c*:-:* -:-:• »< ■< < 4 €*«^ 4 t*< <^ **<*•* S^SSOC*^* * * • * • * * • * 4 Cornell University Law Library THE GIFT OF Hodgson, RuLss, Andrew, Woods & Goodyear 800 . M.,& ..T....Bldg.,. Buf f alp.,„N .y . DateS9.p.fc.embe.r,....9.., 19.5.7 Cornell University Library RD 181.H21 ' Railway and other accidents with relatio 3 1924 017 511 571 Cornell University Library The original of tiiis book is in the Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924017511571 RAILWAY AND OTHER ACCIDENTS WITH RELATION TO Injury and Disease of the Nervous System A Book for Court Use BY ALLAN McLANE JIAMILTON, M.D., F.R.S.E. Late Clinical Professor of Mental Disease in Cornell Medical College ; one of the Consulting Pliysicians of the Manhattan State Hospitals j formerly Physician-in-Chief of the New York State Hospital for Diseases of the Nervous System, and attending Physician to the Hospital for Epileptic and Paralyzed, New York City j President of the Psychiatric Society of New York ; member of the American Neurological Association j member of the Medical Society of London, and co-editor of "A System of Legal Medicine. " Mitb jFffteen iplatee, Uwo SupctfmposeO Cbarta anO Ubfttg=s(s IFllustcatlons NEW YORK WILLIAM WOOD AND COMPANY MDCCCCV Copyright, 1904 BY WILLIAM WOOD AND COMPANY PREFACE. THIS work is intended for Doctors of Medicine as well as for Lawyers, and especially for use in court. The author, whose experience in connection with accident cases has during the past thirty years been somewhat ex- tensive, believes that a book of this kind and scope will be acceptable to those who have hitherto been obliged to rely upon treatises which have taken one extreme view or the other as to the side of the plaintiff or defendant. The author aims to be always just, and, while attacking fraud on the one hand and on the other giving due prominence to the incapacitating effects of real injury, seeks to show in hysterical and unconsciously exaggerated cases where the neurotic predisposition exists, just how much the acci- dent has to do with the alleged suffering and future con- dition of the litigant. In this attempt the patient's proper claims are protected while at the same time an effort is made to prevent the railway from being mulcted, or, at least, to show that it is not entirely accountable. The time has certainly come for some one who is initiated, and has sufficient knowledge, to urge the proper and honest presentation of medical facts in court by the plain- tiff as well as the defendant, for it does not do to pervert medical truths which in their way are quite as well settled as the axioms of the law. It is the author's aim to pre- sent his material as simply as possible, and to avoid in- volved statements and discussion. Believing that the iv PREFACE. method of Caspar (which consists in the presentation of illustrative cases) is the most serviceable and helpful in a book of this kind, a large number of these — in most of which the author has appeared — are presented in the fol- lowing pages. A glossary has also been provided for non-medical readers. This work is not so much for the specialist as for those who go into court needing practical help. In conclusion I wish to acknowledge my indebted- ness to Drs. William Hirsch, R. Bell, C. C. Petit, and G. De F. Smith, to D. W. Patterson, Esq., and John Benning, Esq., both of the Metropolitan Street Railway Company, for valuable aid. Allan McLane Hamilton. 44 East 29TH Street, New York. May ist, 1904. TABLE OF CONTENTS. PAGE Preface, iii Introduction, i CHAPTER I. Accident Aboulia, 15 CHAPTER II. Accident Aboulia {Continued), ... . . 47 CHAPTER III. Injury of the Cranium and its Contents, . . . 87 CHAPTER IV. Traumatic Insanity, .143 CHAPTER V. Injury of the Vertebral Column and its Contents, . . 163 CHAPTER VI. Peripheral Nerve Injuries, .... . 207 CHAPTER VII. Examination and the Possibility of Error, .... 238 CHAPTER VIII. Prognosis in Relation to the Verdict, . . . .257 CHAPTER IX. Fraud .279 CASES. I. Neurasthenia with obsessions of doubt, . .25 II. Neurasthenia with tremor, . . . . .28 III. Hypochondriacal neurasthenia, . . . -34 IV. Neurasthenia with hematemesis, . . .41 V. Hysterical varus recurring as the result of a fixed idea in a hysterical hemiplegic (Janet), . 54 VI. Traumatic paramyoclonus multiplex (Prince), . 57 VII. Irregular hysterical hemiplegia with loss of taste, 69 VIII. Grand hysterical attack aborted by testicular pressure, 70 IX. Hysteria with fixed idea of scalding, . . 72 X. Hysterical mutism, anesthesia, and hemiplegia, . 73 XI. Hystero-neurasthenia with neurotic edema, . 75 XII. Hysteria major, contractures, anesthesia, and ob- sessions, with visual hallucinations, . . 78 XIII. Traumatic catalepsy, 80 XIV. Head injury, depressed bone, and cerebral com- pression and hemiplegia ; immediate symptoms removed by manipulation (Dennis), . . 89 XV. Fracture of the parietal bone with injury of mo- tor centres, rapid recovery (L. A. Stimson), 96 XVI. Fracture of parietal bone, head symptoms, am- blyopia, mental enfeeblement, ataxia, etc., dis- covery of previous syphilis, rapid recovery under treatment (Fraser), . . . .100 XVII. Blow to back of head, cerebellar symptoms, death, discovery of tuberculous growth, . loi viii CASES. CASE PAGE XVIII. Injury of left orbit and frontal lobe, with subse- quent loss of smell and taste, facial anesthesia, neuralgia, and attacks of temporary amnesia, 105 XIX. Basal fracture, injury of cerebellum following occipital injury, 108 XX. Head injury in a child, cerebellar symptoms, death, discovery of sarcoma in anterior median region of cerebellum, ill XXI, Injury to right side of head, fracture of frontal bone, cone bulging, ptosis, paralysis of the first, seventh, and fifth nerves, . . ■ Ii7 XXII. Traumatic injury of the hypoglossus, vagus, and sympathetic nerves (Hirsch), . . . .120 XXIII. Suspected fracture of the inner table of skull; cause of death, tuberculous meningitis due to release of latent bacilli by trauma (McDill), . 