysteria."

Butler in his excellent work on the "Diagnostics of Internal Medicine," which, as he asserts, "is largely drawn from the works of the masters of internal medicine," reflects their conclusions in treating "traumatic neurasthenia," "traumatic neurosis" and "railway spine," as synonymous terms, under the caption of simple "neurasthenia."

Byron Bramwell, in his exhaustive treatise on "Diseases of the Spinal Cord," writes that in his experience in ordinary private practice and in persons who were previously healthy, he has never seen an undoubted case of unmistakable lesions of the cord following a railway accident or injury.

Jacob states that part of the cases of traumatic neurosis belong to the domain of neurasthenia and part to hypochondria and hysteria.

Dana writes: "Traumatic Neurasthenia or 'traumatic neurosis,' 'railway spine,' does not differ from forms of neurasthenia produced by other causes, except that with it there may be certain sprains and surgical troubles. Traumatic hysteria does not differ from hysteria produced by other causes except from its sudden onset and occasional surgical complications.

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"It is the mental impression, the shock much more than the physical injury which produces the functional neurosis or psychosis."

Referring to the general subjective symptoms which Erichsen enumerates as constituting an important part of the syndrome of spinal disease, we would inquire, in what disease of the cord do we find "loss of or defective memory, confusion of thoughts, loss of business aptitude, disturbed sleep (except from pain) with frightful dreams, polyopia, affections of hearing, taste and smell?"

Regarding the spinal pain and tenderness alleged to be of such diagnostic importance in spinal diseases, it is thoroughly well established that it is no indication of disease of the cord, and that it is a more constant and prominent symptom of the functional diseases, hysteria, neurasthenia and hypochondriasis, than of the organic diseases, myelitis and spinal meningitis.

Jacob classes spinal tenderness as one of the stigmata of hysteria, and states that it is often present in healthy individuals, and "may also be suggested by the physician's repeated examinations."

From Ashhurst's "Encyclopedia of Surgery," we quote: "The least consideration will serve to show that if the vertebral ligaments and bones, and joints be healthy, no amount of pressure or percussion, made in the usual way during a clinical examination can much affect the substance of the cord itself, and that we should base no inference upon the negative evidence thus afforded." It naturally follows, per contra, that it can be no positive evidence of disease of the cord.

M. Allen Starr writes: "Pain is a symptom of considerable importance in spinal cord disease. It may be felt in the spine itself; that is, in the back and deeper structures, under which circumstances, as a rule, there is more or less extensive affection of the nerve roots or of the meninges, but not of the cord itself. Severe pain in the back and spinal ligaments is not at all uncommon in functional affections such as traumatic hysteria and traumatic neurasthenia; in nervous prostration; in hysteria.

"When pain is produced by disease of the spinal cord itself, it is due to an irritation or injury of the posterior nerve roots at their 6. Organic Nervous Diseases, 1903.

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Thus we see with what unanimity the term "railway spine," or spinal concussion, is used generically to include the various functional nervous diseases following trauma or shock, and not as a diagnosis of a definite clinical entity.

It is such a term as Bright's disease and apoplexy which requires elucidation to indicate the pathologic condition and permit a probable prognosis.

Fifteen years as examining surgeon of an accident company which carries a great many hazardous risks-among them several hundred members of our city fire department and salvage corps has brought under my observation not a few injuries from unusual violence, such as falling through floors of burning buildings, down elevator shafts and hatchways, alighting on feet, buttocks, shoulders and heads, accompanied by shock as well as by fear of being buried or burned in the buildings, yet among these I have not had a case of "traumatic neurosis," real or alleged. I have also examined a number of claimants after collisions of their fire fighting apparatus at full speed with electric cars, without seeing one permanently disabled, or disability prolonged beyond time required for the repair of the surgical injury.

