Officers of the N. A. R. S., 1896-7.

President..

F. J. LUTZ, St. Louis, Mo. First Vice-President. W. R. HAMILTON, Pittsburgh, Pa. Second Vice President. J. H. LETCHER. Henderson, Ky. Third Vice-President.... ..JOHN L. EDDY, Olean, N. Y. Fourth Vice-President....J. A. HUTCHINSON, Montreal, Canada Fifth Vice-President...... A. C. WEDGE, Albert Lea, Minn. Sixth Vice-President...... RHETT GOODE, Mobile, Ala. Seventh Vice-President... E. W. LEE, Omaha, Neb. Secretary. .C. D. WESCOTT, Chicago, Ill. Treasurer. ..E. R. LEWIS, Kansas City, Mo. Executive Committee:-A. I. BOUFFLEUR, Chicago, Ill., Chair

It is plain to the student of neurology that many of the views concerning neuroses following traumatism have not by any means been thoroughly elucidated. In a discussion upon this subject on February 11 last, at the New York Academy of Medicine, a paper was read by Dr. Philip Coombs Knapp of Boston, and discussed by such shining lights in the profession as Drs. Charles L. D. and Bernard Sachs, M. Allen Starr, Frederick Peterson, J. Arthur Booth and Pearce Bailey. The subject of the paper was "Traumatic Neurasthenia and Hysteria." Dr. Knapp, according to a report in the Medical Record, "limited his paper to two of the commoner and more definite

types of nervous trouble of apparently functional nature following traumatism, but in considering only traumatic neurasthenia and hysteria he did not mean to imply that other neuroses could not have such an origin." The re

court.

The paper was based on an analysis of two hundred cases of traumatic neurasthenia and hysteria in the hospitals of Boston. Of these, one hundred and three were not, so far as he knew, subjects of litigation. Of the other ninety-seven, most of them were sent him for the purpose of getting his opinion for use in He had rarely been consulted in any litigation cases for injury involving one or more peripheral nerves, and seldom for injury pointing definitely to spinal disease. The explanation was hard to make, for cases of spinal injury and injury of peripheral nerves were not infrequent in hospitals. Possibly in litigation, cases of this class the symptoms were so definite that they were settled in or out of court without consulting specialists. The author differed from Strümpell, who claimed that the genesis of most of the trouble in the litigation cases was psychical, the questions which constantly worried the patient's mind being: "Shall I get damages? How much shall I get? Shall I be able to work afterward?" Notwithstanding the malevolent psychical influences attending these cases-the desire for gain, the desire for putting the best foot forward, the gloomy prognostications heard on the witness stand-he could not accept Strümpell's view for reasons, some of which follow: 1. Under conditions precisely similar one saw the symptoms of traumatic hysteria or traumatic neurasthenia in non-litigation cases, in which the factors referred to were absent. 2. The symptoms developed almost immediately after the accident in many litigation cases, before these factors could have acted. No doubt, however, factors connected with litigation aggravated the symptoms somewhat. Further, the relative frequency of the symptoms in the litigation and the nonlitigation cases was about the same. In other words, he could find no symptoms in the one class of cases not present in the other and which would warrant the term litigation hysteria or litigation neurasthenia. In many, but not all of the litigation cases, the patients had worried about the lawsuit, but in the nonlitigation cases the patients had also been disposed to worry, though about something else.

Dr. Knapp thought Strümpell had given insufficient weight to the physical influence, and too much to the psychical. He classified the two hundred cases according to the nature of the injury, the symptoms, etc. The injuries took place from railway accidents, getting on or off tramways, getting in or out of carriages,

etc. In but few instances were bones broken. On the whole, the circumstances attending the two classes of cases, litigation and non-litigation, did not differ greatly, and since the symptoms were very similar, the conclusion was drawn that the desire for gain in the one class played only an insignificant part in the genesis of the trouble.

The author stated that psychical shock alone might produce hysteria or neurasthenia, but it was more difficult to answer the question whether physical injury alone, unattended by psychical shock, could do so. His own belief was that psychical shock played a subordinate part, and that physical injury was the important cause. Neuropathogenic heredity, upon which the French laid stress, he had found of minor importance. He was able to obtain a neurotic history in eight cases of hysteria, in seven of neurasthenia, and in a few there was a history of previous ill health.