127 XXIV. Fracture of the vertex, head symptoms, cerebral abscess, recovery (Mace wen), . . .132 XXV. Fracture of the skull, chronic meningitis, limited injury of motor centres of hand and arm, with ataxia, 135 XXVI. Railroad injury, head trauma, amputation of thigh, stump neuromata, epilepsy, re-amputation, . 141 XXVII. Fracture of vertex and base of skull, general symptoms, optic neuritis, oculomotor symp- toms, epilepsy, moral degeneration, . . 145 XXVIII. Head injury, cerebellar symptoms, loss of mem- ory of recent events, 147 XXIX. Head injury, paranoia, 151 XXX. Head injury, paranoia, 151 XXXI. Head injury, with coincident hypochondriacal melancholia alleged to have been due to a trauma, but in reality syphilophobia, . .154 XXXII. Head injury in a senile dement, modification of the existing disease, 157 CASES. ix CASE PAGE XXXIII. Concussion of the spinal cord, rapid recovery (Holmes), 165 XXXIV. Wrench of cervical spine, permanent impair- ment, 165 XXXV. Rupture of latissimus dorsi and trapezius, rapid recovery, . . . . .166 XXXVI. Veitebral sprain, fractured ribs, ulnar-nerve in- jury, slow recovery, 166 XXXVII. Contusion of the spinal cord, .... 167 XXXVIII. Injury of the vertebral column, compression mye- litis, psoas abscess, death, . . . • 171 XXXIX. Injury of the coccyx as the result of the explo- sion of a hydraulic pump, . . -174 XL. Dislocation of third and fourth cervical vertebrae, 1 82 XLI. Hemorrhachis following a violent muscular effort, 1 86 XLII. Syringomyelia following a fall (Abrahamson), . 188 XLIII. Alleged progressive muscular atrophy, consecu- tive to injury, . . .... 189 XLIV. Hysterical locomotor ataxia of traumatic origin, 201 XLV. Locomotor ataxia following concussion and lacer- ation of the spinal cord, 201 XLVI. Traumatic recurrent locomotor ataxia, . 203 XLVII. Traumatic recurrent locomotor ataxia, . . 204 XLVIII. Contested case of alleged locomotor ataxia, . 205 XLIX. Spinal concussion, injury of ulnar nerve, . . 208 L. Injury of median nerve, neuritis, hysteria, . .214 LI. Injury of shoulder, musculo-spiral paralysis, . 235 LII. Dislocation of humerus, musculo-spiral injury, neurasthenia, recovery, relapse a year afterward through other causes, . . . .254 LIII. Fright, aboulic inertia, 258 LIV. Hystero-neurasthenia, morphine habit, volitional paralysis and contracture, cure, . . .259 : CASES. CASE PAGE LV. Hystero-neurasthenia, complete aboulia, apparent organic symptoms, 261 LVI. Serious injury, fracture of pelvis, with hystero- neurasthenic symptoms and profound organic mischief, . . 262 LVII. Head injury at different times, multiple lesions, 269 LVIII. Destruction of frontal bone, extensive lesions, im- mediate recovery (Keate), .... 270 LIX. Back injury, alleged lead poisoning, . . . 274 LX. Pretended paralysis, incontinence, and deafness, . 287 LXI. Hematomyelia, fraudulent concealment of previ- ous accident, ... ... 290 LXII. Former fracture of skull and hysteria major made to do duty a second time as a cause of action, 291 LXIII. Pretended amj^otrophic lateral sclerosis, in reality self-mutilation, 292 LXIV. Pretended spinal injury, substitution of old Pott's disease, and cerebro-spinal meningitis, . . 293 LXV. Pretended perineal abscess and other results of injury, substitution of old ankylosis of knee- joint, . . . . . 294 LXVI. Pretended recent traumatic diabetes, but of old standing; second suit for same injuries, . . 295 LXVII. Alleged traumatic neurasthenia, in reality symp- toms of long-standing exophthalmic goitre, . 296 LXVII I. Bullet wound of spine, feigned paraplegia, . . 300 LXIX. Feigned hemiplegia, contracture, and epilepsy, . 301 LXX. Simulated katatonic insanity by a melancholic, . 311 LXXI. Feigned dementia and mutism (Ponton), . . 313 LXXII. Feigned unconsciousness, . ... 314 LXXIII. Malingering, simulated agraphia, . . . 321 LIST OF ILLUSTRATIONS. FIG. • PAGE 27 1. Fades Mendicans, 2. Hysterical Paralysis of the Lower Extremities (Raymond- Janet), ... 47 3. Gait in Hysterical Paralysis (Cinematograph by author), 49 4. Hysterical Contracture of Hand (Richet-Preston), . . 52 5. Hysterical Contracture of Foot (Richet-Preston), . . 53 6. The Different Types of Anesthesia (Dana), . . .61 7. Sieveking's Esthesiometer, 62 8. Meyrowitz's Recording Perimeter, 64 9. Functional Crossed Amblyopia (Purves-Stewart), . . 67 10. Galton's Whistle, 67 11. Zwaardemaker's Olfactometer, . . . . 68 12. Scheme of Superior and Inferior Planes of Consciousness (Lefebre), 82 13. Contusion of the Brain (Vibert), 93 14. Depressed Fracture of the Skull with Extension, . . 97 15. TapiWitis (Medicme), 113 16. Traumatic Cerebellar Tumor (J/^^zcm^), . . .114 17. Distention of Optic Nerve Sheath with Compression {Medicine), iiS 18. Right Homonymous Hemianopsia (Purves-Stewart), . 116 19. Facies of Paretic Dementia, 160 20. Final Helpless Stage with Contractures in Paretic De- • mentia, 161 21. Deformity due to Traumatic SpondyUtis (Golebiewski), 170 Xll LIST OF ILLUSTRATIONS. 22. Diagram of Ruptured Hydraulic Pump, .... 175 23. Interruption of Sensory and Motor Tracts in the Cord, . 181 24. Gait and Station in Loqpmotor Ataxia (Cinematograph by author), 198 25. Relations of Motility, Excitability, and Structural - 26. Changes in Peripheral Paralysis to the Electrical Re- 27. actions (Erb), .212 28. Injury of Radial Nerve, 215 29. Leszynsky's Case of Paralysis of Serratus Magnus, . 