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evident by subsequent events and similar alleged wrongs based on these by railroad corporations on the other, rendered it clear to all that radical reforms were sadly needed, both in our medical methods of examination, and the legal adjustnfent of claims of persons suffering from nervous affections due to traumatisms.
Recognizing, therefore, the great diversity of opinion, as well as the evils arising from unjust and unsatisfactory methods employed in determining the full significance of trauma to the nervous system, this society was soon led to devote special attention to its unbiased consideration in the hope of improving and increasing our knowledge of the subject. Without any desire to unduly boast or flatter, I can only say that no one can study, thoughtfully, the published results of the work accomplished, more especially by Dr. Manley of New York, and, I might add, Dr. Levings on "Regeneration of Nerves," and many other members of this organization, without being convinced and satisfied that they not only contain valuable additions to our former knowledge, but also reveal skill and ability of research of undoubted merit, beside honest efforts to mete out unbiased justice to all parties concerned, thus establishing a more just system of scientific medical principles as a guide to the proper examination, care and management of such individuals. Moreover, by far the best, most complete and most unbiased work on the subject that has thus far been furnished the American medical profession, was written by our own Dr. Outten, and published in the second volume of Witthaus & Beckers' "Medical Jurisprudence." When these more perfect methods and principles, based as they are, on a more correct and rational knowledge of cerebro-spinal architecture, are duly compared with our former imperfect and faulty ones, and then again, applied clinically to the study of trauma and its effects on the nervous system, the valuable scientific work of this society, together with all its practical beneficial results, are readily seen, and at once prove the justness of my claim.
The great problem which has been the source of so much controversy and which defied solution by all former methods, was in determining the actual amount of damage done to the nervous system by traumatisms. On
this hinged, also, the equally knotty question of permanency, nor is this strange when we remember, that just in proportion to our knowledge of the anatomy and physiology of a part does our knowledge of the symptomatology of its diseases advance. Not then, until we are in full possession of all the facts connected with structure and function can we ever be certain of the truth. The great aim, however, of all scientific investigation is to bring symptoms into connection with lesions, and this has been done to a remarkable degree of late in the study of the nervous system, chiefly along the lines of anatomy and physiology, with the aid of the microscope. Hence, it is not surprising that up till within quite a recent period, faulty methods of examination, classification and diagnosis obtained, and that the true effect of trauma was largely misunderstood. But today an ever increasing knowledge of the histological data of the nervous system at our command, as well as more complete and perfected means and methods by which to gain a thorough mastery of the questions at issue, greatly reduces our former formidable task, and in the vast majority of instances can be made to yield to the skill of modern medical science. Indeed, so remarkable has been the change in dealing with such cases that within the past decade a complete revolution has taken place in our nomenclature, classification, diagnosis, prognosis and treatment, the combined results of which has not only furnished us the means of detecting and defeating the most perfect fraudulent schemes, but at the same time offered just protection to the great railroad, and other similar interests involved, thereby demonstrating the remarkable efficacy of modern medical science.
One of the greatest stumbling blocks to all true medical progress is the misapprehension on the one hand and gross ignorance on the other, of the full interpretation and significance of medical technical terms. The tendency of modern science is to limit and restrict terms within specified boundaries, and failure to observe this great scientific principle has led to much useless and unnecessary argument. It also, unfortunately, brings with it reproach and condemnation undeservedly on the science of medicine from the laity, and they love to gloat over the apparent failures, and speak sneeringly of honest differences of opinion, and what
they please to call the inexactness of our science. Now much of this is due to our own ignorance, and we, ourselves, are chiefly to blame and not the science of medicine. While it is true that medicine is not an exact science, yet we are rapidly advancing, and much of our former inexactness is yielding to the mighty forces of modern medical progress.
In all ages, however, it has been found both useful and convenient to use certain terms to screen our ignorance of pathology, but just in proportion as our science advances these gradually lose their former significance, and eventually become wholly obsolete. Hence, to-day much depends upon the manner in which we use terms, as this largely expresses our own knowledge of medicine, and is itself often an open confession of our medical weakFor instance, the termns "organic" and "functional" both have a wide range of application, but the latter is rapidly becoming more and more restricted; hence, in speaking of certain diseases, much depends upon which of these terms we use, as formerly many morbid states were recognized as functional in character, which later investigations proved to be of organic origin.