Dr. Knapp then spoke of the symptoms and said that traumatic hysteria and traumatic neurasthenia had many symptoms in common, the boundary line not being in all instances very clear. Among symptoms mentioned were inability to work, mentally or physically, headache, vertigo, pain in the back and limbs, paræsthesia, rapid pulse, loss of appetite, diminution of urine, exaggerated reflexes, congestions, coldness of extremities, etc. The differential points between neurasthenia and hysteria were mentioned, particularly those relating to contraction of the visual field, hemianæsthesia, or local anææsthesia, and disturbances of special senses of a nature usually regarded as diagnostic of hysteria. While attaching weight to these evidences of hysteria, the author did not regard them as always diagnostic. For instance, in four of the cases of neurasthenia there was contraction of the visual field, without other

stigmata of hysteria. But the majority of cases which presented cutaneous anæsthesia and contraction of the visual field were cases of hysteria.

Regarding the prognosis, there had been difficulty in following up cases to determine the ultimate result. In 28 cases of hysteria, 18 of them were litigation cases, IO non-litigation cases. In the former, I patient recovered completely, 5 patients improved considerably, 7 very little, 5 died. Of the 5 that died, I died of unknown cause, I had improved considerably but died of intercurrent pneumonia and delirium tremens, I steadily grew worse and died of a low form of pneumonia, 2 grew worse and died in exhaustion. It would seem from Dr. Knapp's observations that the remarkable recoveries which one heard of taking place as soon as damages were obtained did not appear. A number of cases had continued six to twelve years; they might

improve, but still present some distinct symptoms. There seemed to be no direct connection between the intensity of the hysteria and the gravity of the prognosis. The longer the hysteria lasted, the less likelihood of complete recovery. Some cases of neurasthenia progressed more favorably under treatment than hysteria, and, on the whole, he thought the prognosis was more favorable. But he had seen some cases of eight, twelve and even twenty years' duration.

The author then touched upon treatment. He thought some occupation was to be preferred to allowing these patients to brood over their troubles while doing nothing, yet judgment was required, lest they do too much or worry under the labor and anxiety of making a living. These people were apt to be looked upon as extortionists, but facts showed that the accusation was unjust. A considerable number of them never recovered their health, and the amount received in damages was, in the author's experience, inadequate, especially if the expenses of litigation were deducted. In thirty cases the average damages had been about $5,500; at least half was used in litigation, and very few cases came to trial before two years, some not for ten years. The law ought to be amended to hasten the court proceedings, as delay added to the gravity of the prognosis. It was best to urge prompt settlement out of court, whenever it could be done without too great sacrifice.

This is plainly at variance with all previous statements. When Dr. Knapp says that insufficient weight has been given to the physical influence and too much to the psychical, he states a point completely at variance with the experience of men who see railway accidents and traumatic surgery in all their phases. The writer for years has been in charge of one

institution under his immediate control, and of others in a supervisory way, wherein are treated from twenty-five hundred to thirty-five hundred accidents annually. These cases represent every phase of traumatism from minor cases to the most violent. Aside from this fact he has, personally, an accumulated record of over thirty thousand cases of railway traumatisms and he makes the assertion fearlessly that the occurrences of traumatic hysteria, neurasthenia, hypochondriasis, etc., in violent injuries, are mere coincidences. We do not believe that Dr. Knapp or any other neurologist can show in these cases anything more or less than a coincidence, not remarkably or wonderfully more frequent than the occurrence of phthisis in these cases. Certain

it is that no student of medicine would claim that traumatism was likely to be followed by such trouble. We maintain that no case of physical injury is at all likely to be followed by any of these neuroses, and that the great cause of their production is entirely psychical. We believe, too, neuropathogenic heredity is a far more potent cause than any enumerated.

For many years we have been an honest and eager student in this direction, and are prepared to state that there is no order or regularity of occurrence; it is as irregular in its manifestation as anything in medicine. To us it has ever seemed that the predetermined mental condition of the medical attendant and the ill advised and coercive relation of distressing circumstance have made more cases of traumatic neuroses than accident. To-day we believe that litigation has more elements of danger in it than accident. We heartily agree with Dr. M. Allen Starr, when he said that he was quite convinced that cases which developed traumatic neuroses were cases predisposed to neuroses before the injury, just as was the case in occupation neurosis. For over twenty years of practice in hospital work in connection with railway hospitals, treating annually from five hundred to three thousand cases, this has been our conclusion. We defy anyone who has honestly studied these cases, from their inception to their cure, to demonstrate anything more than coincidence, and the fact of predisposition. Dr. C. L. Dana said that ten years ago, perhaps five years ago, he would have agreed entirely with the conclusions of Dr. Knapp, but during the last few years the tide of litigation had risen and seemed more frequently to play an important part that the psychical effect of litigation injured the patient more than the original injury. Finally, we are perfectly convinced, and do not believe that anyone can show to the contrary, that these cases do not occur unless some previous predisposition exists. We have always maintained that early compromise is among the best therapeutic measures. We are thankful to Dr. Knapp for this paper, because he has stated a proposition which courts investigation, and which we believe that neither he nor anyone else can prove. God only knows how many ills predetermined mentality and suggestion have created in patients, helped by physicians. Certain it is

that predetermined mentality and suggestion have made many cases of traumatic neuroses.