In one instance of a collision of hose reel and electric car, the driver was thrown over the car, alighting head first upon granite pavement, fracturing base of skull, from which recovery was complete, without developing symptoms of spinal injury. Making a night run to fire, a hose wagon struck an excavation, throwing driver some fifteen or twenty feet on to a macadam pavement, where he lit on right buttock. He was unable to arise, though in fear of being run over by the engine and ladder truck which followed. He suffered pain and stiffness in lumbar region, which was accompanied by swelling and ecchymoses, but returned to work, sound and well, in three weeks.

It must not be forgotten that there are many

causes of diseases of the cord and that because a case develops, or is present after a railway journey, it is not necessarily due to physical injury.

I have seen a case of myelitis follow an uneventful night's ride in a chair car. The patient awakened from a nap feeling stiff and sore, which was soon followed by paresthesia and paralysis of the legs, altered reflexes, constipation and impotence; subsequently causing paresthesia and incoördination of hands and

arms.

Although not attempting to prove (nor do I assert) that traumatism can not, or does not, cause injury to the spinal cord, I do contend that alleged injuries to the cord, as well as to the general nervous system, are proportionately less frequent after accidents from which there is no possible legal redress than where there exists a probable legal liability with prospects of financial compensation. Also that when all possible sources of error are eliminated, injury to the cord and its membranes, without fracture or dislocation of the vertebræ, is of infrequent occurrence.

As has been demonstrated, most of the cases in which the symptoms are genuine, belong to the domain of functional neuroses; either hysteria, directly following the shock and fright, or neurasthenia or hypochondriasis, which develop subsequently from pscychic stress, often through apprehension of serious injury, or anxiety for financial reimbursement. Authentic cases are recorded wherein nervous diseases, both functional and organic, of long standing, have been ascribed to recent injury.

It is not unusual to find people on the verge of nervous breakdown, or the subjects of insidious organic nervous diseases, who first learn their condition through the introspection incident to an accident. In like manner, neurasthenia of long standing is frequently revealed after grief or business reverses, to which the disease may be erroneously attributed.

It is not infrequent for the sagacious physician in the course of an ordinary medical examination to detect an unususpected nervous disease, the presence of which the patient himself may doubt until the appearance of collapse.

Some time ago, a passenger on a rapidly.

moving railway train, whom I had warned a years previously of impending nervous breakdown, and advised vacation and treatment, which was unheeded, jumped from the coach window to escape the espionage of the conductor, whom he had erroneously suspected and accused of watching him.

In the beginning of a new century, with its prophesies of even greater advancement over the marvelous achievements of the nineteenth century in the domain of medicine and surgery, it is proper that we relegate to the past, the superstition, mysticism, scepticism and empiricism, which have in the past ages harassed medicine in its progress to the scientific basis it has at last attained. In burying the effete, there is nothing which requires a deeper grave than the vague, unscientific, unwarranted, mythical "railway spine," with its aliases, "spinal concussion" and "traumatic neurosis," and its conglomerate symptomatology.

As an epitaph we offer the following, though we would yield to one more poetic, even if not so expressive:

Here lies the remains of "Railway Spine,"
Died of exhaustion in the year '99.
May its rest be as peaceful,
As its life was deceitful.

If we are unable to make a scientific diagnosis, let us at least make a rational specific one, which will always indicate the same probable pathologic conditon, when "railway spine" and "traumatic neurosis," with such other indefinite terms as "nervousness, heart disease, dropsy" and "jaundice," will be dropped from our nomenclature.

Paraphrasing a familiar maxim:

"In 'science' as in fashion, the same rule will hold,

Alike fantastic, if too new or old;

Be not the first by whom the new is tried,
Nor yet the last to lay the old aside."

LINMAR BUILDING.

The higher the injury in fractured spine. the greater seems to be the mortality; particularly does this apply to lesions in the cervical portion. Some deaths from hemorrhage of the vertebral artery during operations in the cervical region have been reported.-Owens.

CASE OF FRACTURE OF THE SKULL WITH DISLOCATION OF THE CLAVICLE FROM ITS ACROMIAL ARTICULATION.*

BY A. O. WILLIAMS, M. D., OF OTTUMWA, IOWA.

