been injured by slipping on a banana peel on a West End Street Railway Company's car in Boston. Complained of symptoms of paralysis of motion and sensation from waist down. and that she was unable to control her bladder and rectum. Scrapes along the spine. Received $325 or $425. II. June 6, 1894. Claim on N. Y., N. H. & H. R. R. Co. at Boston. This case was an exact reproduction of the preceding, even to the claimant's maintaining that it was "her first accident." But she was unfortunate in being visited by the same physician who had seen her a month previously for the West End Street Railway Company. The physician this time recognized the fraud, which he had failed to do before. III. December 24, 1894. Fannie Freeman made claim. through her mother, on the Chicago, Rock Island & Pacific Railway Company, for injuries received by falling on her back in one of the company's cars. She alleged entire inability to move the legs and entire loss of sensation. There were so many suspicious circumstances about the case that the family was watched and the alleged cripple was seen to walk perfectly well. At the time of her examination "an unexpected test of raising the foot in the air, caused it (contrary to all custom in well regulated paralyzed legs) to stop there, though tests of physical force were applied and successfully withstood." It is not probable that such absolute frauds as these are of frequent occurrence. In the larger number of cases the claimant has received some injury, although he may very much exaggerate its importance. Whoever tries to counterfeit a symptom which has absolutely no foundation in fact is surrounded by many difficulties. Objective nervous symptoms are particularly difficult of voluntary creation. He is the clever simulator who limits himself to assertions of pain in the back, headache, inability to keep his attention on his work and similar indefinite evidences of nervous disorder. Such complaints as these may not reveal themselves by any signs accessible to the examiner; whether they are true or false may be a matter difficult to determine without information from outside sources. But when a claimant undertakes to sham paralysis, or loss of sensation or inability to control the bladder or rectum the case is different. Such symp toms as these are indicative of profound disturbance of nervous function, and to feign them well the simulator must not only be familiar with general medicine, but must also have devoted some little attention to the study of the diseases of the nervous system. And even if a claimant had an intimate familiarity with the symptoms of nervous disease, I very much doubt if he could even then imitate them with sufficient cleverness to deceive a painstaking and skillful physician. Serious injuries to the nervous system which occur as a result of accident are manifested by definite groups of symptoms. Traumatic paraplegia is almost invariably associated with loss of sensation in the legs. Anæsthesia, as a symptom of organic lesion, is usually accompanied with paralysis and other associated symptoms. Loss of control of the sphincters is almost unexceptionally combined with paralysis of the legs. To successfully simulate any one of these symptoms implies that some of the others must be simulated also; and to simulate two different things at the same time necessitates a greater concentration of the attention than most people are capable of. Let us take an example: a man alleges to be paralyzed for motion and sensation, from the waist down, as a result of a fall on the back. Upon examination he is asked to move the legs and he declares he cannot do so. The legs are lifted up and fall heavily again to the bed. So far the evidences of motor paralysis may be fairly good. Sensation is then tested and the claimant gives no expressions of pain when pricked with a pin. The examiner then returns to try the motor power and while the patient says he is trying to lift the legs, the physician pricks him sharply with the pin. In this way the person under examination is taken off his guard. If the anæsthesia were feigned, the patient might be able to repress expressions of painful sensation when his attention was entirely devoted to that end, but when his attention is drawn to other things, as in keeping up the imposture of motor paralysis, some evidence of perception of painful irritation will usually escape him before he can sufficiently collect himself to control it. Feigned loss of muscular power may often be detected in similar ways. Fannie Freeman, when her leg was lifted up, forgot to let it fall, but held it in the air, thus furnishing a convincing proof of voluntary motor power. Disease changes in the reflexes cannot be conterfeited. If the bladder is paralyzed, the meatus urinarius will constantly be wet. For obvious reasons it is generally impracticable to examine the genito-urinary organs if the claimant is a woman. But if there is true incontinence of urine, there will certainly be a strong urinary smell about the bed and about the patient, The absence of this odor should excite suspicion in regard to any case in which urinary incontinence was alleged. Paralysis of the sphincter ani may easily be recognized by digital examination. In paralysis, the anal opening is large and the soft muscle does not contract around the finger of the examiner. These means for the detection of simulation are often unnecessary. The genuineness of any given case may usually be determined by a brief review of clinical possibilities. In