If perform it at once, and not wait an hour. the surgeon is certain that this condition of the spine exists, he should not wait to apply a mechanical appliance, but should cut down and find out the actual condition. The history of laminectomy is, that it is a procedure which has been followed in a great many cases by absolute failure, so far as the permanent results are concerned. It is true that relief in some cases is temporarily afforded, but not in all. With reference to drainage of the spinal canal, I would hesitate before resorting to it, because I am convinced that there are conditions in which, by the application of any aseptic dressing, we are utterly unable to prevent the occurrence of septic trouble. In injuries of the spinal column where we have a partial dislocation-a sub-dislocation, if I may be permitted to style it-we rarely have any difficulty, and in all of the cases I have treated a well adapted plaster of Paris bandage, as advised by Sayre, has met the indication. I can show you case after case where there is some rigidity of the spinal column where the injury occurred, yet the patients are able to perform all of the functions of activity, minus those which require excessive bending of the spinal column. Dr. Hoy said that he did not believe a dislocation would occur without fracture. I am convinced that it can occur without fracture. If I have interpreted the conditions rightly, I have had at least two such cases. Finally, of all the grave surgical cases I have come in contact with in my practice, which require acute sense, good judgment, and an active, rapid and proper interpretation of the existing conditions, I have met with none that have perplexed me so much as those unfortunate accidents which occur in connection with the spinal column. Dr. J. A. Barr: Just a word in reference to the instrument or brace shown. I agree with the reader of the paper in devising and advising an instrument by which we can relieve the pressure on the spinal cord. I have a man under my care at the present time who was injured last December by jumping off a moving train. There is an area of about three inches in the lumbar region which is sensitive and of which he complains. There is no swelling, no dislocation, in fact nothing to show that there was any injury except that there is soreness in the region referred to. This case showed evidences of paralysis of the lower extremities and of pain running over the top of the head and into the eyes, etc. It went on in the usual way until there was an improvement in the weather, when the spinal cord also showed slight improvement and signs of the patient's recovery. When the man got out of the house into the open air, and breathed God's oxygen, he seemed to improve a little. When he undertook to use crutches for the first time, he could not do so. When the crutches were placed under his arm and he attempted to straighten his back, it caused such intense pain that he could not use them. He meandered around outside of the house as far as he dared to go, for a short time. I then procured a shoulder-brace from an instrument maker and applied it with the idea that some slight appliance to the spine would overcome the pain incidental to the stretching of the body. This afforded some relief, and I think a light instrument such as we have seen to-day will meet the indications in these cases of spinal trouble. A plaster of Paris cast, as we all know, is one of the finest things that we have, but it is weighty, as a rule, and if we could get something that is light and apply it so as to give us the necessary motion without allowing the body too much freedom and hurting the parts, we will have arrived at something that will be of value to us in the treatment of these cases. Dr. Jabez N. Jackson, of Kansas City: I desire to call attention to one point with reference to the use of a brace or a plaster of Paris cast, in the treatment of spinal troubles. I do not think any brace has ever been devised thus far which will meet the indications like a plaster of Paris cast, in the primary fixation of the spine. A brace, such as the one that has been exhibited, may serve very well to prevent flexion or antero-posterior motion of the spinal column, but I do not see how it can prevent rotary motion of the spine. There is but one thing that will bring about complete fixation of the trunk, and that is the use of a plaster cast. If the doctor's device has any place in surgery, it will be in the later stages, after the reparative process has taken place, having for its object the partial strengthening of the spine while the patient is able to get around. In the later stages of treatment of spinal troubles this brace may be of some benefit, but I do not think it can be used with benefit in the primary treatment. Dr. J. B. Murphy, of Chicago: I think we can explain the disparity between the comments of Dr. Hoy and Dr. Outten as regards the beneficial effect of operation, if we will consider for a few moments the pathology and the degree of the injury referred to by Dr. Outten. We know from experiments that where we have a complete division of the cord above the point mentioned by Dr. Outten, there is no particular barrier to the production of motion. We do know, however, in further analyzing these cases, that where we have a fracture which produces a complete