233 30. Drop Wrist from Palsy of Musculo-spiral Nerve (Bailey), 235 31. Mathieu's Dynamometer, ...... 240 32. Areas of Referred Pain, . 33. Verifying Method of Making Skiagraph of (Walsh), 34. Keate's Case of Head Injury, . 35. Derby's Stereoscope, .... 36. The Box of Flees (Janet-Raymond), the ■ 247 Head 250 272 316 318 PLATES. PLATE FACING PAGE I. Hysterical Contracture of Trunk (Raymond-Janet), . 55 II. Various Types of Functional Anesthesia (Purves- Stewart), . . 72 III. Fractures of the Base of the Skull (Hutchinson-Hel- ferich), .... .... 96 IV. Fracture of the Skull with Rupture of the Middle Men- ingeal Artery (Hutchinson-Helferich), . . .99 V. Horizontal Mid-section of the Brain, . . . .107 VI. Base of Brain, 117 VII. Old Injury of Brain, showing Softening, Atrophy, and Porencephaly, 133 VIII. Artificially Formed Dislocation of the Cervical Verte- brae (Helferich), 169 IX. Fracture and Crushing of Cord (Helferich), . . 171 X. Scheme of Nerve Distribution (Jakob), . . . 217 XI. Result of Section of Ulnar and Median Nerves (Bowl- by), .231 XII. Areas of Cutaneous Sensory Supply of upper ex- tremities (Testut), .... . . 224 XIII. Areas of Cutaneous Sensory Supply of lower ex- tremities (Testut), 230 XIV. Recovery in Hysterical Paralysis (Purves-Stewart), . 256 XV. Recovery in Hysterical Paraplegia (Purves-Stewart), . 261 Charts I. and II, Topography of Cerebral Cortex, . . 329 RAILWAY AND OTHER ACCIDENTS. INTRODUCTION. The spirit of acquisitive litigation has undoubtedly existed since the establishment of legal tribunals, and the disposition of the majority of mankind, when suffering through the laches of others, has generally been to ignore the simpler forms of settlement and arbitration and " go to law " to obtain compensation for real or fancied wrongs. Sometimes the machinery of justice enables the ag- grieved one, as he thinks, not only to obtain balm for his wounds of mind or body, but to punish the other more publicly and fully, thus at once filling his pocket and re- venging himself. The belief may also exist that in the hearts of the twelve jurymen ample sympathy may be aroused by a tale of woe, which would not be the case with a hard-hearted adjuster of claims whose days are spent in investigating and settling such cases as his, and who of necessity cultivates a highly critical and discriminating sense of the fitness of things. Probably the simple recital of the plaintiff's story also brings with it the satisfaction which so often attends the expression of suffering, for it need hardly be said that the human tendency is to derive comfort from the privilege of sharing its troubles with others. Then, again, the love of a fight is a human weak- ness that sometimes leads the individual to lose sight of the fact that his best interests may be more advantageous- 2 RAILWAY AND OTHER ACCIDENTS. ly settled by a calm argument in camera, for it is doubtful if the real help of a tribunal is appreciated at all by a cer- tain class of claimants. Then, again, it would seem as if an imitative tendency had frequently led to the bringing of suits, for certain cities (notably Brooklyn and New York) have more litigants of this kind than others, and at times there is almost an epidemic of damage suits. Another incentive not to be despised as an important factor is the influence of a book upon so-called " Spinal Concussion," written some years ago by a distinguished English surgeon, Mr. John Eric Erichsen, which among other things sought to show that often the most trivial shock might be followed by the gravest symptoms of pro- gressive nervous disease; that railway shocks were the worst of all in fact, and litigants and their friends were apprised of clinical and pathological possibilities that were before this undreamed of except by a small number of French physicians who were prepared to ascribe to " ebranlement " an etiological importance, which in reality was often the product of guesswork and speculation ; so that Erichsen 's little volume became a guide book that might lead the dishonest plaintiff, if he felt so disposed, to set out upon the broad road of imposture and dissimu- lation with the expectation of getting a heavy verdict. There have been but few cases during the past twenty-five years in which the writer has appeared upon the witness stand that this work has not been introduced by the plaintiff's counsel and made to do yeoman's duty. Long before Erichsen's advent and subsequently, Tar- dieu, whose medico-legal experience was perhaps greater than that of any other teacher, had seen and reported no less than sixty accident cases of varying severity, and he INTRODUCTION. 3 had no difificulty in discriminating between those of a serious character and the vague cases which he considered hysterical, or examples of malingering and exaggeration. Although at all times there has undoubtedly been too much recourse to courts of law and too little to arbitration, one must to-day stand aghast at the wholesale litigation indulged in since railways of all kinds have increased and new methods of propulsion, not entirely free from dan- ger, have been adopted ; for a certain number of accidents must occur in spite of the improved safeguards and the most active precautions. The bulletin of the Interstate Commerce Commis- sion shows that for the three months alone ending March 31st, 1903, 300 persons were killed and 2,854 injured in train accidents in the United States, including those in- juries sustained by employees at work and by