ordinary injuries the lesion is either organic or functional. If organic, it is either peripheral or central. If peripheral, it rarely happens that all the nerves of an extremity are injured at one time and bilateral symmetrical nerve injuries almost never occur. If one or two nerves only are injured, the paralysis will be limited to the muscles supplied by them. Sensory disturbances are rarely prominent in injuries to peripheral nerves. If the case is of central organic character, whether cerebral or spinal, there will be considerable constitutional disturbance. Organic cerebral lesions are easy of recognition. In spinal lesions it is well to remember that the different segments of the spinal cord have fairly well recognized functions, by the loss of which spinal injury may be, not only recognized, but localized. The anesthesia which results from spinal lesions is usually very profound, and its distribution is entirely different from that caused by injury to the peripheral nerves or that observed in hysteria. Also, paralysis resulting from injury to the spinal cord is rapidly followed by atrophy, and the reaction of degeneration in the paralyzed muscles, and notable disturbances of trophic function of the skin. If the case is functional there are greater difficulties in determining just how far the symptoms are exaggerated or feigned. The two functional disorders which come most frequently to the physician's notice in accident cases are neurasthenia and hysteria, although there are a few rare forms of traumatic nervous disease which cannot satisfactorily be classed with either of these two conditions. Traumatic neurasthenia is the "Railway Spine" of Erichsen, and in it the integrity of nervous function is impaired. The condition of nervous exhaustion is unquestionably real, but because nearly all its symptoms are subjective, it is sometimes difficult to be certain (in a case in which there is a motive for simulation), whether the symptoms are entirely genuine or not. But even in most of the cases of traumatic neurasthenia the experienced physician can usually tell when the symptoms are entirely feigned, although it must be admitted that sometimes corroborative information from outside sources is necessary for a certain diagnosis. The other functional nervous disorder following accidents is hysteria. Hysteria is not, as many seem to think, a disordered mixture of deception and exaggeration, but is a well recognized disease, governed by definite laws. It is the most difficult disease of all to simulate, as its symptoms are so various. The visual disturbances, the paralysis and anæsthesia of hysteria are different from similar symptoms due to other causes, and the mental state in hysteria is characteristic. Traumatic hysteria is a comparatively rare affection in this country, but its existence should be remembered, in order that a patient suffering from it should not be catalogued as an impostor. 60 West Fiftieth street. VENESECTION; ITS THERAPEUTICAL VALUE IN DISEASE AND INJURY.* BY J. W. YOUNG, M. D., OF BLOOMFIELD, IA. Up to fifty years ago nearly all teachers of medicine and surgery held that blood-letting was a powerful agent in controlling inflammation and greatly assisted in prolonging life and relieving suffering. Indeed it was taught by most of the forefathers in the healing art that in all acute diseases and in the course of many of the chronic ones the abstraction of blood was the main thing to do when trying to cure or bring relief. If the physician did not do it *Read before the annual meeting of Wabash Railroad Surgeons at St. Louis, Mo., Nov. 5, 1896. himself he called a barber and instructed him to take so many ounces of blood, or till fainting occurred, and if the patient was not better the next day the performance was repeated. From the time of Hippocrates until the middle of this century our most learned and scholarly men wove theories in support of this wholesale loss of blood, and the patients, "Though they be kings or peasants," were satisfied their lives were prolonged and that they were cured of their maladies as well as that the pains of their diseases were relieved. The belief became so fixed in the minds of the people that many persons who made no pretense to medical knowledge purchased the old spring lancet and bled their neighbors when feeling indisposed to any extent, with a view of warding off impending disease. In my boyhood days, I ber that many old persons would call on one of these amateur bleeders every fall and spring to have the bad blood taken out of them, with a view of rendering their bodies less liable to disease. Before this era of blood-letting came to a close, Von Helmont was forced to exclaim that he believed "a bloody Moloch presided in all the chairs of medicine." remem Now all is changed! Most of our text-books. speak of bleeding as obsolete and as a mischievous and dangerous proceeding. A few only recommending this remedy in a very few conditions in disease, and write about it as though they were afraid of the ridicule of their fellows. I am of the opinion that bleeding is seldom necessary, but hold that there are a few conditions in which patients will do better, and their lives may be saved and prolonged by the abstraction of blood. I am also of the opinion that the old masters in our profession, certainly at times, did do good by blood-letting and could see the benefit derived therefrom in certain conditions, or else the people or the doctors would have called a halt long before they did; also