That a line of demarcation be made, how ever, between these terms when applied to disease, is at present a recognized necessity, I think all will agree, notwithstanding the fact "that the notion of functional diseases, as distinct from organic, that is of disease due to no structural change in the diseased organ, is fast becoming obsolete." In no department of medicine is the application of the preceding propositions more important, and perhaps more difficult to apply, than the one to which my theme refers. We must ever bear in mind, however, that with increased facilities for investigation, and consequent improved methods of study, our powers of discrimination of diseased conditions has been greatly enlarged, which again has led to a more perfect system of classification, at the same time rendering a complete revolution in nomenclature a necessity. Moreover, increased knowledge of pathology has furnished us the key for more successful methods of treatment, thereby changing entirely the whole aspect of prognosis in these particular cases. Failure to recognize or keep in touch with the true import of all the evidences of modern medical progress is, in my judg
ment, largely the responsible agent for much of the reproach and censure on the one hand and useless controversy on the other, which unfortunately too often characterizes the medical profession. As a pertinent example of this, where can be found in the voluminous annals of medical literature a more conspicuous series of conflicting theories and erroneous opinions than those advanced by the different writers in explanation of the term spinal concussion? Some go so far as to claim there is no such thing, and that by virtue of its bony and muscular protection, concussion of the spine is an absolute impossibility. Others, again, would seem to include under the term almost every lesion of the spinal column which results from a traumatism. Now, neither of these extreme views is correct, and the time is certainly at hand when we, as a profession, should come to some definite understanding, based upon reliable scientific modern medical progress, as to the true interpretation and significance of the term; and this brings me to the very climax of my theme.
In reviewing the history of its creation, we learn that in 1866 Dr. Erichsen of London was the first to direct the attention of the scientific world to this subject by the publication of six lectures on certain obscure injuries of the nervous system, commonly met with as a result of a shock to the body received in collisions on railways. In 1875 he revised and enlarged his work, claiming that the resulting symptoms were due to concussion of the spine, and considered that the shock of the injury caused molecular changes in the cord, which ultimately led to chronic spinal cerebral meningitis, or that the shock caused anæmia or hyperæmia of the cord.
You will observe by this that fully twenty years have now elapsed since his work appeared, and as it was written at a time when nervous pathology had made but little progress, and long before hysteria and neurasthenia were fully recognized, we can readily understand why Erichsen embraced so many distinct morbid entities under the term spinal concussion. During the past twenty years, however, marvelous developments have taken place in medical science, and this morbid syndrome of Erichsen has been at different periods subjected to severe criticism and critical analysis, which has re
sulted in the manufacture of other terms which have been offered us as a substitute, such as railway spine, railway brain, cerebro-spinal concussion, traumatic neurosis, traumatic hysteria, traumatic neurasthenia, etc., all of which are intended to account for the varied phenomena resulting from trauma and its effects on the nervous system. Without going into detail, it can be said that the great aim of scientific research has been to differentiate organic from functional conditions, and thus place the whole subject on a more scientific and substantial basis. Hence, we find Hodges, Page, Putnam, Walton, Charcot, Thomsen, Oppenheim, Strumpell and many others, each in his turn, contributing his share in the great work of enlarging and improving our knowledge by adding to it from time to time the newer and more complete results of advanced modern neuropathology.
During the process of evolution many terms have lost their former significance by having their use restricted, while others have gradually appeared and become quite prominent, hence, the whole subject, since Erichsen first called attention to it, has undergone a complete revolution. For instance, the term "spinal concussion" has been deprived of its former wide application, and its use is now, according to Outten (and with him we can all agree), "Strictly limited to those cases in which undoubted symptoms, indicative of derangement of the functions of the spinal cord were directly due to shock communicated to the cord as the result of external violence, and in which there is no obvious, naked-eye lesion in the bones, membranes or cord itself to account for the condition."
