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ried to the extremity; but if the circulation has been absolutely cut off, it makes little difference in regard to the other tissues, for every effort at conservatism will fail. If nutrition is all right and the surgeon decides it by individual judgment, it is possible for him to save the limb, otherwise not.
Dr. Milton Jay: The paper is an excellent one and deals with a subject which is of great importance. There is only one point I would touch upon, and that is this: A man's foot or leg may be badly crushed, and seemingly the circulation is almost entirely cut off, but the surgeon succeeds in saving the limb. He may have another similar case, and yet in spite of all his skill he will find that he cannot save the limb, and therefore has to amputate it. It is in such cases that malpractice suits are brought. Two of these malpractice suits we have had in Chicago during the last three months. One surgeon testified that he saved a limb as bad as the one in which the other surgeon made an amputation, and says that that surgeon ought not to have amputated. My point is this, brother surgeons should never testify one against another unless they know what they are talking about.
Dr. A. I. Bouffleur (closing): I thank you very much for the consideration which you have given my paper, which was not as complete as I had contemplated. But it has brought out some points that I feel were important. I do not care to take up the time of the association in discussing the paper further, but there are one or two points which I would like to touch upon very briefly and hurriedly. First, in regard to a car wheel passing over a limb. There is no question but that a leg or an arm so injured can be saved. I had a case recently in which the car wheels passed over the forearm at the wrist and succeeded in saving the limb, notwithstanding that it threw the car off the track. I have no doubt that this man, in the course of six months, will have a fairly useful hand.
In regard to the case of the girl whose limb was nearly cut off in a reaper, of course it is similar in some respects to a railroad injury, but at the same time entirely different in that we are dealing with an incised wound, and conservatism is more applicable in incised wounds than it is in those cases where heavy
car wheels, with their crushing force, pass over a limb.
The rule that I wish to lay down in regard to amputation has been dwelt upon by Dr. Jackson, and which I hold is the cardinal one, namely, that in trying to save limbs we should only save as much tissue as will be rendered useful. For instance, it is useless to save a finger unless you save the flexor tendons, too; and the same rule holds good in other parts of the body. Unless the saved limb can be made a useful member, it is largely a detriment to the individual, more especially in the case of a leg where we have artificial means that will enable the individual to have a useful member.
RAILWAY SPINE A SPECIES OF IN-
BY SAM'L C. BENEDICT, M. D., ATHENS, GA.
There is one satisfaction to me as I begin the preparation of a paper on this subject, in that I can shift the responsibility for its imperfections to other shoulders than my own. When the request for papers for this meeting was sent out by one of our fellows, and when mine reached me I had my hands full with the preparation of a paper upon another subject, and so wrote, saying that it was impossible to prepare a paper for this meeting in so short a time. In reply I received from my worthy brother a letter, couched in most polite language, saying my excuse was not accepted, because I was not speaking the truth about my time being fully occupied. This epistle, in a measure, hypnotized me! My mind was subjective and I became willing to accept the suggestion to do more work than I was able to, and thereupon wrote another letter, stating that if I would be saved the trouble of selecting a topic and if he would suggest a title that I would do my best. Forthwith came the information that I had been put upon the program for "Railway Spine, a Species of Insanity."
ing under the suggestion of my ability to hanAnd here I am, still hypnotized, still labordle this subject, and not even the auto-suggestion of my utter incompetency will dissipate the influence over me. I am allowed no alternative. Poor miserable me! Would that I
*Read at the meeting of the surgeons of the Central of Georgia railway at Augusta, Ga., April 14, 1896.
had never been born, to have to stand before this gathering of scientific men to discuss a subject already threadbare; already so dissected and disseminated that even the final day of meeting will do no more than to bring together mismatched vertebræ and spinal cords, and such a conglomeration of cerebral cortices that not even the sub-conscious mentality will ever be able to recognize the once noble man before he was so unfortunate as to have his spine injured in a railroad wreck. If this railway spine is not in the borderland of insanity, I am, and so please pardon my intrusion and look leniently upon my shortcomings in this article. Whatever merit or demerit may lie in this remember that not I, but my friend and hypnotizer, Dr. J. Howard Williams, is responsible absolutely and wholly for the wreckage.
It is well, at the outset, to state that the term "railway spine" in this paper is used only for such injuries from railway accidents as have left no doubt as to the integrity of the vertebræ from fracture or the cord from damage; that is, those cases in which there is a very serious doubt whether the spinal column or its contents are injured at all. Starting with this premise, we simplify this discussion very much and we are in a better position to draw a logical conclusion between the results of minor injuries in the neighborhood of the spinal column and the more grave and lasting functional disturbances of the cerebrum as terminating in a mental unsoundness, by which the symptoms referable to the back are maintained.