THE COMING CONVENTION.

The committees having in charge the preparations for the annual convention in Chicago are actively at work, and everything points to an eminently successful meeting. The sessions will be held in the convention hall in the Medinah Temple, which is admirably adapted for the purpose and where, in close proximity to the hall proper, there is ample space available for the display of exhibits and for the treasurer's office. The following papers have already been arranged for:

Dr. John Punton, Kansas City, Mo., "The Treatment of Functional Nervous Affections Due to Trauma.”

Dr. Frank H. Caldwell, Waycross, Ga., "Relief and Hospital Departments." Discussion to be opend by Drs. Outten and Chaffee.

Dr. H. L. Getz, Marshalltown, Ia., title not announced.

Dr. Solon Marks, Milwaukee, Wis., title not announced.

Dr. W. T. Searles, Sparta, Wis., "Traumatic Infections and Their Treatment." Discussion to be opened by Drs. Bouffleur and Hoyt.

Dr. Jabez N. Jackson, Kansas City, Mo., title not announced.

Dr. G. P. Conn, Concord, N. H., “Relation of Railway Companies to State Boards of Health."

Dr. C. W. Tangeman, Cincinnati, O., "An Exhibition of the Various Devices for the Determination of the Color Sense of Railway Employes."

Dr. A. L. Clark, Elgin, Ill., "A Case in Practice."

Dr. A. C. McClanahan, Red Lodge, Mont., "Plaster of Paris and the Difficulty of Applying it to Recent Fractures."

Dr. W. R. Hamilton, Pittsburg, Pa., title not announced.

Dr. Thomas H. Briggs, Battle Creek, Mich., "Problems."

Dr. A. C. Wedge, Albert Lea, Minn., title not announced.

Dr. Rhett Goode, Mobile, Ala., “A Case of Osteo-Sarcoma from Railway Injury."

Dr. E. W. Lee, Omaha, Neb., "The Treatment of Burns."

Dr. A. I. Bouffleur, Chicago, Ill., title not announced.

Dr. W. A. McCandless, St. Louis, Mo., "Brain Abscess."

Dr. T. O. Summers, St. Louis, Mo., "Shock in its Relation to Permanent Injury." Discussion to be opened by Drs. Goode and Davis.

St. Louis, Mo., March 13, 1897. Dear Sir: The annual convention of the National Association of Railway Surgeons will be held in Chicago on May 4-6, 1897. It is not necessary to tell you now what the Association is or how it is striving to make its work of value to railway companies. It is hoped that you will continue to extend to the members of the association the same courtesies as you have extended in former years, viz.:

1. To issue transportation over your own lines to such of your surgeons as may wish to attend the convention.

2. To request transportation for them, as may be necessary, over connecting lines to and from Chicago.

3. To honor such requests made to you by

the proper officers of other lines in behalf of their surgeons.

As in former years it is not expected that you will issue transportation for members of the surgeons' families, or for any other parties than the surgeons themselves.

Trusting that you will accede to this request and will so inform the undersigned, I am yours very truly,

W. B. OUTTEN. At this writing (March 20, 1897) responses have been received from thirty companies, all without exception expressing the cordial will. ingness of the management to comply with the requests.

A novel feature of the convention this year will be a "Daily Railway Surgeon"-an edition of the official journal which will be issued. every morning, giving a full report of the previous day's proceedings and other matters in relation to the convention. It will be a novelty which will be of great value and assistance to the convention.

SIR JOHN ERICHSEN.

A lecture delivered at University College Hospital, London.

BY CHRISTOPHER HEATH, F. R. C. S. Holine Professor of Clinical Surgery, University College.

Gentlemen:-I could not begin the work of the session to-day without making some allusion to the loss we have all sustained in the death of the President of University College and my immediate predecessor in this chair. I think it will be best to give you a short sketch of this hospital and its connection with Sir John Erichsen. Being here as a student in 1896, you are not likely to know what happened sixty years ago, and it will be interesting for you to learn something of the previous history of this institution.

UNIVERSITY COLLEGE AND THE HOSPITA!.

