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lation tissue, as may be observed in many of the cases of hip-joint disease. The only diagnostic symptom in such cases, in fact, in any case, is the presence of the tubercle bacilli. When we have mixed infection-pyogenic cocci and tubercle bacilli-we should be able to demonstrate the pus micro-organism and the bacilli of tuberculosis by culture. Who would venture to assert that tuberculosis was present when no specific micro-organism can be found? In other respects, such as the anatomical conditions, the age of the patient, and the area of infection, there is little difference between the two diseases. In our clinical observation, however, we may be able to distinguish fairly correctly by the acute attack, the great pain and the higher temperature in the suppurative variety, as compared with the chronicity and lower temperature, with an evening rise and failing health, due probably to a primary infection elsewhere, denoting secondary metastatic tuberculosis in the medullary substance of the bone.
So far as the etiology is concerned I claim that no case of tuberculosis depends upon trauma, slight or severe. It has not been claimed that tuberculosis of the lungs or other glands depend upon traumatism as an exciting cause, yet bone is of the same histological structure and presents the same pathological change as lung tissue and infection in both is the same. There is no doubt in my mind that the medulla of the diaphysis is the most susceptible to tubercular infection of any of the anatomical structures in children. Authorities, in speaking of tuberculous bone use the stereotyped expression, "it is often due to slight trauma;" in other words, a trauma that has not been observed. Taking into account the anatomical features already spoken of in connection with suppurative osteo-myelitis, and the deep-seated point of infection, I have always been constrained to believe a slight injury is simply the means of calling attention to an existing focus of infection in the medulla of the diaphysis of bone and has nothing to do with the origin of the disease. The tuberulosis has been established. Slight periosteal inflammation has set up over the focus of infection in the medulla, and an insignificant blow merely marks its location. Tuberculosis does not develop where a child is apt to sustain an injury. Moreover, if it were due
to trauma, children running about striking against this or that a hundred times or more in a day, would be quite liable to contract tuberculous trouble of the bones. On the contrary, exceedingly few children are afflicted with tuberculous disease of bones compared to the large number who contract other diseases when exposed. It is fair to presume that if it is ever due to slight trauma it would commence in the periosteum or more compact tissue of bone, a location where we seldom, if ever, find the disease primarily. I maintain that it depends upon a predisposition and pre-existing tubercle that finds a vulnerable structure where the infection is lodged, and the reason we attribute it to slight injury is that there is a tender spot, a diagnostic symptom, on deep pressure of periosteal inflammation having been established following the disease in the deeper portion of the bone tissue, namely, the medullary substance. The patient, in running about, probably strikes the limb against something, over the point of tenderness, and in this way makes hs first complaint, through which the disease is attributed to that special injury, when such injury had nothing to do with the origin of the disease, except in a damage suit. for personal injury.
Tuberculosis of the lungs, lymphatic glands and other organs in the interior of the body is never considered to be due in any sense to traumatism. Then why should the bone tissue alone be singled out as an exceptional example of insignificant injury as an exciting cause? A severe trauma, which might invade the medullary substance in the central canal or the cancellous tissue in its interior where the tuberculous focus is implanted, would be a more rational conclusion in ascertaining the
The diagnosis and treatment of bone inflammation is a matter of the greatest importance to the patient. There is no surgical disease necessitating early treatment so positively as osteo-myelitis, and the older the patient the greater is the necessity for prompt early treatment. Radical measures in both suppurative osteo-myelitis and tubercular osteo-myelitis may save not only a large destruction of tissue, but the life of the patient as well. In all suspicious cases of bone disease the surgeon should be constantly on the watch for the development of inflammation, and as early as
possible, after the first evidence of tenderness serving to locate the infected area is observed, surgical interference should be resorted to, either by means of parenchymatous injection of iodoform emulsion, or the more radical operation for the removal of the limited foci in the medullary substance. There is no possible means of escape for the non-absorbable product of inflammation except by penetrating the bony structure externally, then the periosteum, and finally the para-periosteal tissue. This in young adults is often quite tedious, and very great destruction may occur before nature has accomplished the necessary results to effect a cure. It is in these cases that we should be particular in making our diagnosis. Pain and tenderness, with constitutional disturbance, are usually the only symptoms in the early stage of the disease that furnish a guide to its location, and as soon as we are reasonably certain that we have an inflammation we should at once prepare for surgical operation.