Oppenheim prefers to describe the varied nervous affections which result from trauma under the general term "traumatic neuroses," but the tendency of the present time is to differentiate the various traumatic nervous affections rather than to group them under one general heading. There can rarely be much difference of opinion, however, among educated and honestly-inclined physicians and surgeons concerning organic disease when plainly evident traumatisms and lesions present themselves, but it is in the field of functional affections, where purely subjective phenomena rules, and where the changes are not visible, that the chief source of danger lies in
making mistakes. But even here, modern science comes to our rescue and greatly assists us in adjusting our former imperfections. While it is true that at times the effects of trauma may be responsible for nearly all the varied forms of organic and functional nervous disease, yet, experience warrants the assertion that the greatest difficulty is met with in functional realms rather than organic. Modern research also teaches us that the most important of these functional affections, due to traumatism, can be limited to three conditions, viz., first, traumatic lumbago; second, traumatic hysteria; third, traumatic neurasthenia. These, then, are the affections which of all others test the skill and knowledge of both the physician and surgeon, and are undoubtedly the responsible agents for more petty disputes and professional misunderstandings on the one hand, and fraud and deception on the other, than all other problems in medical science; indeed, this trio. embrace the most vital medical puzzle of the age, and millions of dollars are at their mercy annually. Nor is this strange when we remember that in their study we are challenging the very highest department of medicine by virtue of all parts of the intricate and complex mechanism of the nervous system being represented in their manifestation, hence, their clinical phenomena are as varied as human nature itself, presenting a wide range of purely subjectve phenomena, which at the present time are well nigh unfathomable.
In the past there has been a disposition on the part of surgeons to ignore the purely neurological aspect of many cases, believing that the science of surgery was all-sufficient and competent of itself to master the many problems presented, but the profession has yet a very important lesson to learn when it refuses to yield to neurology that particular right which justly belongs to it, for surgery is not the equivalent of neurology, or vice versa.
What we need to-day, however, is broadminded, educated physicians and surgeons, who, in the face of unknown problems, have the courage of their convictions and are willing to employ or call to their assistance any of the recognized scientific aids in solving such difficult problems. Those of you who have had much experience in our courts of law, recognize the force of such a truth after listening to the medical testimony. Time will not permit
my enlarging upon either of the conditions referred to, only in a fragmentary way, but there are a few features I desire to emphasize before concluding. Following traumatisms, a variable time elapses, as a rule, before symptoms are made manifest. The initiatory symptoms, however, may come on immediately, or after a few hours, days or weeks, and occasionally it may even take months for them to develop. One of the commonest conditions which often complicate many of these nervous affections is "traumatic lumbago," or strain of the muscles of the back. Its striking feature pain in the back, which is moderate severity, and seldom becomes sharp while the patient is at rest, but any attempt at movement increases it; hence, a peculiar attitude is assumed by the patient to avoid any jar, bend or twist of the spine. Another common effect of injury to the nervous system, either by physical force or psychical influence, is the production of a state of nervous weakness or nervous exhaustion, known teacnically as traumatic neurasthenia. The essential elements of this form of neurasthenia are the same as those of other forms. It is the first manifestation, however, of disintegration of the nervous system from any cause, and as Dejerine has shown, it may arise in the healthy organism and form the foundation upon which more profound degeneration may develop, either in the individual or his descendants.
"The weakened nervous system usually shows no definite loss of function, but it incapable of persistent and prolonged effort." "With more profound disintergrating causes," says Dercum, "or with causes acting on a weaker organism, there may develop an affection which betokens more pronounced disintegration of the nervous system, and which presents more marked symptoms of deficit, with absolute loss of function, instead of impairment, namely, hysteria."
These two affections then are very closely allied and represent a difference of degree, rather than of kind, as the symptoms of one shade imperceptibly into the other, so that often it is difficult to fix a boundary line between them. While they may be distinct, at times, they are more often combined. For many years attempts have been made to refer both affections to alterations in the blood supply of the affected parts, or to vaso-motor distur
bances. This vaso-motor theory, however, while not altogether improbable has little positive evidence as yet in its favor.
In an elaborate study of the changes due to functional nerve cell activity, Hodges has found that "in normal fatigue the nuclei decrease in size, assume a jagged, irregular outline and have several other changes." He also .asserts that normal fatigue has a close kinship to neurasthenia; hence, in so-called functional affections we may have at first cellular changes, which may give rise to degenerative and other changes, which so far has baffled the best efforts of the investigator to demonstrate.
In regard to diagnosis our ability is in proportion to our knowledge of the nervous system and its diseases due to other causes than trauma, and in many cases it is necessary to keep a patient under close observation for a variable length of time before venturing an opinion. In every case it is necessary to eliminate the possibility of organic changes. This can be done by reference to the symptoms, and this again refers to the character of the cause, seat, mode of onset of symptoms, and other facts in connection with the clinical history of the case.
The chief symptoms of traumatic neurasthenia, however, are headache, mental depression, neuralgic pains, especially in the back, insomnia, muscular weakness, vaso-motor disturbances, changes in the reflexes, disturbances of the special senses, particularly of vision, digestive disturbances, vertigo, etc., etc.
