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find any definite lesion, so I was constrained to tell the physician that I believed his patient was malingering. He got a settlement out of the railroad company, but continued to get worse and in less than a year he died.

In another case where a man was injured in a railroad accident there was incontinence of urine and feces with rigidity of the spine, that is a rigidity of the lumbar muscles on the one side, with a dragging of the limbs. It has generally been understood that where there is a rigidity of the lumbar muscles on one side that there is no malingering in such a

case. case.

There was some doubt, however, in this particular The man got a settlement from the railroad, and in spite of this the man has made very little improvement. He is still unable to walk without two canes to support him and there is some incontinence of urine. He is not a well man by any means.

The third case was that of a lady who was also injured in a railroad accident, and at that time received a severe blow over the back of the neck. The parts were very much swollen, and she was compelled to give up her work. After some months she attempted to return to work, but on account

pain, headache, etc., she had to give it up again. In the meantime a growth appeared on the spinous process of the cervical vertebra. She was operated upon for this, and I assisted in removing what appeared to be an osteoma. There was no microscopic examination made of it, but it did not appear to be malignant. This lady obtained a good settlement from the railroad company, still she is not a well woman. She has never been able to return to her original work, and I do not believe she will ever be a well woman. So I have found that not all of these cases get well when they a get a settlement, and I think this should always be borne in mind.

Dr Martin Stamm, Fremont: I would like to ask the doctor a question. Where all of the reflexes are abolished, and remain so for weeks, would he operate upon such a case? I had two such cases where I was urged for weeks to operate. One of these cases was operated upon about four years ago. The patient, a boy 16 years of age, fell from a tree. He presented symptoms of fracture in the eleventh dorsal region, and all of the reflexes were abolished. He did not improve for weeks and the family constantly urged me to operate. They brought to me clippings from news

papers describing successful operations performed on patients, and they thought that an operation must be made upon their boy. I finally consented to operate in this case, six weeks after the accident. He had an immense bedsore, and, as I said, all of the reflexes were abolished, together with trophic disturbances. He improved for about 10 days after the operation; he could move his toes somewhat,-the bladder and rectum improved a little, but that is about all the improvement he has made, and he has remained in the same condition for the last four years.

I saw another case last summer in which the patient was injured over the fourth dorsal vertebra, but there were no signs of fracture. In this case all the reflexes were abolished. I refused to operate on the ground that most of our authorities advise against operation in such cases or, at least, have had very discouraging results. He is living today with but very little improvement in his condition. Ì would like to ask Dr Means what he would do in these cases?

Dr Charles J. Aldrich, Cleveland: I think the Society is to be congratulated upon the paper which has just been presented, and further, medicine and surgery are to be congratulated upon the fact that the railroad surgeon has begun to realize that we can and do have cases of traumatic hysteria and traumatic neurasthenia, and to recognize the fact that these cases do not all recover. In all of the cases which Dr Means has recited, he mentions only two cases of malingering. That malingering occurs among these personal injury cases none can doubt, but to say that the majority of them are malingerers is a great mistake. It is easy enough for us to get together and indulge in a lot of talk about these patients recovering as soon as they get their money. Those who have followed up such cases know differently. If you will read the article by Dr Phillip Combs Knapp, of Boston, on this subject, you will change your mind. He dwells especially upon the fact that comparatively few genuine cases of traumatic neurosis absolutely and permanently recover. Because a man is able to walk on the street and do business is no sign that he has recovered. I believe that few of them entirely recover. I would like to believe otherwise, and am willing to investigate any case of genuine traumatic neurosis with a reported complete and absolutely permanent recovery. These cases will have more or less hysteria and psychic

degeneration to the end of their days. If we could go into their families, get their home life, we would find there hysteric manifestations, and psychic obliquity that is a constant torture to their families and hinderance to personal happiness.

I would like to say a word or two in reference to medullary hemorrhage or intradural hemorrhage. I recently had my attention called to this by a traumatic case. The patient and others were shifting cars with a pole when the pole flew back striking him on the chest. He sat down suddenly on the ground and at once experienced considerable pain and cramps in his legs.

Dr C. B. Parker asked me to examine him. I found him to be suffering great pain and hyperesthesia in the distribution of both external popliteal nerves. The tibialis anticus and peroneii were weakened, and a partial double foot-drop was manifest. There was no loss of sphincter power or anesthesia. Atrophy and loss of power has supervened in the muscular groups mentioned. The lesion was undoubtedly a small extravasation into the conus. Instances of such slight lesions could be multiplied. Indeed I am convinced that many of the so-called nerve injuries of the cord are due to small, perhaps punctate, hemorrhages into the spinal marrow.