The preparation in these cases should be quite as thorough as if we were preparing for an abdominal section. Perfect cleanliness, and the use of antiseptics cannot be too strictly observed. The point of infection having first been detected and the field of operation rendered absolutely aseptic, and the limb if possible rendered avascular, an incision should be made down to the bone. This should be trephined and the product of the inflammatory process cleared out, after which the bone cavity should be filled with iodoform, and the wound packed with iodoform gauze and closed up, with the exception of the drainage opening.
This, briefly, is the manner of treating bone inflammations or abscesses, whether the inflam mation be due to pyogenic cocci or the bacilli of tuberculosis. Dr. Nicholas Senn's apparatus for forcible injections of iodoform emulsion is very useful in cases of limited tuberculous foci. Even if we are mistaken in our diagnosis little harm, if any, will be done, by the operation carefully performed. If the inflammatory trouble exists great benefit will be accomplished, and much tissue saved that would under other circumstances have been destroyed by the destructive inflammatory process, to say nothing of the danger to the life of the patient.
Allow me to further suggest that the time is at hand marking an epoch of personal damage suits when railway and other corporation surgeons, of whose number I am not, must go on record for or against the theory I now advance. My record was made up long ago, and as an expert witness in various courts of justice I have earnestly and honestly taken the stand enunciated in this paper, and have earnestly contested controversies against great odds, and have succeeded in saving corporations from very heavy damages in many cases, and the information and clinical evidence I have recently obtained on the subject has still more thoroughly convinced me that my position is correct.
In conclusion I desire to emphasize a few salient points.
First Neither spontaneous suppurative osteo-myelitis nor tubercular osteo-myelitis originates in the compact tissue of bone primarily.
Second-The structures involved in the primary infection in each are exact anatomical counterparts.
Third-The conditions under which the infection originates are alike.
Fourth-The infection in both forms of inflammation is conveyed to a locus minoris resistentiæ, under like conditions.
Fifth-The area of bone tissue involved is far remote from the part where a slight trauma could obtain through the blood current.
Sixth-The infection and inflammation always exist prior to the injury supposed to produce it.
Seventh-Restitutio ad integerum without the formation of an abscess never occurs.
Eighth-To preserve bone tissue and protect the health or life of the patient an early and thorough operation is imperative.
DISCUSSION OF DR. FULTON'S PAPER.
Dr. Evan O'Neil Kane, Kane, Pa.; I heartily agree with the doctor that there is something more to look for than mere trauma in the bone troubles that we encounter. The disease sometimes starts at the end of a stump, and annoys us when we thought we had an excellent flap. Undoubtedly tubercular disease does a great deal of damage, both in children. and in adults, but I would go further than the doctor in trying to get at the root of the difficulty. When I get a brakeman or other rail
way employe whose limb is badly crushed, I put him through a careful questioning, and endeavor to ascertain the condition of his blood, determining whether or not there be any hereditary predisposition to disease. I put such patients on mixed treatment, where I find I cannot rely on their statements, and see how they get along, and I find by the use of iodide of potash, in full doses and minute doses of mercury, that most of the diseased medullary cavities are avoided, while formerly I had a great deal of trouble with them.
Dr. P. Daugherty: While I was very much pleased with the paper, I cannot agree with the position taken by the doctor. I believe that most of our bone troubles in childhood and youth are the result of trauma. In childhood the boy or the girl is continually falling and climbing and constantly bruising himself or herself, as the case may be. In order to produce a disease of bone we probably have to have more than simple trauma, however; we must have a predisposition to that disease. What I mean by predisposition is simply an inherited tendency of the parts to certain diseases-tissues that are prone to take on certain forms of inflammation. Then with the trauma you get a locus minoris resistentiæ; your inflammation is set up. This is the position I took three years ago in a paper presented before the Golden Belt Medical Society. Dr. Hilton, in his "Pain and Rest," gave me the first ideas in regard to these things. His idea was that in case of coxalgia we should place the patient upon his back, apply extension to the limb, keep the patient there for six or nine months, and give no treatment whatever except to feed him well. He got fat in this way by simply physiological and mechanical rest. There is a good deal in it.
Dr. Martin: Dr. Fulton in his paper claims that the cause of this disease lies in the vulnerability of the part, through the predisposition of the patient. While that is undoubtedly a fact, yet may not the trauma still further increase the vulnerability? May not the trauma still further reduce the already feeble resisting power of the part? He says that tuberculosis of the lungs is never attributable to a wound. While that may be the case, does it not frequently owe its inception to an attack of pleurisy, pneumonia, or some inflammatory affection? The inflammatory affection does not set up the tubercular process, but by overcoming the resisting power of the parts, it allows it to
take hold of the part, and in that way is a cause of the disease.