I propose to speak, firstly, of some of the prominent symptoms of railway spine; secondly, of the conditions of mental unsoundness, the symptoms of which are similar to those of the spine, and give evidence that the "railway spine" is in reality a railway brain in a large proportion of cases. At the conclusion of a recent editorial in one of our leading journals, upon "Spinal Injuries in Railway Accidents," the editor asks the question: "But do many people really believe in a railway spine at the present day?"
From the days of Erichsen, the spinal concussion Erichsen, to those of Page (who did more than anyone else to enlighten our minds. as to the true pathology in railway spine), it was supposed, and so argued, that all symptoms in the region of the back and limbs fol
lowing a railway accident were the result of damage to the cord, or, in other words, a concussion of it. That diagnosis is untenable in the light of recent discussion.
Railway spine is defined as "an injury which results occasionally from violent shaking received in a railway accident, having, as a rule, no external hurt to mark the damage done, with symptoms of extreme debility and weakness, in some cases approaching partial or complete paralysis.”
This may be a sufficiently explicit definition, but it would seem that even in the mildest cases, where symptoms were early referred to the spine, that there must be bruising, twisting or straining of the tissues external to the columns.
In persons of neuropathic temperaments the slightest jar may produce symptoms of railway spine, a fact which has thrown much light on the pathology of this affection, because it points to a condition of hyperæmia or hyperæsthesia of the cerebral cells, producing what is known as traumatic hysteria, and not a disturbance in the cord itself. Included in the various symptoms are such as pains in the back and elsewhere loss of sexual power, general malaise and weakness of the extremities as well as headache, sleeplessness, loss of memory, vertigo, inability to fix the attention, and others which would point to the brain rather than to the cord for location, so that the spinal cord is not essential, as a factor, for the explanation of the symptoms. Strain of the muscles of the back and the ligaments of the vertebræ have probably been the chief cause of calling attention to the back, and yet most of the symptoms of railway spine can be satisfactorily explained by disordered functions of cerebral centers, and are very closely allied to, if not the same, in defect of function, as those in hysteria, neurasthenia and hypochondria. It would not be accurate to debit to the spinal cord centers and the cord meninges, as is done in spinal irritation and concussion, such symptoms as peculiarly belong to the functional disorders of the brain as sleeplessness, morbid apprehensions, irritability, heaviness in the limbs, formication, mental hypersensitiveness, flushes, chills and impotence, as well as defects in vision, such as asthenopia and amblyopia, or of the ear, like nervous deafness.
Because pressure upon a spinal process and
around the spine produces painful sensations, it is not uncommon to conclude that the seat of the hyperæsthesia lies in the cord, while, as a matter of fact, tender spots over the spine simply refer to the terminals of sensory nerves from the cerebrum, and are not conclusive of spinal irritation any more than tender spots on the scalp are.
The feeling of weakness in the back and loins may be due to fatigue of the muscles themselves the contraction necessary to keep the trunk upon the pelvis or the limbs in position. The feeling of fatigue is appreciated sooner because the cortex, receiving the impression, is hyperæmic. Again, morbid fears, vaso-motor irregularities and extreme sensitiveness to temperatures are all found in functional cerebral disturbances. One of the most usual symptoms complained of is the loss of sexual power or desire, but this does not necessarily point to an injury of the spinal centers, for the centers of erection and ejaculation are under the control of the brain and may be inhibited by a thought or by fear. Post-mortem examinations reveal nothing, so we adopt the theory of functional disturbances of the central nervous system, without, however, claiming them to be due to malnutrition, irregularity in vasomotor control or to reflexes from diseased organs. An atrophy of an optic nerve has followed a simple cerebral concussion.
On the other hand, the functional disorders of cerebral cells which furnish symptoms analagous to those of railway spine, so called, are hysteria, neurasthenia and hypochondria, degenerating in some cases into hypochondriacal-melancholia or into dementia.
Let us look briefly into the symptoms of these disorders.
Hysteria belongs to a diseased state of the nervous system, inherited or acquired, and has an infinite variety of symptoms, the most marked of which are easily referable to cerebral disturbances, the principle cortex sufferers being those of sensation and motion. Diseased irritability of these centers give pseudoparalyses exalted irritability gives spasmodic seizures. In the etiology of the affection we find, operating as causes, mental and physical shock, violent emotions, severe trauma and psychical shocks, such as found during and after railway collisions or severe wrecks.