passengers getting on or off cars, and by minor accidents which increased the figures to 827 killed and 11,481 injured. There were 2,831 collisions and derailments of all trains, and 291 collisions and 125 derailments affecting passenger cars. This is a decided increase over previous statistics, and it would be of interest to know the sums already paid in settlement or to be paid as the result of such litigation. From a comparison of steam and electric road casualties in the United States it will appear that the trolley lines have six times as many deaths and nearly ten times as many injuries as the steam roads, as will be shown by the following table : Electric Roads. Steam Roads. Milesof track 25,859 265,352 Passengers carried 4,813,466,000 607,278,121 Passengers killed i ,2 16 282 Passengers injured 47i428 4i988 4 RAILWAY AND OTHER ACCIDENTS. It would be a difficult matter to estimate the amount of damages paid annually throughout the world by rail- roads to claimants who present themselves with real or assumed injuries. Sums of thirty to forty thousand dol- lars have been many times awarded by sympathetic juries, and one serious accident will often wreck a cbrporation. The trolley or street lines fare worse than the steam roads, for the reason that on the former it is impossible to safe- guard passengers who often persist in getting off the car before it stops or in the wrong way, and because, to a cer- tain degree, it is obliged to pick up or set down passen- gers at places most convenient for the latter. A steam road, on the contrary, stops only at fixed stations, its cars are enclosed, its lines are fenced off, and it has the right of way. The situation is getting constantly worse for the street lines, and the Brooklyn Rapid Transit Company will serve as an illustration of this, for in 1902 its earnings amounted to $12,500,000, and its expenditure for the set- tlement of damage claims was over $1,000,000, or nearly ten per cent of the gross receipts. The average damage loss throughout the United States is nearly five per cent, and the example of the easy way in which money is made by a large number of the claim- ants undoubtedly induces others to embark in the same profitable business, and, for a time at least, the losses will increase. As a rule the real sufferers are more poorly paid than the exaggerators or impostors, and many people who are deserving of compensation go without any rather than undergo the annoyance of appearing in court and being badgered by cross-examination, or by the loss of time and INTRODUCTION. 5 neglect of more important affairs. The victims who are well-to-do are naturally not so much inclined to demand compensation as others who have everything to gain, but it is to be hoped that eventually all of these cases will be submitted to expert examiners whose report shall form the basis of arbitration ; for too often other belongings of the case than the injury itself and the patient's condition are considered, and the spectacle of a comelylyoung woman on the witness stand, or an apparently helpless patient wheeled into the court-room or brought in on a litter, will lead to the awarding of an undeserved verdict. Dorliat says : " It is to be regretted that in certain cases there may be too "great a disproportion between the indemnity received and the gravity of the accidents, whether the in- demnity be insufificient, or, on the contrary, the damages be excessive. . . . This arises from the difficulty of mak- ing a prognosis sometimes, and it would be well if the case could be reopened and the patient's subsequent con- dition determined." The cases of this writer, as well as most of those known to medical men who are at all familiar with the sub- ject of railroad litigation for personal injury, show that wide latitude exists both in connection with the allow- ance of damages and in the withholding of compensa- tion. The error in judgment is more often connected with the first, and it is comparatively rare for a case to grow worse after the receipt of a substantial verdict. The German system {Unfallheilkunde), which is so general, not only fixes in an intelligent and equitable way the amount of indemnity in a given accident case, but insures subsequent additional compensation if the patient's state becomes aggravated or complicated, or there is a reduc- 6 RAILWAY AND OTHER ACCIDENTS. tion of the contingent award if he improves. As has been said, the jury system is not all it should be, for it is difficult to convey to a body of laymen— no matter how conscientious and fair-minded— a true idea of the reality of the patient's claim ; or, again, to point out to them what is perhaps exaggeration, either intentional or the reverse, or the barest simulation. So indulgent have juries be- come that the policy of most roads is to settle if they can out of court for any reasonable sum ; but the demands are growing more and more excessive, and the court calendars are correspondingly laden with impending cases. In the city of New York alone, the suits in which claims for personal injuries figure are so numerous that the work of the local division of the Court of Appeals has two-thirds of its time taken up' with contested cases of this nature, and the lower courts are even more busy. The great car lines are represented by a small army of lawyers and claim adjusters who seek in vain to relieve the congestion of cases, but in spite of this the number of hungry claimants for real or undeserved compensation has so greatly increased during the last two decades that it not only keeps the courts busy with legitimate cases, but has developed a form of legal practice in which the temptation among disreputable persons is to manufacture evidence or form conspiracies for the purpose of fleecing corporations ; and although radical criminal prosecutions have been often instituted, this species of villany still flourishes. Throughout the entire country we find the same state of things, for there seems to have been engen- dered a litigious spirit and a search for gain which has induced individuals to embark upon well-organized plots, going from one city to another, concocting testimony and INTRODUCTION. 