Dr. Hungate: This subject is interesting to me, and I must compliment the doctor in expressing my ideas about the matter. I am satisfied that it is the proper way of looking at this subject. I do not believe that inflammation of bone is due to trauma alone, but that there is a pre-existing condition which develops diseases of bone, more especially that of tuberculosis. The lamentable ignorance that is exhibited by the ordinary practitioner was made manifest in a case that came under my observation. The history was this: A little boy was taken with diphtheria; a country doctor was called, and said he had "something that would cure diphtheria every time." After receiving treatment the boy did not get well. He had a lump in the side of the jaw, but the physician told him that it did not amount to anything. He complained of pain in his hip and knee, and it was supposed that he had fallen off a fence or was hurt in some way. The boy was taken to another doctor, who was asked to explain the cause of the pain in the hip and knee. He replied that it was a "growing pain." This temporarily satisfied the parents, but the boy grew worse. He was then taken to another physician and treated for rheumatism or myalgia, without relief. A third physician was called and placed the boy on his back for six months until he was nearly worn out. He got a little better, but did not get well. The case eventually proved to be one of tuberculosis of the hip-joint. It was plain to anyone that the disease was due to a micro-organism which had existed in his system all the time; that the diphtheria was only an incident. After resorting to parenchymatous injections of iodoform emulsions, and establishing free drainage, under antiseptic precautions, the boy recovered.
President Murphy: This subject is so extensive that to intelligently discuss it would take us all the morning. But there are some points about it that should be brought out, and first in regard to the history of the two classes of cases mentioned in the paper. In the make-up of the history you do not need to have a microscope in your vest pocket to make a diagnosis. There is a classical course for a large proportion of these cases, and if you get them early you can make a diagnosis from that
I agree with the doctor that there is a pre
disposing cause, but we are convinced by researches that these microphytes are in the circulation almost all of the time. They are taken care of; they do no harm; they are eliminated by the emunctories, and we go on as though nothing was wrong with our system. But the very moment the microphytes are placed under favorable conditions for their growth and multiplication, trouble begins. I have never seen an acute osteomyelitis of the shaft of the bone. I have seen an acute diffuse osteomyelitis before we knew whether it was due to tubercle, the staphylococcus or streptococcus. But the position is the same. There is a weak point in the bone at the junction between the epiphysis and diaphysis. The two cases are just as opposite as day is from night. Take a child three, four or ten years of age, which is playing and falls on the floor and sustains a slight injury. If that child is going to have tuberculosis it will not be sick the next day, but it will be in three months from that time, because it takes three months' time for the disease to develop to any marked degree. Take the opposite picture. A lad falls on the floor, receives a slight injury, or a boy in skating falls down on the ice, and the next morning he does not feel well. At night the temperature is 102 degrees, the next day 104 or 105 degrees, and the boy is delirious and has a dry coated tongue-that boy has osteo-myelitis. He has pain. You may call it rheumatism. If you examine the joint you will find it has no effusion. Examine it above the joint or below it, depending upon the position. The knee is a common position for osteo-myelitis, and that is the reason I take it for an example. Examine above and below the joint, and you will find he has tenderness. Wait until the second day and there is more tenderness on deep pressure. Press upon the affected joint for two minutes and the pain is really unendurable. On the fourth or fifth day the pain is not so great, he feels better, but his leg is sorer. What has happened? The osteomyelitic center which he had here, which was encapsulated within the bone in the beginning, as it enlarges destroys the line for escape it follows along the artery and escapes beneath the periosteum. As soon as tension is relieved his leg feels better. If you have an acute infective osteo-myelitis of the surface of the bone beneath the periosteum it is exactly the same as this. The pain is central and the symptoms of sepsis continue as long as there is pain.
Dr. Fulton (closing): I am somewhat disappointed in not having had more criticism or more opposition to the views enunciated in the paper. I want to make one remark to the railroad surgeon, and that is regarding trauma as an exciting cause of tuberculosis. You have got to meet it in the near future. This is an epoch in which we have a craze for trying to get something for nothing, because times are hard. In the city in which I live (Kansas City) damage suits to the extent of over $300,000 dollars have been brought by people against the city, on account of slight injuries received from falling through sidewalks or broken boards, or some imperfect pavement. The people have now dismissed the old idea of Erichsen's disease of the spine, because it has been practically exploded. Now they have got another craze, and that is the craze of bringing personal damage suits for tuberculosis, and you have got to meet them. I have been meeting them for several years. I have taken a positive stand that there is a predisposition, as illustrated by Dr. Murphy's diagram, in other words, an anatomical peculiarity of the bone-a vulnerable point, a locus minoris resistentiæ-the cause of the peculiarity of the circulation at that particular point in children and young adults.