Let me remind you first that University College was originally called the London University. That institution was the outcome of the superabundant activity of the late Lord Brougham. It was proposed at first to teach everything there, but in 1828, when it was opened as a teaching institution, arts and laws formed one department at one end and medicine another department at the other end of the building; for in those days there was merely one straight block of buildings without any wings. The science of medicine was taught in a way in which it never had been taught before in any London school, by the professors who then

held the several chairs in what in a few years later became University College; but a difficulty arose in regard to the practical teaching of medicine and surgery, which could not be carried out without beds and a hospital. It was at first proposed that Middlesex Hospital should be the teaching place for the practical work, and accordingly Sir Charles Bell, who was one of the surgeons at Middlesex Hospital, was made professor of surgery here, and Dr. (afterwards Sir Thomas) Watson was the first professor of clinical medicine. That arrangement worked for a year or two, but it was soon found necessary that there should be a separate hospital, and accordingly this building was erected on a piece of ground which fortunately had been secured at the time the college was built, and in the year 1836 this hospital was opened. You can judge very well what it was like then, for it is not much changed. This theatre, for instance, is exactly the same as it was then, and it was here that Robert Liston, one of the first surgeons of the hospital, did all his great operations. The professor of surgery who succeeded Sir Charles Bell was Mr. Samuel Cooper, and I may here say that this surgeon must not be confused with Astley Cooper, or Bransby Cooper, who were both surgeons of Guy's Hospital. Mr. Samuel Cooper was an old army surgeon who had seen much service in the Peninsula, and who after the war had become attached to a private medical school, as was the custom in those days. In this hospital he was appointed one of the surgeons, and communications were opened with Robert Liston of Edinburgh, who had made a reputation there as an anatomical teacher and surgeon, and who, though he was surgeon to the infirmary, had not been appointed professor of clinical surgery, Syme holding that position. Liston gladly accepted the offer to come to London, and became the first professor of clinical surgery here, and also one of the surgeons of the hospital. Thus on opening, the surgeons were Cooper and Liston, and Richard Quain was the assistant-surgeon.

LISTON.

Liston soon made his mark here, and if you look back at the contemporary press of that day you will see that his operations attracted large classes and many visitors, and he, in fact, inaugurated a new phase, so to speak, of operative surgery. I believe that up to that time many of the operations which he did had never been performed in London, and he particularly distinguished himself by his operations on large tumors which had been allowed to develop, partly by the neglect of the patient and partly because surgeons of that day rather eschewed interference with them. Now, nothing was too large or too desperate for

Liston to undertake. He was over six feet in height, handsome, as you can see from the marble bust in our museum, with large powerful hands, which enabled him to undertake and to perform the very largest operations with rapidity and skill. Let me remind you that this was in the days before anæsthetics, and therefore rapidity was of considerable importance. It is said of Liston that in amputating a thigh, such was the rapidity of his manipulation of the knife and saw that it almost seemed like a flash of lightning. We do not pride ourselves nowadays on our speed; with anæsthesia the patient is insensible and the surgeon can take his time; whether this occasionally leads to over-deliberation and perhaps waste of time, and exposure of the patient to too much anæsthetic, is another. matter. At all events, this hospital started as regards surgery under good auspices, and there was a large class of students who "walked the hospital," as it was then termed, and did not do much else. They followed Liston around, and if he did not teach very much they looked at his cases, and with the few crumbs of knowledge thus procured they and the examiners of that day were satisfied.

SYME.

The hospital continued in this way till 1847, and then unfortunately Liston died quite suddenly from aneurysm of the aorta. Cooper had got somewhat past his work when Liston died, and there was of course the difficulty of filling his place. Mr. Quain was then assistant-surgeon, and so also was Thomas Morton, who had married the daughter of Samuel Cooper. But the Council thought that it would not be wise to promote either of these gentlemen, and they therefore applied to Edinburgh for another surgeon, and James Syme, the eminent surgeon of Edinburgh, was persuaded with some difficulty to abandon that city and come to London. This surgeon began his work here on February 14, 1848. Liston having died in November, 1847, and he was received with somewhat mixed feelings. On the one hand, there was a good deal of feeling against him because it was thought that Quain and Morton had not been fairly treated. On the other hand, there was much enthusiasm on his account because of his reputation, and he himself in his written statements, which I have lately looked up, makes no complaint whatever of his reception here. But he found on the whole that the place was not an easy one to fill, and he was here for only three months, for in May, 1848, he sent in his resignation and returned to Edinburgh. Fortunately the chair which he had vacated there had not been filled up, and he therefore dropped into his old position, and there he remained distinguished and beloved till he retired from that position because of age.