7 inducing numerous persons to perjure themselves, and where the railroad has had no report of an accident (and probably none has occurred), these dishonest individuals have had the hardihood to go into court and by the bold- est false testimony get a verdict. Such a case was that brought by a young woman seen by the writer several years ago, who with the help of her father and others de- ceived the New York Elevated Railroad and a distin- guished surgeon so successfully that she received com- pensation to the extent of $3,000 for a deformity of the sternum which she claimed had been produced by an in- jury, but which, in reality, had been of long standing, and was caused by the too early use of a machine for making moulds for artificial leaves. It subsequently transpired that she had never been in the defendant's car at all at the time of the accident. This is one of numerous cases, to some of which allusion will subsequently be made, and which illustrate what has just been said.' The history of litigation connected with personal in- jury certainly shows that, until a comparatively recent time, damage suits were always brought for material in- juries — the loss of an arm, leg, or an eye — as the result of violence, and there were usually objective appearances which were unmistakable. Little or no attention was paid to the mere relation of subjective suffering, except perhaps in the matter of alleged impotence, when much latitude was permitted, the affliction being regarded as being dependent upon some physical weakness and not due, as it is often to-day, to psychical inhibition. While frauds were largely practised, the methods of the dishon- ' See Freeman cases, reported by Bailey. 8 RAILWAY AND OTHER ACCIDENTS. est plaintiff did not compare with the iniquities of the present time. The exhibition of violence which takes place in a railroad accident is necessarily of the most varying kind, and its results range from simple abrasions, jars and wrenches, to fractures and dislocations, muscular and tendinous rupture, nerve injuries, wounds of many kinds, and often more or less injury of deeper parts. When, for instance, we consider a telescopic collision with all its horrors of broken woodwork and glass, splin- ters and twisted ironwork, we may appreciate the possible consequences to the unfortunate passenger. Strange to say, the material accidents lead to fewer suits than certain ill-defined injuries which leave no external trace. The burden of the complaint of most of the plaintiffs, which is generally reinforced by more or less expert testimony, is that they are the victims of shock. Now there is no sub-- ject about which so much ignorance exists as the effect of shock upon the human subject, and none which has been so differently interpreted by medical men upon the witness stand. Of course the misleading hypothetical question has had much to do with this, but medical liter- ature, especially during the past few years, has sadly con- fused the cases presenting more or less conspicuous symptoms of an objective kind, in which well-marked cen- tral lesions existed, with those of a peculiar psychical type. So, too, sight has been lost of the mental organi- zation of the patient, his susceptibility to suggestion, and the influence exerted by anxious or grasping relatives with whom he may be housed ; or occasionally the meth- ods of an ingenious or unprincipled lawyer. It may be confidently stated that many persons are injured or sub- INTRODUCTION. 9 jected to great shock who do not present any after-effects whatever, but with the prospect of Htigation ahead and possible awards in view, usually under suggestion, develop a train of familiar symptoms which are better known to the habitues of the courts than to the profession. Page says: "It will not be denied, we think, that there is a very widespread impression that the spine and spinal cord are liable before all other parts to meet with injury in railway collisions ; and under the nanie ' concussion of the spine ' is classed a number of complaints and symptoms which are commonly met with after railway accidents, but are rarely seen or heard of in the ordinary practice of the profession." While, as has been said, these patients come into court with symptoms which are too often suggested, it does not follow by any means that they are always malin- gerers or knowingly impostors ; but that their condition is what the writer many years ago termed the " litigation psychosis." A state exists which is modified by the ex- citement before and incident to the trial, by the expecta- tion of a favorable verdict, or by the various forms of disap- pointment that may be felt, as is well known. All this often disappears with a settlement of the claim and when the suspense is over, although in exceptional instances the mental mischief that has been done is such as to give rise to a serious if not permanent continuance of ill health. " Shock " is really a most general and elastic term, and applies to so many varying kinds of sudden depression of the vital powers, and so many