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

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 adjustment 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. 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

It

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 weak

ness.

For 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, however, 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