In a person easily or already predisposed to
it, the slightest injury or shock may produce an attack, the severity of which bears no relation to the violence of the cause. Disturbances oi sensation, motion, circulation and secretion, all referable to disturbed cerebral cells, are noticed. Hyperæsthesias and anææthesias of various areas of the body are common; disturbances of the special sensations with hallucinations are among the innumerable abnormal symptoms; also anæsthesias of single extremities, or of spots on trunk or back or limbs, bladder, rectum or vagina, with numbness of different portions of the body.
A hemi-anæsthesia may rapidly change sides or be induced by blisters, metal contact to skin surfaces, or even the patient's expectant imagination may produce it. Among other disturbances of motion we may find spasmodic contractions in every part of the muscular system, or general convulsive seizures may come on as a result of physical or mental shock or from strong emotions. A hemia or paraplegia. may attack any and all of the extremities.
Among the symptoms of neurasthenia we find many like those of hysteria, and in addition, anxiety, dread, morbid fears, fears of walking alone, dread of crowds, neuralgias, backache, and excessive tenderness or pressure over the spine. The pain of neurasthenic backache may be along the spinal column or farther outward-at the attachment of the sacral or iliac muscles; sometimes the most prominent symptoms are sensitiveness of the back to slight pressure, or pain without pressure. Pains in muscles and joints are not uncommon. Intense muscular pains in the legs, starting up after remaining quiet for half an hour or so, have become of such severity as to prevent the person from walking at all. Insomnia is one of the most important symptoms of neurasthenia, and is usually present at one time or another during the disease. Hot flashes are frequently complained of by neurasthenics and may be due either to vaso-motor irregularities or simply to disorders (central) of sensation.
Impotence, premature ejaculation, sense of prostration after cohabitation, are often met. with among this class of sufferers, and by apprehension may lead to serious mental conditions, even to insanities. Among the causes given, as productive of neurasthenia, are concussion, accidents, fright or mental strain. As
either hysteria or neurasthenia may develop into hypochondria and hypochondria into a condition of mental unsoundness bordering on dementia, or at least as taking the forms of delusion or milder hallucinations and illusions, and as this form is most frequent in persons with a railway brain, let us look a little closely into the symptoms peculiar to hypochondria.
We are all more or less conversant with the symptoms of the hypochondriac.
He is an intense introspector, a first-class egotist; he makes mountains of molehills, and in its fixed development his hallucinations and illusions become delusions which amount of argument can change. The slightest sensation made upon the body, or a suggestion or auto-suggestion may be sufficient to start a train of symptoms limited in variety and extent only by the amount of information he may have of his anatomy, from hearsay or reading. Every kind of pain, every sensation, from a toothache to a paralysis, may be felt by this poor mortal. The concentration of his attention upon his special disease increases cerebral irritability and so increases the disease and magnifies it until his whole system seems disordered-he believes he will never get well and is a total wreck. Sensations of twitching of the limbs, numbness, pins and needles, heart palpitations and weaknesses of any portion of the body are among the prominent symptoms of this class.
Now, while my desire is to discuss this subject as much as possible from a pathological psychical standpoint, and to avoid a suggestion of malingering, it is almost impossible to keep out the thought that a great number of cases of railway spine are willful malingerers. I use the word willful as distinct from the cerebral condition of the patient in which, while his physical injury is extremely slight, he cannot avoid the cerebral state which forces upon him his delusions, and while we may think that many such persons are keeping up their symptoms and complaints with a view to litigation, yet to them-the non-willful malingerers-the condition is very real. I wish to show that a railway spine is more often a railway brain, and in the majority of non-malingerers may degenerate into such a condition of mental unsoundness as to preclude responsibility.
Page has clearly and interestingly described
the surroundings of a severe railway accident, be it collision with all its horrors, or any other accident producing impressions of horror, fright, impending death, cries of the injured, crushing of timbers, escape of steam, darkness, or what not, as producing upon a brain, especially one with a neuropathic heredity or tendency, such a series of tremendous impressions, exclusive of a concussion, as to disturb seriously and for a long time its normal function and to throw the person into a condition of hysteria or neurasthenia or to lead to a hysterical mania, a hypochondria, dementia or a monomania.