different causes, that it should not be necessarily accepted unre- servedly until after it has been analyzed and clearly de- fined in the case under consideration. Generally speak- 10 RAILWAY AN£> OTHER ACCIDENTS. ing, it is a state due to a sudden exhausting or depressing influence for which the individual is usually unprepared, and, as has been said, there has been made a more or less profound impression upon the vital forces, the extent of which depends upon the subject's power of resistance. In this connection attention may be directed to what might be called the preparedness, that is to say, the atti- tude of the individual so far as expectation is concerned. It is a somewhat curious fact that many persons engaged in occupations, or exposed in ways fraught with more or less likelihood of danger, rarely suffer from nervous con- ditions, which, on the contrary, are expressed by those who are unconscious of any impending injury and who succumb at once upon its receipt. Prince several years ago took the trouble to collect statistics which show that there is a comparative absence of nervous disorder among those who are on the lookout, or who are consciously "taking their chances." He found that while football players may sustain almost any form of violent injury, they are never the subjects of trau- matic neurasthenia or hysteria. Outten also found that of 18,275 cases of railway injury among employees, there were but 8 cases of the so-called traumatic neurosis, or i in a little over 2,000; while of 884 injured passengers, there were 11, or i in about 76. The physical results of severe shock are those depen- dent upon the impaired cardiac force with resultant cere- bral anemia, and for a time an exhaustion of general nervous function. The mental symptoms are ordinarily at first unconsciousness, and afterward depression and psychasthenia. These latter may exist for a long time, possibly leading to forms of neurasthenia and to a psy- INTR OD UCTION. 1 1 chosis of a characteristic kind, should conditions be favor- able for its development. It is hardly necessary in this connection to call attention to the careless way in which the word " shock " is used in courts of law, or to say that, strictly speaking, shock may be applied to an ordinary fall without consequences ; or, on the other hand, to the results of a blow that may instantly kill the person. So the medical witness should be careful in accepting unre- servedly the general meaning that the examiner seeks to attach to the word in any particular case. While there can be little dispute about the existence of the real evidences of external injury and their possible mode of receipt, battles royal have been fought in settling the question with regard to the extent and exhibition of that kind of shock which leaves no external mark. The signs of general ill health which follow long brooding and enforced invalidism, the loss of fresh air, and the discontinuance of a regular occupation need not be ascribed to shock ; and why should fright incident to a railway accident differ so radically from that of a dozen other kinds which rarely leave any such traces ; or the train of ill-assorted symptoms preserve such an invariable similarity, especially when presented by an ignorant per- son, unless they be thought of by some one else and pro- posed by him .? A series of well-directed questions, based upon the famiHar lines of Erichsen and his followers, may be all that is needed to prepare a very plausible basis for a suit such as is so often brought, and in which the symp- tom complex is clearly inconsistent with the expressions of genuine disease. The personal equation is of course an element of great importance, and much depends upon the relations of tem- 12 RAILWAY AND OTHER ACCIDENTS. perament and previous habits and mode of life to the development of the vague nervous states under discus- sion. As a rule the active, intellectual man is more read- ily apt to collapse under mental excitement and become demoralized than the individual of coarser stuff. This insensitiveness which belongs to the unintelligent and criminal is, I think, generally recognized. Lombroso and other criminologists and psychiatrists know that in persons of low organization a variety of ordinarily painful injuries and mutilations may be borne without suffering. This same inhibition of painful sensory impressions, which is also seen among religious enthusiasts, stoics, and savages, undoubtedly plays a part in enabling the malin- gerer to carry out his role ; this, however, must not be confounded with the analgesia of true hysteria. The hypersensitiveness of the first named leads to the greater susceptibility from within or without and to consequent loss of self-control. The writer has known many subjects of this kind to give up entirely and surrender to their aroused and domi- nating emotions after the most trifling shock or injury, who in their capacity for resistance have shown much courage under other circumstances. A lucrative occupation has sometimes been abandoned, and the available time of the person has been given to visiting physicians, or talking to any willing listener. The dull, unimaginative laborer rarely gives up in this way, and when he becomes a litigant his conduct is in marked contrast. If, however, he has not much the mat- ter and is coached, he is apt clumsily to overdo the part to be played and add fictitious complaints to the real ones. Many litigants are young women at a time when INTRODUCTION. 