if bleeding did cure and bring relief one hundred years ago, the same causes will bring the same results now under similar conditions. Nearly all writers of the present claim that we have a remedy to put into the body, either in the digestive canal, or in the tissues, or local applications to the surface, that will do as much. in abnormal conditions, and fully take the place of the "barbarous use of the lancet." While the above is true in general, yet the older mem bers of the profession who have used bloodletting in the treatment of disease will tell you that there are a few conditions found in a general practice in which the use of phlebotomy, cupping or leeching, seemed more satisfactory than any modern mode of treatment. If you ask me my reasons for the abstraction of blood in pathological conditions, I will say: First: It relieves the pressure of the blood in the capillary system in every tissue, including the brain, liver, spleen, kidneys, etc., in exact proportion to the amount taken. Second: The relief of pressure to a proper extent in the brain and nervous system causes, through the great sympathetic system, a softer and slower action of the heart, and a consequent reduction of temperature. Third: It removes from the blood a part of certain foreign matters, such as the materies morbi of rheumatism and uremia, ptomaines, and possibly microbes. Fourth: It promotes and stimulates absorption from the tissues by the lessened pressure from loss of blood, thereby relieving congestions, as seen in the relief of acute pleurisy, rheumatism, concussion of the brain, and in any condition where there is migration of the corpuscles and serum out of the vessels, into the tissues, after an injury. Fifth Certain individuals seem to have more blood than is necessary for their wellbeing, and it is a known fact that after a loss of a certain amount of this fluid in most systems there is increased activity in blood-making from fluids and foods, as well as from all tissues of the body, thus increasing vital action in every part. Sixth: There are many known conditions of the body in which the abstraction of blood will do positive injury, and should be considered bad practice In a general practice of twenty-five years I have used blood-letting to some extent, and so far I have never had cause to regret the loss of this vital fluid in any condition in which I have used the lancet. I now recall a number of eclamptic cases, in young, strong women, nearly all in first pregnancies; patients with short, thick necks, full blooded, with dropsical feet; and after the first convulsion I invariably took from the arm of the unconscious women from 16 to 30 ounces of blood. By this means I got rid of some of the uremic poison, and relieved the delicate structure of the brain of some pressure and congestion. I always found the next convulsion delayed and the condition is then more amenable to the usual and recognized treatment of the eclamptic state. In watching these cases to recovery or death, I am certain the abstraction of a proper amount of blood assisted materially in lessening the mortality of the 12 cases of this affliction which I have seen with but one death. Acute pleurisy, after exposure and fatigue in the strong and robust subject, is another condition in which I have often brought relief by abstraction of 30 ounces of blood. Often by the time I had bandaged the arm, after a full bleeding in an acute pleurisy, my patient would tell me he could breathe without pain, and in a day or two would be as well as usual. In certain cases of pleurisy, after effusion had taken place and fluid in the chest was plainly evident, by percussion and the hypodermic needle, a loss of a proper amount of blood, in connection with saline cathartics, has caused a rapid absorption of the fluid, and a normal condition of the chest has resulted in less than ten days. The philosophy of these results, by blood-letting in pleurisy, is simply relieving the blood pressure, thereby changing the exosmotic condition of the capillary system in the pleura to endosmotic; the current is changed from outward into the pleura to inward into the vessels. In sthenic pneumonia, in robust individuals, when the skin had the dusky, purple appearance, and breathing was labored, I have often taken 20 ounces of blood, and at once brought great relief, both to breathing and pain, and have always thought my cases ran through the regular stages in a milder manner, and the mor tality would be less. My conviction in regard to blood-letting is that too great a loss of blood in any self limited disease may do damage, and, in fact, in all selflimited zymotic diseases, great caution must be exercised in taking any amount of blood. Good blood is the food for all tissues. and when its nourishing property is destroyed to a certain extent, either by lack of assimilation of food, as seen in continued fever, or loss of blood by the lancet, death must take place. In congestive or hemorrhagic apoplexy I have often taken a moderate amount of blood from the arm and have never had cause to regret so doing. It seemed to put a stop to further hemorrhage and set up absorption of effusion or clot. In violent concussions of the brain, when the patient has a hot head, with muttering delirium or confusion of ideas, I have found a copious bleeding from the arm to materially assist nature in restoring order to the injured brain. I will say, in conclusion, great care and good judgment must be exercised in resorting to this remedy in disease