division of the cord we have nothing to hope for from the operation of laminectomy; but unfortunately we are not able primarily to tell whether the paralysis that is being produced after the injury is due to a complete division, to a concussion, to a hemorrhage, or to continued pressure of the deformed spine without a division of the cord. If we could tell the difference, then we could say in one class of cases we will operate, where the cord is not divided, and on the other hand, we will not operate. Furthermore, paralysis in the case of the man from Dakota, mentioned by Dr. Briggs in his paper, is typical of the class of cases reported by Victor Horsley at the last meeting of the British Medical Association, that recover after a secondary operation. It must be borne in mind that these cases gradually get worse. The paralysis is not complete at the time of the injury. The paralysis is due to an inflammatory exudate within or without the cord, producing compression on the cord at the seat of injury. This is exactly the same as the paralysis which we have as a result of triangu-. lar deformity in tuberculosis. It is not due to compression by bone at the site of the deformity, but to an abscess formed within the canal and compression by that abscess. This abscess can be opened and drained on the side of the cord without interfering with the meninges of the cord and it will relieve the compression. the Dr. Briggs (closing): There seems to be a misunderstanding in regard to the statements I made in my paper. I said no opera tion should be considered as complete upon the spinal column until the cord had been properly supported. I did not say that you must wait until the fragments are raised. These things we all consider imperative. I believe any appliance that will support the spinal column posteriorly is far more acceptable and useful than one which passes around the body. The Cryptoscope. Our special correspondent in Rome writes: At a meeting of the Perugia Medico-Chirurgical Society held on February 5, Professor Salvioni, teacher of physics at the university, made a most important communication on the new results obtained by him in Roentgen's rays. In studying the question his aim was to invent an apparatus which would enable one to see direct and without the intervention of photography certain bodies inclosed in wood, flesh, cardboard, etc. He therefore studied the possibility of rendering the retina. sensitive to Roentgen's rays. In this he has succeeded by inventing an apparatus which he has called a cryptoscope, which he exhibited at the meeting, and by means of which one can clearly see the contours of the bones of one's own hand, objects inclosed in cardboard boxes, leather purses, etc. This apparatus is very simple, and consists of a black cardboard tube inclosed at one end with a disc of black cardboard coated internally with a fluorescent substance (barium platino-cyanide, sulphate of calcium, etc.); in the other end is placed a lens which permits one to ciearly see the fluorescent surface. The object to be observed is placed before the luminous source given by a Crookes tube, and then one looks at it through the cryptoscope placed at a suitable distance. As in the fluorescent cardboard the parts of the object impermeable to Roentgen's rays are drawn in shadow, thus one clearly sees the contours of the bones of the hand, etc. A model of the instrument was made under the direction of Professor Blasema at the physical cabinet of the Roman University on February 11, and with it one could clearly see the bones of one's own hand, coins in a purse or the clenched hand, etc. It is evident from these results that the apparatus, when perfected, will be of great use in medicine and surgery. -British Medical Journal. The tendency to ultraism which influences public opinion in great social questions * ** has been also prevalent in the affairs of practical medicine. Dr. J. Bigelow. A most able and admirable editorial recently appeared in the Boston Medical and Surgical Journal, drawing attention to the sociological problems involved in the immediate and ultimate effect of traumatic or psychic shock on the nervous system. It speaks of the moral effect upon the community, particularly upon the working classes, of the more or less indiscriminate bestowal of damages for real and fancied injury, and the writer gives the views of a sociologist of distinction, who says that he regards the attitude of mind influenced by the general bestowal of damages in Germany and England as a most ominous and threatening problem. He calls the attention of physicians at large to the necessity of their having in these cases, when called upon to treat them, as clear an idea as possible of the subtlety of the problem and to realize fully the wide bearings of their expert decisions, averring that there is no doubt that many of the symptoms following accident are psychical, however they may be physically manifested. That a chance of money redress produces an inevitable tendency, inherent in human nature, "to exaggerate and, through more or less voluntary auto suggestion, to construct an organized complex of symptoms which might have sunk into the background of consciousness and disappeared." Trauma has come, in the popular mind, to be identified with "accident;" a "traumatic neurosis" means an "accident