13 they are undergoing sexual development and most likely to become hysterical. The excessive susceptibility in these immature subjects to powerful emotional stimula- tion during revivals, or when other religious influences are brought to bear, is quite likely in the same way to render them fit subjects for the railway psychosis. The same fixidity of attitude and absorbed expression which may be often recognized in hysterically melancholic girls frequently belongs to the states under consideration in connection with a number of ill-adjusted symptoms. The terms subjective and objective of course apply on the one hand to symptoms which are felt and complained of by the patient, and on the other to those presented by him and observed by the outsider, and which are beyond the subject's control. Full value can be attached to the former only when there is some corroborative testimony, or when they are inherently consistent. While exaggeration need not of necessity imply dishonesty, the patient's pow- ers of analysis and judgment are so often affected by his condition that his statements are apt to be unreliable. It is here that the experienced physician is often able to test the gravity of the alleged suffering, to approximate the nature and severity of pain, the extent of the loss of will-power, and the reality of the various disturbances of the organs of special sense. There has been so much un- certainty about the value of subjective expressions that it has been ruled upon on more than one occasion ; that the objective indications are the only ones that can be taken into account and testified to by the expert. From a medical standpoint this is hardly fair, for the true expert should be able, even if he depends upon the patient's statements, to form a just opinion of their significance. 14 RAILWAY AND OTHER ACCIDENTS. While what has been said about the abuse of the courts and the claims of dishonest persons is true, it is not the writer's intention to minimize real trauma and its results. Many serious forms of injury of the nervous sys- tem come daily under the notice of the adjuster and his advisers, the neurologist and the surgeon. Grave fractures, both of the skull and of the vertebral column, possible in- fection of the brain and its membranes, coarse injury such as laceration or contusio cerebri, dangerous forms of in- creased cerebral tension, possibly from hemorrhage, press- ure from the products of inflammation ; and injuries of peripheral nerves, all occur, and should receive the atten- tion they deserve. Besides these we find psychasthenia, fixed ideas, hysteria, neuromimesis, general exhaustion of the nervous system, and neuroses and psychoses incident to depression of vital force in subjects so predisposed; finally there is a disreputable band of exaggerators. " sub- stitutors," and more or less ingenious impostors. CHAPTER I. ACCIDENT ABOULIA. Synonyms. — Railway Spine — Spinal Concussion (Ericksen) — Traumatic Neurosis (Oppenheim) — Trau- matic Neurasthenia — Traumatic Hysteria — Litigation Psychosis. Even before the appearance of Erichsen's book the relation of hysteria to certain vague forms of neurotic disturbance in connection with injury was recognized by the older writers. Brodie, Russell Reynolds, and Paget in England had much to say, not only about the effects of trifling injuries in certain neuropathic subjects, but the latter showed how closely hysteria might mimic real joint trouble. Although Tardieu in France had for years gone on reporting cases, many of which resembled those collected and described by Erichsen as instances of a newly discov- ered affection, it did not occur to him to recognize a dis- tinct traumatic neurosis. After the appearance of Erich- sen's book in 1868 the subject attracted much wider attention, especially in England and the United States, and others published their experiences, among them Hodges of Boston (1880) and the writer, who had before this been called into court frequently to testify in railway cases, in 1878 and 1883. In 1883 Walton, of Boston, fully recog- nized the identity of the symptoms of the alleged trau- matic affection with those of hysteria, and Page (1883), 15 i6 RAILWAY AND OTHER ACCIDENTS. a. surgeon of the London and Northwestern Railroad, whose experience was extensive, analyzed and published his cases, to which allusion has been made. In Germany Oppenheim (1889), Westphal, and Striim- pell gave the disorder following trauma a distinct place of its own. Charcot in France, on the other hand, was not disposed to regard it as an affection by itself or one that differed from the familiar forms of neurasthenia and hysteria, in which conclusion Oppenheim 's countrymen, Eisenlohr and Schultz, concurred. Prince (1898) ex- plained the nature of the psychasthenia which gave rise to many of the symptoms, and has since done much original and suggestive work. Dana (1894) thought the condition was but neurasthenia with the added ele- ment of sprain, while Bailey (1894) was inclined to give full weight to the psychical etiology of the condition. Knapp and Clevenger inclined rather to Oppenheim's views. Thanks to the voluminous and valuable contributions of Raymond and Janet, Lefebre, and many modern writ- ers and teachers, there should be no diflficulty in regarding the state of nervous suffering following a shock without serious or bodily injury as due to a mental rather than a physical disturbance, and one often suggested. The term accident aboulia has been chosen by the writer because it seems to be that most applicable to the condition mani- fested by a collection of symptoms of a hystero-neuras- thenic nature, the chief of which is a loss of will-power. This is undoubtedly the result of auto-suggestion, and the creation