In hysteria all these are even more pronounced, and are accompanied with characteristic stigmata, anæsthesia, contracted visual fields, spasm or convulsions, tremor and, indeed, many other features too numerous to mention.
The symptoms of all these morbid states, however, can be conveniently classified under seven heads, viz.:
1. Defects of motion, including all degrees of paralysis.
2. Defects of sensation, including the special senses.
3. Defects of reflex action.
4. Defects of nutrition, including trophic and vaso-motor changes.
5. Defects of secretion, including changes in glandular organs.
6. Defects of psychical and mental appa
7. Defects of the visceral or internal organs. A knowledge of the complex mechanisms, governing each of these great functions of the nervous system are absolutely essential for all true success in diagnosis.
We must ever bear in mind, however, the possibility of simulation, but with this knowledge well in hand, and being well grounded in the principles of diagnosis, the possibility of such an error is almost out of the question.
Every case demands systematic and thorough treatment from the beginning. I am led to believe, both from observation and experience, that the profession has yet valuable lessons to learn as to the value and efficacy of isolation as a therapeutic measure. This, again, implies rest, which is also one of the first indications to be met in the treatment..
We are all too prone to lean on drugs, and think lightly of the consequence of frequent examinations, and the susceptibility of such patients to suggestion, of the absence of certain symptoms, all of which greatly tend to injure the patient's chance of recovery.
Time forbids further enlargement, and no one is more conscious of the imperfections of this paper than I to call your serious attention to a subject which of all others in medicine demands our best united efforts, yet, in its preparation I have consulted the recognized modern authorities and quoted freely from the able articles of Dercum and Outten, besides other equally competent writers, in the hope of eliciting its further interest and study.
Dr. J. McF. Gaston, Professor of Surgery in the Southern Medical College of Atlanta, in an article with the above title, in Gaillard's Medical Journal, draws these conclusions: (1) That various agencies are always at work in rendering the human organism to a greater or less extent free from the injurious impressions of surgical procedure. (2) That local and constitutional influences operate in conferring immunity, and the environments of individuals, with their habits and customs of the life exert great control over the vital powers. (3) Certain marked changes in the conditions of the nervous system, constituting shock, in course of surgical operations, may be averted by proper measures in advance, and in default of
such precautions should be corrected by vigorous means of treatment. (4) That the immunity for normal structures in operative work, which was supposed to be given by germicidal solutions, has proved to be a delusion and a snare, and that they are only admissible in septic contamination of the tissues. (5) That a preliminary examination of all the functions of vital organs should precede surgical operations of every kind, and that efficient correctives should be resorted to for their derangements. The issue of the case depends upon proper means of preparation for an operation. (6) It is not essential for the management of a surgical case that the patient be placed in a hospital, but cleanliness in private quarters, with proper nursing, may secure entirely satisfactory results, by conforming to the ordinary surroundings of the patient. (7) A thorough comprehension of the reciprocal relations of immunity and susceptibility should lead to the adoption of conservative measures in the practice of general surgery, and the use of the most radical and aggressive measures, when indicated by the nature of the case. (8) Those appliances which may promote surgical immunization should be adopted, and those means which lessen susceptibility and predisposition to infection are warranted in all cases of surgical interference.
Late Suture of Divided Tendons; Restoration of
At a recent meeting of the New York Surgical Society Dr. R. H. M. Dawbarn presented a man, twenty-six years of age, who, about ten weeks before he saw him last fall, had sustained an injury of the left hand, resulting in complete division of the flexors of the index and middle fingers at the palmar junction. He had no power of flexion of the phalanges supplied by the long flexor tendons. Dr. Dawbarn made an incision, and had no trouble in finding the distal portion of the tendons, but had to go up nearly to the anterior carpal ligament to find the proximal portions. By strong traction he was able to approximate the two ends to within an inch and three-quarters of each other. Each tendon was united by four distance-sutures of silk-worm gut, which spanned the space of an inch and three-quarters. The hand was kept flexed about five weeks. The result had been excellent, the man had probably as strong a flexor power in those fingers as in the others, and evidently new tendon had formed among the sutures. He could not fully extend the two fingers, but ability to do so would probably come with use. Perhaps it would have been better not to have kept the hand flexed so long, but as he was a laboring man Dr. Dawbarn had chosen the safer side.-Annals of Surgery.