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there was paralysis of the upper extremities which eventually disappeared as well. I quote the example from Dr. Ashurst.
Gross primary injuries of the cord and membranes. Examples of this class are so common and well-known to you all, that it is hardly necessary for me to detail any cases. The commonest form of injury in this class, is meningeal hæmorrhage with laceration of the cord, both due to the dislocative rupture of a vertebra. In cases where there has been no dislocation or rupture, intramedullary hæmorrhage is the most common lesion.
3. Organic lesions of the Spinal nerves. As an example of this class and the foregoing, I shall presently relate the history of a case now under my care. I will merely add here that injuries to the Spinal nerves, when near their origin, are usually the result of gunshot wounds.
4. Injuries to the osseous and ligamentous structures of the Spinal column. This is a very large class, and the nature of the lesion varies greatly, namely, from fractures and dislocations of the bones to mere strains of the ligaments and muscular attachments. Injuries of the former nature are frequently complicated with gross lesions of the cord and meninges as pointed out before. But the cases where the injury is confined to the ligaments and muscles, are of particular interest to us on account of the great frequency of their occurrence after railway collisions. A good example of a slight injury of this nature I take from Mr. Page. “M. A., a strong and active man, was riding in a first-class carriage, when a slight collision took place. He was at the moment leaning forward reading, and was not even moved from his seat. He felt a little upset and shaken and had some brandy in consequence, but he was able in a few minutes to get off and walk to his business. The next day he felt some pain in the lumbo-sacral region, which on the following day became acute, especially on movement, and on the third and fourth days after confined him to the house. He was ordered a belladonna plaster and in a week began to improve, though having occasionally sharp pain. There was no local tenderness.” Cases like this are very common. They have been aptly termed “Traumatic lumbago," and when the pain is very acute and persistent, and there is in addition some evidence of nervous shock, we have what is usually termed “Concussion of the Spine" or "Railway Spine." The objection to these names has been already considered.
5. Secondary injuries to the Spinal cord and membranes: As you know, Mr. Erichsen first described a chronic meningo-myelitis, taking its origin in a blow or concussive injury of the back. He cites numerous cases that certainly look very like it, but it is not to be forgotten that, as Mr. Page so emphatically points, out there is absolutely no post mortem proof of such a lesion. An interesting question in this connection, is the traumatic origin of Locomotor Ataxia and other systemic diseases of the spinal cord. It would certainly seem probable that in a tissue prone to such diseases, a blow or jar might be the determining cause. Dr. Wilks in his “Diseases of the Nervous System” thinks that a blow by reason of its stunning effects on the cerebro-spinal centres may initiate morbid changes in the cord. Of the few recorded cases of Tabes Dorsalis following on accidents, the connection is not very apparent, and I doubt if there is in any of them more than a coincidence.
6. General Nervous Shock. This is another large and varied group. The symptoms are those of a functional disturbance of the nervous system especially of the cerebrum. The psychical shock is probably more concerned in bringing about this condition than the physical. The symptoms of general nervous shock are in their order of frequency, according to Mr. Page, as follows: Sleeplessness, circulatory changes, such as flushings, etc.; sweating and vaso-motor paresis; headache and a sense of oppression and fatigue on making any mental exertion; a state of nervousness; loss of memory; and asthenopia, But especially is there present that condition we call hysterical which shows itself as an abnormal acuteness in perceiving organic sensations, and by exaggerating and dwelling on any pain present. These people are the last who should undergo the worry and anxiety of litigation; rest is imperatively demanded for them; is it any wonder then that this hysterical state is fostered and continued by the cares and anxieties of a law-suit? Unfortunately it is impossible to give any rule by which we can distinguish these cases which are merely prolonged by litigation and which recover from all their bad symptoms, promptly on a settlement, from those which subsequent events show to have been but little influenced by such litigation. Each case must be decided on its own merits, but ex. cluding pure malingering, it should not be overlooked that even if a patient's symptoms are aggravated and kept up by legal anxieties, he has none the less received a serious injury to his nervous system else would the worry have no more effect on him than it would have had before the accident. Doubtless a proclivity has always existed in sufferers from general nervous shock.
