« AnteriorContinuar »
exactly twelve days before the first appearance, Mr. F. having examined the flesh of an animal that died from anthrax.
DIGITAL TENOTOMY IN PIANISTS.
The operation devised by Dr. Forbes, of Philadelphia, Dr. Noble Smith, of London says, in the Brit. Med. Jour., July 4, 1885, promises to be one of great benefit to accomplished pianists, as well as to learners. In making some dissections on the dead body, with a view to determine the usual position of the slips of tendon which limit the action of the extensor of the ring-finger, he found that these vary very much in different cases; so that it becomes necessary to carefully determine their position by the eye and finger, during movement of the extensor tendon, in each case before operation.
He has just succeeded in freeing the ring finger of the right hand of an accomplished lady pianist, without causing her much more pain than is felt from the prick of a needle. Before operation she could raise the finger only five-eighths of an inch beyond the others. Directly after operation, she could raise the finger easily to one and a half inches, without the least feeling of loss of control over its action. The division was, of course, made subcutaneously so that only a minute wound was left in the skin, one-eighth of an inch in length.
BY DR. F. E. WALBRIDGE, OF MILWAUKEE.
I propose, briefly, to draw your attention to the subject of injuries to the spinal column and the nervous system consequent on accidents. The subject is one of great interest to us, both from a scientific and from a medico-legal standpoint, for we are all liable to be involved in these cases, as witnesses in suits brought to recover damages after a railway collision, or less frequently after some everyday accident. Although it is just twenty years since Mr. Erichsen first brought the matter before the profession, no very great amount of literature has accumulated on the subject, and it is only during the last four years, that his opinions have been seriously called in question, and even now the influence of his opinions is very strong. Such being the case it will be best to preface my remarks by a short examination of his views of Railway Spine.
Mr. Erichsen in some lectures published in 1886, and also in a book on “Concussion of the Spine, Nervous Shock, etc.,” published in 1875, held that as the brain might suffer serious functional disturbances and become organically diseased from injuries, sometimes slight, to the head, so might the spinal cord, from injuries to the spinal column. He distinctly states, that such secondary changes are not peculiar to spinal injuries from railway accidents, but that they may follow, though less frequently, the ordinary accidents. Mr. Erichsen, however introduced or rather extended the meaning of the term “Concussion of the Spine.” He carefully excludes from this heading cases in which there has been dislocation of fracture of the vertebræ, with or without direct injury to the cord, and also those cases in which the blow or accident has been the starting point of Caries and abscess of the vertebræ, though he admits the frequent coincidence of the two; but he includes such lesions of the cord and membranes, as hæmorrhages, intramedullary and meningeal; “Inflammatory Effusion;" and "Softening and Disorganization" of the cord; as well as cases of general nervous shock and hysteria.
He describes three clinical groups, and three pathological groups underlying these.
In the first, or as he says, spinal concussion after severe injuries, there will be motor and sensory paraplegia, more or less complete, together with the other symptoms indicative of the lesions just enumerated and frequently associated with fracture and dislocation of the vertebræ.
In the second, following injuries to the bony and ligamentous structures of the spinal column, we get pain referred to the spine, sometimes a slowly developing paralysis, and he even includes here some of the grosser lesions of the cord described in the first group. The pathology of this class, is a tearing of some of the intervertebral ligaments, together with the occasional lighting up of a chronic inflammatory process which eventually extends to the cord and its membranes.
In the third, after slighter injuries, we get transitory functional loss and symptoms referable to "spinal anæmia;” the pathology here he describes as due both to certain molecular changes in the cord, the result of the jar or shock, and also to an anæmic condition of the cord, the latter possibly superinduced by way of the sympathetic nervous system.