Dr Brooks F. Beebe, Cincinnati: I wish to take exception, first, to the expression of applause which went up from this audience when the first case was reported as having recovered. I wish also to take exception to the lack of applause when the other patient recovered from the bulletwound of the spine. These things simply suggested to me that we had a society of railroad surgeons rather than a State Medical Society. I wish to compliment not only the paper, which I might say does not need any compliment, and also to compliment the number of speakers who have taken the subject up so nicely and emphatically. One of the greatest mistakes which the profession made for a number of years was in pronouncing these cases malingering. It has been positively demonstrated, to my mind, that we have simply been in the dark to a great extent. It has been the custom to consider these cases as not an organic condition but rather of a much simpler state of affairs. We have used the word "functional" (a word that certainly ought not to be used) to cover up our ignorance. Because we cannot find by the

microscope these finest of molecular changes in the nervous system that does not mean that they are not there. One of the worst cases which I have ever come across was one in which there was no wound, absolutely, no shock other than the general shock to the nervous system. The patient was riding in a street-car which was coming down one of the steep hills around Cincinnati, when the shock was received. There was not even a fall, the patient standing up at the time holding on to one of the straps in the car. The shock has lasted now for three years and instead of getting better the case is growing worse. $7,500 in damages have already been recovered from the Street Railway Company. So I would say to the railroad surgeons go a little slowly.

While there may be a few cases of malingering, or of a disposition to exaggerate their conditions, I feel confident that there are many others who are never thoroughly appreciated by the physicians.

Unquestionably a lawsuit tends to prolong, as it compels the patient to think more or less constantly of his trouble. Rest, or freedom from work and worry, has much to do with the cure; and therefore time is an element in it that cannot always be controlled.

Dr W. J. Means, Columbus, closing: I am under many obligations to the last speaker, also to Drs Carpenter and Aldrich for their forcible presentation of traumatic hysteria, demonstrating that these cases are real conditions rather than functional manifestation. I did not intend to advocate in my paper that in these cases there were no positive lesions to the nerve-cells. I believe in the majority of cases there is a traumatism that is positive. If you will recall it, I only reported one case diagnosed as malingering, and only two cases which got well after settlement of damage suits. I do not believe that these two patients were malingers.

I hope the points made by Drs Carpenter and Aldrich will have weight with the members of the Society. My experience coincides with theirs that only a few of these cases recover permanently.

In reply to the question asked by Dr Stamm as to when we shall operate in injuries of the spine and upon what cases, is a pertinent one. I thought I stated my position clearly, that with our present knowledge it is quite impossible in the primary stage to differentiate between a compression of the cord producing complete paraplegia and a cross section of the cord. Some surgeons think differently, but this has

been my experience. I do not believe in an early operation, especially if the injury is in the cervical region, or well up along the dorsal. I believe an operation should be deferred until the primary shock has subsided. If you will recall my statement, my cases were operated upon after the primary shock had passed away. I believe in cases of complete paraplegia that an operation should be made immediately after the primary shock has subsided. Degeneration of the nerve fibers will take place quickly, and unless relieved will not repair. I would operate upon all cases where there is some evidence of continuity of the cord, even weeks or months after the injury. In the cases mentioned by Dr Stamm I would certainly have operated.

Emphysematous Gangrene

By MARTIN STAMM, M. D., Fremont

Emphysematous gangrene or gaseous phlegmon is a comparatively rare affection and, though it has been observed and described centuries ago, it still engages the attention and interest of the surgeon and pathologist. It is, however, only during the last decade that its etiologic and clinical features have been made the subject of special study. Before that time such cases were mixed up with those of malignant edema. Velpeau described in 1858 gaseous abscesses of the mamma with very offensive odor, and he thought that the gas was derived from the lungs, owing to their close proximity. This opinion was, however, soon upset by Chassaignac who ascribed it to the decomposition of the milk infected by coming in contact with the baby's mouth. Some cases of purulent pleuritis with formation of gas were described by Biermer, Ducheck, Drasche, and others. Friedrich also mentions a case of pneumopericarditis. Formation of gas in the peritoneal cavity is also mentioned by Breslau and Dressler. Abscesses with spontaneous development of gas, however, are rarely mentioned in literature. Puerperal pyemia observed by Lavallée and Saexinger, a case of abscess of the liver reported by Schreiber, a phlegmon of the knee-joint by Luebke and a puer

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