neurosis." Experience will no doubt show that the term "traumatic neurosis" should be used with more and more caution and never as indicating a special disease. No doubt, both practically and scientifically, we would do as well to speak of "accident hypochondria," "accident neurasthenia" and "accident hysteria," since it is evident that not every trauma is due to an accident. Our author further shows that "socalled objective symptoms are in reality subjective and that their diagnostic worth lies in the fact that their presence points more or less distinctly to the absence of organic disease." For years we have maintained that there is no sharply defined type of disease which could be called traumatic neurosis. We believe that many cases are dependent entirely upon the force and conditions which are created. We quote from an article by the editor of The Railway Surgeon, in "Withrow and Becker's Medical Jurisprudence:" "While realizing that, owing to the by-play of extraordinary circumstances, trivial injuries, particularly with back symptoms, can readily shape themselves into neuroses, yet we believe that racial differences, perfection of physical condition and the multiplex force of surroundings are constantly modifying factors. We also believe that favorable surroundings and the influence of an unprejudiced and thoroughly impartial medical attendant will be productive of the exact condition of trauma as it exists." And if trauma produces a condition similar to hypnosis, as in traumatic hysteria, we cannot help believing that the existing force and predetermined mental condition of the medical attendant will oftentimes change trivial conditions into serious ones. It seems rather startling that the physician, by virtue of mental superiority, prejudice and suggestion, could create an essentially serious condition, but we candidly believe that it is possible in a weakened and receptive mind to suggest and develop consequences of a very serious nature. And if, as claimed by authority, such cases have been cured by hypnosis, it certainly seems natural that hypnotic suggestion would have equal effect in their causation when the conditions are favorable to it. There cannot be any doubt that accident traumatized minds, if we may so use the expression, absorb sensations not only directly from the effects of the injury, but also receive impressions produced by the suggestions of an already convinced mind, as exemplified in the description of cases given. Any case treated by Oppenheim, where the mind was in an hypnotic condition, certainly would partake of the character of Oppenheim's suggestion. We cannot believe that there is a typical complex of symptoms in every case possessing anything like uniformity, but the local trauma aids to develop the neurosis dependent upon predisposing central disturbances and peculiarities. But where we have physical perfection and mental strength trauma is very rarely likely to produce the psychic condition claimed to be peculiar to traumatic neurosis, for we find that where intelligence is blunted and where surroundings have made incidental elements of danger familiar, physical injuries are manifested as physical injuries only, and very rarely terminate in psychic troubles unless there exist extremes in intensity and a predisposition upon the part of the individual, either racial, inherited or acquired. Again the contributing elements of modern civilized life in generating psychic conditions are of undoubted force and effect, and when these conditions are added to injuries inflicted by corporations of responsible character, accident neuroses are of constant occurrence. These corporations are made the great prime cause when other contributing elements are infinitely more forceful. It is a well established fact that there is an enormous increase in hysteria under the peculiar influences of modern life. The excessive use of narcotics and stimulants, with little exercise, high living, the eating and consequent absorption of organic poison in tainted foods all tend in the direction of hysteria. Overwork and consequent fatigue are powerful tangle our idea of the cause from the effect by which many know it? In the interpretation of this modern social enigma the effect is made the substance, while the cause is ignored. All causes have power to produce effects, but in accident neuroses, we have heretofore perceived the event, change or phenomenon, and ignored the cause. The general idea of cause is that without which another thing called effect cannot be; hence, in accident neuroses, while every trauma is not the result of an accident, the accidents from cyclones are not as frequently followed by accident neuroses as are railway accidents, and simply for the reason that the surrounding conditions are oftentimes far more potent than the accident, and are justly the cause. But the brain of man is the organ which receives and manufactures suggestions, and these suggestions seem to shape themselves eternally to the wants of the individual possessing the brain. "In judgment of her substance thus they vary, SOME PSYCHIC CONDITIONS IMMEDIATELY FOLLOWING A CYCLONE. It may not be uninteresting to give our readers the impressions of the editor concerning the effects in a psychic way on some persons who passed through the St. Louis cyclone of May 27, 1896. An endeavor