I have not prepared a formal paper. I brought this young man with me from Ottumwa. About five weeks ago, while riding on the. top of a freight car, the train going at the rate of six or seven miles an hour, he fell upon the track, and in so doing his head came in contact with the rails, and he sustained a fracture of the skull, as was evinced by copious hemorrhage, which continued for some time. There was also hemorrhage from the nose and mouth, showing that the line of fracture was forward instead of backward. I mention this incidentally.)

The main thing I wish to point out is that he also sustained at the time a dislocation of the clavicle from its acromial articulation. This you have doubtless seen before, and know how almost impossible it is to retain in situ. If any member of this association present can tell me how to retain a clavicle that is dislocated from the sternum without strapping a man upon his back, I would like to know it. Unfortunately, I have had two or three such cases, in which the clavicle is still dislocated. This young man, by reason of the skull fracture, was unconscious and delirious for some time, and very little attention was paid to the clavicular dislocation from its acromial articulation then. My idea. was that it would be necessary to resort to wiring, as the clavicle would stick up about an inch or an inch and a half, and it was apparent to anyone that there was a well-marked dislocation of the clavicle. As you know, the clavicle is held only by a very strong circular ligament, and as this was torn, the clavicle was very readily displaced or dislocated. After four or five days the mental condition of the young man began to clear up, and then I thought it worth. while to make an heroic effort to retain the clavicle in place without wiring, if possible. I have brought with me a device which I used in this case, and I will endeavor to place it on the young man, not with any idea of bring

*Read at the first annual meeting Rock Island System Surgical Association, Kansas City, December 3.4, 1903.

ing out anything particularly new, but simply to show you that this apparatus held the clavicle, and the patient has recovered without the necessity of any cutting or wiring. If you will allow me, Mr. President, I will place this apparatus on the patient just as I formerly did. This (indicating) was the clavicle that was dislocated. (Here Dr. Williams demonstrated how the

this apparatus will afford comfort to the patient and be an absolute guarantee of success, obviating the necessity of wiring.

I claim no originality, but am using appliances that are so old that I have forgotten whence they originated.

Adjust the dislocation, then apply a 3-inch surgeon's adhesive plaster long enough to pass over the dislocation around the arm, about 3 inches below elbow, place arm across the chest and hold it in place by the bandage, which is shown in Fig. 1, "A" representing the adhesive

SHAW

B

Fig. 1. Apparatus in Place. dislocated clavicle was reduced, and held in position.)

There is nothing special about this except that I have succeeded in retaining this dislocation from its sternal articulation,, and have succeeded in getting a good result without any operation. The clavicle, as you observe, is in place, although it is perhaps a little bit higher than it should be. Without doubt there is ligamentous union in this case, and unless the patient resorts to some strenuous or violent muscular exercise I do not think it will be redislocated. He has not resumed his work yet. He wore this apparatus for about six weeks. After a week or a little more he was able to be about the house, and he has been going around ever since then. The apparatus was applied about one week after the dislocation. At this time nature had made some effort at repair, and it was a little difficult to reduce the dislocation, but I succeeded in doing so. I am satisfied that

Fig. 2.--Bandage.

plaster, "B" the bandage in place, and "C" (Fig. 2) the bandage. This bandage can be made in a few moments, is easily adjusted, and is the most comfortable appliance that could possibly be devised for broken or dislocated collar bone.

INTERNATIONAL CONGRESS ON ACCIDENTS TO WORKMEN.

This congress will meet at Liége, Belgium, during the world's fair to be held there in June of the present year. The following discussions have been provided for so far: (1) Traumatic lesions and post-traumatic affections; (2) The organization of first aid to the injured, especially for workmen in large cities and industrial centers; (3) Uniformity and centralization of statistics in regard to accidents to workmen; medical evidence in regard to such accidents.

HOSPITAL CARS.

Forty new railway cars, with their compartments built and arranged in such a way that they can be easily transformed into ambulance or hospital compartments for the transport of sick passengers, have been distributed among the chief express routes in Prussia. On each line the new carriages are in charge of special officials, who must previously have been trained in the theory and practice of disinfection.

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