Mr. Erichsen further points out that a given case may present symptoms of more than one group, and that hysteria and general nervous shock (caused by the same accident) may complicate the
His main position, namely, that a concussive blow applied directly or indirectly to the spinal column, even though it fall short of fracturing or dislocating some of the bones thereof, may cause many and varied injuries of both the spinal column, and spinal cord, is undoubtedly a sound one; but the idea of grouping together of all these under the name of “Concussion of the Spine," and including under that name about all the nervous symptoms that follow an accident, is not a sound one, and not one calculated to give a clear impression of the nature of the nervous injuries received either in ordinary or railway accidents. As a matter of fact endless confusion has arisen from its use. Concussion of the Spine, has been confounded with concussion of the spinal cord; and has been regarded as analogous to concussion of the brain; indeed Mr. Erichsen's liberal application of the term has, as I have just said, made it possible to include under it nearly every nervous symptom following an accident, for while he warns us against the complications of hysteria and general nervous shock, as well as against what have been humorously described as “Litigation Symptoms,” he does not regard them as being frequent, and he himself gives many cases, as examples of "Concussion of the Spine" of one variety or the other, the histories of which are almost entirely made up of these complications:
Mr. Erichsen's views seem to have dominated medical literature on the subject for a good many years. The first eftective attempt to separate the cases he describes as concussion of the spine into several different classes and in a scientific manner was made by Mr. H. W. Page in a work entitled “Injuries of the Spine and Spinal Cord and Nervous Shock” published in 1882. If Mr. Page had devoted less of his space to a somewhat too personal attack on Mr. Erichsen, his book I think would have been more readable and more valuable. Being the surgeon to a large railway company, he has doubtless met this Protean malady “Concussion of the Spine," in many a law court, and to judge by the petty expressions of animosity towards its creator, Mr. Erichsen, so freely distributed throughout his work, he has frequently had the worst of the encounter,
Nevertheless he shows very plainly, the disadvantages of the term, and the abuses to which it had been and could be put; he dwells on the importance of general nervous shock, its great frequency, and the difficulty of distinguishing it from what may be called “Unconscious Malingering;” and also the frequency of pure malingering for fraudulent purposes, and the impossibility of its detection in many cases, more particularly where subjective symptoms alone have been relied on in making a diagnosis of "Concussion of the Spine." By far the best chapter in his book is that on “The Common Spinal Injuries of Railway Collisions," in which he gives a very succint and clear account of these injuries. Mr. Page argues for the extreme rarity of “concussion of the spinal cord," and appears to doubt its ever occurring,and the same may be said as to his views of “concussion of the spinal column;" especially does he doubt the starting of a meningo-myelitis from such an accident. Later writers have not all concurred with Mr. Page. Dr. Hamilton in the last edition of his surgery expresses the belief that chronic inflammatory changes may be set up in the cord membranes as the result of strains and ruptures of the ligaments of the spinal column. A number of writers in the journals, have for the most part sided with Mr. Page.
I think myself that the term “Concussion of the Spine” and its equivalent “Railway Spine” had both better be dropped, and the injury in the case described as a general nervous shock, a laceration of the cord, or whatever it may be. A great many accidents, are capable of being classed as “concussion of the spine,” if we accept Mr. Erichsen's definition thereof, but we cannot but err if we follow him in ascribing to concussion of the spine, those distinctly cerebral symptoms known as hysteria and general nervous shock, and it can hardly be denied I think, that these cerebral symptoms form a prominent feature in nearly every case of railway injury that gets into the courts; it is particularly for this reason that the ordinary names which seem to imply some connection between these symptoms and a spinal lesion, are so misleading and unsatisfactory. From my own rather limited experience of this class of cases, it has appeared to me that the brunt of collisions and other accidents, excluding of course ordinary fractures and surgical injuries, is chiefly borne by the spinal column and the nervous system. As a matter of convenience I classity these injuries as follows; though it might be as well to state now that any given case will usually present symptoms of two or more classes.
Concussion of the Spinal cord.
Concussion of the Spinal cord. By this I mean a temporary arrest of the functions of the cord, analogous to that of the brain in concussion of the brain, and the result of a sudden jar or blow. Cases of the kind are undoubtedly rare, and Mr. Page doubts if they ever occur, but though I have never seen one, there are several reported cases which seem to be real examples of the affection. The following is reported by Dr. Hughes in vol. xxxiv, new series, of the American Journal of the Medical Sciences. In this case paraplegia supervened immediately, but lasted only four hours; later however