was made to study the general mental effect, facial expression, psychic anomalies and various subjective manifestations. Psychic shock or trauma under the influence of a cyclone seems almost the same as psychic shock from any other source, where sheer intensity of circumstance makes it productive of all the degrees of this passion as expressed by the words fear, dread, terror and consternation. Some moodily told how they had passed through a more or less brief period of unconsciousness. "I did not know what had happened or where I was for some time afterward," was a common observation. The psychic condition was one of general obliquity to external impressions in which many voluntary acts were performed almost automatically; the higher mental faculties alone being in abeyance. Here strode a woman up the street immediately after the cyclone had ceased with her dress and underclothing high up around her waist, oblivious to surroundings with fixed look staring straight ahead, carrying beneath her arms a flower pot and in it a ruined plant. Another woman followed almost in a nude condition, carrying a bird cage minus its occupant. They acted as in a dream, thoroughly dazed and having the vacant stare of the hypnotic. Person after person aimlessly wandered, unconscious of their surroundings or of the calamity which had occurred. One person informed me that he had wandered for four hours in this condition, utterly oblivious of what had occurred or where he was located; that he was so dazed that he lost his way home many times and at times found that he was talking at an excited rate; also that when he arrived home there was an almost irresistible impulse to still aimlessly wander. On the faces of many could be noticed a blank, yet pinched expression, an inattentive, blunted mentality, a seeming inability to concentrate attention or to think. While in others an increased impressionability arose, making them refrain from conversation and, as some expressed it, "Oh, I want to be alone; entirely alone." The change in voice was very noticeable; some talked with cyclonic explosiveness, while others had a halting speech, and again others a whispered utterance. In many claiming to be unaffected by the cyclone there was seen the hysterical involuntary symmetry of movement so frequently characteristic of this disease. Some would detail stories, showing plainly that peculiar excitability present in hysteria, where energetic movements were necessary to prevent irritating mental effects. Between psychic trauma producing many hysterical conditions of more or less severity, an unconsciously produced fatigue added bountifully to hysterical manifestations. Many persons spoke of the inordinate oppression of the silence which followed immediately after the terrific and almost stupifying roar of the cyclone. The influence of this silence seemed to add an intense impressionability in many persons, creating an additional. element of hysterical cause. Said an intelligent gentleman: "I never knew the horror of an after cyclonic silence before; it is inde scribable. I remember once to have heard the following in relation to silence. Two adventurous and money-making men once fenced off the entrance to the Yosemite Valley in order to cheaply raise stock in the valley. A man was employed to take care of this stock and lived in a ranch house on the mountain side near by. This man spoke of the extreme oppressiveness of the silence by which he was surrounded. As night approached he would cook his supper and then go out and call in loud stentorian tones: 'Hello, someone, here is a good supper; come and eat it with me.' He would thus go and call in different directions; no one answering, he would irreverently grumble and become so mad that frequently he would leave the meal untouched. One day he appeared before his employers, some fifty miles distant, with as blank a looking face as was ever seen on a human being; his eyes protruded and glared, he had a begrimed countenance, he was hatless and almost without clothing. He told in slow and uncertain tones how in the early part of the night while reading he was suddenly aroused by the most awful and horrible noise as though the mountains were falling and the earth breaking in twain. Without hat or even looking back he started and ran and walked all night and all the next day, only intent on leaving behind him the cause of his terror. It was found upon investigation that the cause of his alarm was that a portion of the 'El Capitan' mountain at the entrance of Yosemite Valley, had fallen, undoubtedly producing a hideous enough noise to frighten anyone. This man. averred that millions would not tempt him to undergo again this killing silence nor receive the shock which the falling mountain gave him. I now can well conceive of the demoralizing effects of excessive noise, followed by oppressive and overpowering silence. I certainly would at one time have given worlds to leave that ponderous silence." The immediate effects of the cyclone can now be seen in many cases, but its ultimate effects are as yet an unknown quantity. We candidly believe that the full effects are not yet manifest. Psychic shock, trauma, exposure and fatigue will be productive of many cases of well defined hysteria and neurasthenia. The permanency of their effects can only be determined by time. |