In a brain which has received such impressions we have a condition of hyperæmia and hyperæthesia, which may account for every one of the symptoms usually described as attributable to a railway spine. It answers readily to suggestions either from actual sensations, as the result of strain upon parts external to the spinal column, or to blows upon the extremities or trunk. It responds to auto-suggestions of the possible results of such injuries and, as the severity of the symptoms increases by repeatedly referred suggestions to the cortical cells, the disturbance in motion and sensation increases, until all kinds of sensory and motor phenomena develop, even to paralysis. The increased irritability of the cortex, holding sensory cells, increases their functional activity and consequently the possible manifestations of all symptoms which such cells can possibly give to our consciousness. A pressure along the spine, when there is no abnormal condition, may be transmitted along a normal nerve tract and the impression upon its cerebral cells suggest an amount of abnormal condition about the point of pressure, or a distribution of motor impressions from the cortex, as may make real to the individual all the sensory and motor disturbances so prominent in hysteria and neurasthenia. The seat of the disease is the cerebral cortex, not the spinal cells.
An examination of such a patient may be all that is necessary to suggest an unnatural condition of the part examined, and if a direct question be put to him, it may be all sufficient by insinuation to make him really "feel" the suggested condition.
To one who has studied the possibilities of brain function under hypnosis, as being able,
by suggestion, to produce all sorts of sensory, motor or mental phenomena, it is unnecessary to argue to what extent a suggestion to the cortical center of any sense used to transmit the suggestion, may evoke symptoms of abnormal perception, in the patient. Authorities upon insanity state that it is difficult to determine where a true hysteria ends and a hysterical insanity begins, or where a hypochondria of not sufficient intensity to preclude control ends, and a hypochondrical insanity begins.
Looking at it from the standpoint of a mental unsoundness, we might say that when in either condition the opinions of the individual so control him in the transaction of business, in his family relations or with the world at large, as to cause him to conduct himself at variance with the habits of persons in his station of life, that he is insane. Hypochondriacal insanity is usually of a melancholic type; the varieties are manifold, depending, to some extent, upon what portion of the body is under inspection. Let us take now, as illustrative of one type of so-called railway spine, a person of neuropathic temperament and follow up the development of his train of symptoms to see if we cannot draw a conclusion which would confirm an opinion that he not only has no bodily physical injury approaching his subjective symptoms, but may show that he has reached such a state of mental unsoundness as to constitute a species of insanity.
He is in a railway collision of severity. He hears the crashing of breaking material; he feels the sudden stop and is thrown violently about; he hears the cries of seriously injured or frightened persons, or sees them pinned down, dying or dead. Everything has happened with lightning celerity. He may be in darkness with parts of the wreck afire, or possibly some loved one is injured or killed. He himself is apparently unhurt. What strong man can go through such a mental strain and not feel that he is unable soon to get over the impressions made at such a time? Who could soon forget such horrors? The brain has had such tremendous accumulations of impressions rapidly made upon its sensory centers as to throw them into a state of abnormal activity. The batteries have been so charged and shaken as not soon to settle down to a normal current. A hyperæmia of all such shocked cell areas inevitably ensues, and hyperæmia means hy
peræsthesia: Here we have a condition which, in a brain of neurotic heredity or acquirement, does not easily change from a pathological to a physiological state; on the contrary, as soon as the hyperæsthetic cells begin to bring to the consciousness of the individual, symptoms in peripheral areas, of pain, formication, numbness of others errors of referred sensations, then we have developed the apprehension of possible permanent lesions, morbid fears and the dreads of the neurasthenic or contractures, paralyses, etc., of the hysteric. The brain enters, as it were, into a state of hypnosis, ready for auto-suggestion originated by hyperæthetic areas and terminating in (to him) real pathological conditions as to peripheries. Then as the fear of an approaching inability to make his living, to take care of his loved ones, and possibly to be bedridden, the question of remuneration for his damages arises and he becomes a litigant. As the suggestions repeat and repeat themselves the irritability of centers increases, other sensations arise and he soon imagines himself physically a total wreck— possibly he is mentally.
Every sensation of the peripheral nerves is wrongly interpreted by his abnormal cortex, and he becomes impotent. His back is weak, his limbs are numb and he cannot walk. A pressure upon the spine is interpreted by his condition of exaggeration into pain, numbness or paralysis, or even the suggestions of his examiners brings out new disorders. is worse in that respect than the first course medical student. As this cerebral tax goes on the man becomes a constant introspector. All his thoughts are of himself, and when he has mentally so far progressed into a pathological psychic that he cannot by reasoning or argument rid himself of his delusion; when his illusion becomes a delusion and for whose dissipation there seems to be no relief; then does this poor mortal become hypochondriacally insane-mentally unsound. Then it is that he can convince judge and jury (and sometimes his lawyer) that he has really a railway spine, and as each court term approaches and the suggestion of the necessity that he should not lose, his worse symptoms present themselves to his deluded brain and he becomes worse and worse, and may present a face which gives. evidence of a physical wreck. He is mentally not sound; he is morally irresponsible. One