or injury. A good rule to follow is to extract blood only from persons who seem to have abundance of this fluid, and in conditions where experience has taught us it will do more good than any other remedy at the time, believing that blood-letting acts mechanically in part, by relieving pressure in the capillaries, and thereby causing absorption of obnoxious material from the tissues. Resection of Nearly Eleven Feet of Small Intes tine in a Boy Eight Years Old. Dr. Ruggi has reported the case of a boy who was struck on the abdomen by the car of a large swing, and thrown into the water about forty feet distant. For two weeks he had some tenderness in the abdomen, but no other symptoms. He then showed signs of obstruction. The abdomen was opened, and a loop of intestines was found constricted by a band of omentum. He improved for a time, but signs of obstruction returned in more pronounced form, and the wound was reopened. The intestine was found stenosed at the point where the contricting band had been divided. This was freed, and for a time the boy again had relief, but complained, as he had before the first operation, most bitterly of hunger, crving night and day, in spite of the fact that large quantities of food were given, in addition to rectal feeding. Obstruction again returning, it was decided to again open the abdomen. A large mass of intestine was found adherent to the abdominal wall. On attempting to free this, it was dicovered that a large extent of bowel had been stripped of its mesentery. Dr. Ruggi determined to resect these portions and removed successively ten feet nine inches. The lowest incision was six inches from the ileocæcal valve. The ends were brought together by silk sutures. In a few days the boy was again crying for food. Gradually, however, the hunger lessened, and in five weeks he was discharged cured. At the time of report, fifteen months later, he was in perfect health.The Canadian Practitioner. President.. Officers of the N. A. R. S., 1896-7. First Vice-President.. Second Vice President. Third Vice-President. .F. J. LUTZ, St. Louis, Mo. W. R. HAMILTON, Pittsburgh, Pa. .J. H. LETCHER. Henderson, Ky. ..JOHN L. EDDY, Olean, N. Y. Fourth Vice-President....J. A. HUTCHINSON, Montreal, Canada Secretary..... man: J. N. JACKSON, Kansas City, Mo.; JAS. A. DUNCAN, Toledo, O.; J. B. MURPHY, Chicago, Ill.; S. S. THORNE, Toledo, O.; W. D. MIDDLETON, Davenport, Ia.; A. J. BARR, McKees Rocks, Pa. MUTIPLICITY OF MEDICAL ASSOCIATIONS. It is a rule in the business world that a great volume of trade or great profits in some particular line is a great incentive to competition. It matters not how necessary the business nor what sacrifice of time and means that the successful man has made to establish it, he is always liable to have one or several men step in to share the lucrative field with him. The situation is then one of the survival of the fittest, or, as is frequently the case, the failure of all, with the consequent destruction of what was a promising business. The present position of Medical Associations is quite analogous. Medicine is a great and growing science, and a vast army of men are devotees thereto. How natural that we should need medical societies and that men should meet each other and enjoy and profit by the interchange of social friendship and scientific thought. Likewise how natural that all societies and organizations which are capable of doing great good and wielding a mighty power in the community are often destroyed or rendered practically useless by needless and destructive duplication. The scope of the science and art of medicine has so broadened that specialties have been evolved; the whole field is too great to be grasped by single minds. With the development of specialties we find new medical societies organized, until we now have, in addition to the local, state and national medical associations, which pretend to embrace the whole scope of our professional work, similar classes of societies devoted to Surgery, Orthopedics, Gynecology, Ophthalmology, Dermatology, Laryngology, Electrology, Pædiatics, Neurology, Homeopathy, Eclecticism, Microscopy, etc., etc., including Railway Surgery. The literary productions of the medical world are, in fact, so great that even the great American Medical Association is conducted under the heads of various specialties. The great needs of the day are not more medical societies, but fewer and better ones; not more medical journals to spread the light of modern thought and practice, but fewer, cleaner and more select ones; not more medical papers for our medical societies, but more complete and original ones. Our attention is called to this subject by the excellent paper by Dr. J. W. Wright of Columbus, which appears in this issue. The paper unquestionably presents the unbiased views of an earnest man. We are willing to accept much of the doctor's statement but believe other points will bear further consideration. The statement, for instance, that "Any good surgeon is a good railway surgeon," cannot go unchallenged, but on the contrary we must insist that many good general surgeons are poor railway surgeons. It is true railway surgery is included in general surgerv, and in many particulars is identical with other traumatic surgery, but there is a vital difference: First, persons injured on railways put a pecuniary element into every injury, regardless of circumstances; secondly, the patient is placed in the care of the company surgeon; thirdly, the surgeon is selected by the |