Many interesting cases might be instanced, but lack of time compels me to leave them out. It will be seen that I have said nothing of concussion of the spinal column in this classification. have done so because simple concussion without organic lesion cannot possibly produce any symptoms, and where there is an organic lesion the case comes under class four, “injuries of the spinal column."
Having said this much on the injuries of the spinal column and nervous system I will with your permission conclude by giving a short account of the case referred to a few moments ago, and let me add here that for much of the history of this case, as well as for valuable aid in preparing this paper, I have to thank my friend Dr. Ogden of Milwaukee.
A. D., a stout healthy young man of twenty, fell in December 1884, some sixteen feet from a ladder. He came down exactly in the sitting position on the edge of a table, so that the full force of the blow was received on the buttocks. No other part of him touched the table and he slid off on to the floor. He did not lose consciousness. There was complete paraplegia immediately after the accident, and a feeling of deadness about the buttocks. Motion began to return in six weeks and progressed from above downward. For four months he suffered from an attack of cystitis. For eight months his water had to be drawn, and he could not pass it; the control of the bladder was regained very slowly. During the same time the bowels would move without his knowing it, he having no control of the sphincter ani. Priapism was at no time present. About the fifth month he discovered a couple of bed sores on the buttocks; and about the same time he found one evening that the right leg was considerably larger than the left. When I first saw him nearly a year after the accident his condition was as follows: He was a well nourished healthy looking young man.
He walked in a clumsy, plodding manner, a lack of “spring” being the best description of it, and due to the inability of the calf muscles to raise his weight onto his toes.
The partial paralysis of those muscles was very marked. There was also some general loss of power in the thigh muscles;still he managed to walk long distances without fatigue. The right thigh was an inch larger than the left and the right leg 2 1-8 inches larger than the left.
The plantar reflexes were absent; all the other superficial reflexes were present. The knee-jerks were exaggerated but equally so.
There was no ankle clonus. He passed his water slowly and had to strain. He could hold his fæces though with difficulty at times. Two bed sores were present in the gluteal region, the larger was about an inch and a half long, and three eighths of an inch deep. A symmetrical patch of anæsthesia existed in the gluteal region; it extended vertically from the lower segment of the sacrum to an inch and a half below the gluteal fold, horizontally it reached four inches each side of the middle line. Within its borders were the two bed sores mentioned above. The transition to normal tactile sensibility was gradual. In addition to the anæsthesia there was over a very extensive region more or less complete analgesia and loss of the temperature sense. This area extended several inches beyond the anæsthetic part, in all directions, passing in front so as to include the skin of the penis and scrotum, and reaching down the back of the legs and involving the sole and outer side of each foot. The affected part on the right side was a trifle more extensive than on the left. The sensory loss was well limited to the cutaneous area of distribution of the Pudic, Small Sciatic, external or short Saphenous, and posterior Tibial nerves. A careful examination of the pelvis, per rectum, discovered no indications of a fracture. The electrical examination was negative. From that time up to the present, May 1886, there has been a steady improvement in most respects. The bed sores are healing, his muscular condition is better, the area of anesthesia is diminished, while there is better control of the sphincters. The analgesia however is as extensive as before. This case I take to be one of injury to the spinal cord in the lumbar enlargement together with an injury to the lower trunks of the sacral plexus. The bladder symptoms cannot be adequately accounted for I think by any peripheral lesion; while it is very improbable, to say the least of it, that such symmetrical sensory loss should result from a medullary lesion, and moreover with such extensive sensory derangement, we should expect more motor disturbance than there is, were the lesion central. Of the nature of the injuries, that in the cord was probably a hæmorrhage, from its sudden onset and the absence of any sign of fracture or dislocation; while the peripheral, I believe to be due to the nipping of the nerve trunks by an impacted fracture of the sacrum, or spines of the ischia, although none such can be felt. The treatment has been tonic, rest, and the galvanic current. The prognosis as regards complete recovery does not at this late date seem good. In conclusion I may point out that, as is usual in such accident, there is entire absence of general nervous shock.