Dr. Daugherty remarked that in connection. with trauma, as a cause of tuberculosis, children were constantly climbing over everything, up trees and over fences. We have done it ourselves. We have all more or less been climbers here and there. How many within the sound of my voice have contracted tuberculosis? If tuberculosis had its exciting cause from these injuries, I am free to believe and to confess that I would find a hundred cases of tuberculosis of bone where I find one to-day. They are very scarce. We see them but rarely. There is another cause, namely, the anatomical peculiarity of bone. The micro-organisms floating along in the blood are arrested in their course at this point in the anatomy of the child, and osteo-myelitis is thereby set up.
Regarding the use of iodoform, I have been using it a long time and still believe in it. I do not know how it acts. But I know one thing, that I have taken cases which have resisted all other plans of treatment for years, and have injected iodoform and obtained most magnificent results at once. I believe there is
no better proof of the character of the pudding than the eating thereof. While I continue to have this success with iodoform I do not feel like giving it up.
REMARKS ON TRAUMATIC NEUROSES RESULTING FROM RAILROAD AND OTHER ACCIDENTS.*
BY JOHN PUNTON, M. D., NEUROLOGIST TO THE MISSOURI PACIFIC RAILWAY, ETC., KANSAS CITY, Mo.
In perusing the published transactions of this organization, I find that the subject of "Traumatic Neuroses" has already occupied so much of its valuable time that I hesitate to further tax your interest and patience in its behalf. Nevertheless, various views and opinions are constantly being presented for our approval to account for the intricate and varied phenomena associated with such obscure neurotic lesions, which have both a general as well as a special significance, as they appeal not only to the knowledge and judgment of the neurologist, but also to every medical practitioner. This fact, taken in connection with the extreme importance of the subject to all parties concerned, is my only excuse for provoking its further discussion.
In this age of rapid advance and enterprise in all departments of learning, the desire to introduce novel and original ideas in regard to disease and other kindred phenomena has become so very prevalent and contagious that there is a strong tendency in our day to entirely ignore the more settled facts of medicine by this modern illogical yearning for something novel, even if it be ever so far-fetched and radical, besides abstract and equally unreliable. In view of this, is it any wonder that I hesitate to call your attention to a theme, which, above all others in medicine, affords a greater opportunity for speculation and conjecture on the one hand, and exaggeration and pretense on the other? The physician who attempts to write, or read, a paper on such a topic, without being able to advance something new and original, is liable to be branded as an out-of-date, non-progressive practitioner, and, at best, an old fogy; and yet, after all, gentlemen, what can be said of traumatic neuroses
*Read by title at the ninth annual meeting of the National Association of Railway Surgeons, at St. Louis, Mo., April 30, 1896.
that is really new and original, at the same time practically beneficial, since the able presentation and discussion of this all-important subject by the different members of this society at its sixth annual convention, held at Omaha in 1893, together with the different views and opinions it has since called forth?
It seems to me that amid the erroneous and jarring opinions thus expressed, that many of the more important features pertaining to the subject are liable to be entirely ignored, and not given the attention they richly deserve, thus depriving many doubtful cases of their special significance and value. It will, therefore, be my aim to emphasize some of these, with a degree of partiality becoming their fitness as they appear to me, in the hope that if I err in my judgment I may be corrected.
In studying the history of trauma as a causative factor of nervous affections, I am led to believe that prior to the inauguration of this association, little was known in America concerning its subtle and pernicious influence on the animal economy, and much of the practical, tangible, scientific knowledge in regard to it, that we as a profession to-day possess, is largely the result of the combined labor and effort of the individuals comprising the membership of this very worthy institution we represent. In thus claiming for this association the credit it richly deserves in this department of medicine, I do so with becoming pride, in spite of the fact that to-day the necessity of our existence is being questioned, and we are openly accused of devoting our annual gatherings to purely social enjoyment, and that our meetings are wholly devoid of any scientific significance or value whatever, and, consequently, not worth so much as the consideration of a pass from the hands of the general managers of the different railways represented in the organization.
Without attempting to go into detail, however, a critical review of the history of my subject teaches me, that prior to Oppenheim's famous monograph, published in 1889, our knowledge of the subject was largely borrowed from our European colleagues, which, unfortunately, all admit, were largely based upon a very imperfect nervous pathology, and consequent faulty methods of classification, diagnosis and prognosis. A long-continued series of mistakes in diagnosis and prognosis by physicians on one hand, which was made the more