of one or more fixed ideas in connection with a deception of the sensory centres. To understand its origin and significance we must consider the relation to ACCIDENT ABO U LI A. 17 conscious and subconscious cerebration, the suspension of higher control, and the development often of a certain automatism following the repetition of an idea in the in- tellectual sphere until it fully dominates the conduct of the subject. In natural conjunction with such a disturb- ance are certain physical indices of ill health, but the objective expressions are greatly out of proportion to the subjective. The terms traumatic neurasthenia and hysteria are referred to for convenience, because the derangements are symptomatized by states and symptoms which are conventionally grouped under these heads. The departure from mental health proceeds from an accident, usually one of a vehicular kind, but the con- dition may follow a fall or the receipt of any shock or fright ; and from many sources. What has been said be- fore as to preparedness may be again referred to in show- ing that a knowledge of what may happen minimizes the danger of shock. In this connection reference may be made to the part played within the past few years by electric shocks, which are frequent causes of hysteria major. Attention is further called to the fact that the psycho- sis may follow either immediately, or be slow in its appear- ance and progress, the patient responding quickly to in- fluences in his environment. One of the best proofs of its psychic origin is that the subject at the time of the accident often goes about helping his injured fellow-pas- sengers, and then returns to his home later to develop gradually his incapacitating condition. This tardy devel- opment is often erroneously explained by the assumption that the " nervous centres are injured immediately, but 1 8 RAILWAY AND OTHER ACCIDENTS. that the excitement of the moment keeps the patient up " ; but it is the author's experience that some of the most obstinate cases are those in which there has been neither a history of a dramatic or horrifying accident nor any ap- parent serious immediate shock or injury whatever, but in which the condition tardily and slowly grows in a manner already to which reference has been made. This view is also strengthened by the fact that the subject may be one of many others who are subjected to the same violence, but it is he who is seemingly alone prostrated. In this connection the question has often arisen whether or not the person was asleep at the time, and if so, whether this circumstance had any bearing. Many cases occur to the writer in which the accident happened at night or when the subject was asleep ; and excluding those in- stances in which actual bodily injury was inflicted, there remain a number which subsequently became psychas- thenic at a later period, there being an interval of com- parative health, and in these suggestion played the major part. Even if the early demoralization is not great, there appear to be additional factors of considerable impor- tance, such as the thought of a suit, the persuasion of a "runner" or "ambulance chaser," and the sympathy and solicitation of friends in connection with the injudicious watching which in so many ways has to do with the awakening of hysteria and the establishment of a lowered physical tone. Day after day the victim broods upon his condition. Possibly he may be subjected to an unneces- sary course of medical treatment and coddling, and the result is the formation of a carefully nursed central idea due to an unconscious and excessive stimulation of the ACCIDENT ABOULIA. 19 centres for memories of pain, and finally the loss of cour- age for effort making. There may be no wound or injury at the time, nothing perhaps more than a bruise or trivial abrasion with slight attendant discomfort and pain; yet these may ultimately be developed into tyrannical mas- ters so far as their exaggerated importance is concerned when the patient may be possessed by veritable obses- sions. The symptoms of accident aboulia are those of inaction and disordered cerebration, which need not have a serious pathological explanation; and although at times they very closely resemble real disease, there is never the con- sistency that is associated with degenerative and systemic lesions of the brain and cord. The writers of to-day are disposed to consider three forms of trouble due to trauma : First, the so-called traumatic neurasthenia; next trau- matic hysteria; and third, an alleged condition the out- growth 0/ one or doth, and practically a^i incurable disease. Observation of several hundred cases has con- vinced the writer that the two former usually coexist, and that the latter, except in very rare instances, is really the result of some violence which has caused a true lesion and tissue disorganization. Both neurasthenia and hys- teria, however, if neglected and improperly managed, or when the patient remains in the same environment, are sometimes apt to become obstinate and almost intract- able. Osier, whose consideration of the subject of traumatic neurasthenia is conservative, also divides the disease into three forms. The first includes the expressions of gen- eral nervous weakness, which are in no sense distinctive except that they are apt to appear after an accident. Two 20 RA/LWAV AND OTHER ACCIDENTS. of Osier's personal cases had nothing to do with railroad accidents, that is, so far as direct injury was concerned, one being in a railway engineer who was unnerved and shocked after he had run over a child ; the other, in a naval officer who had been exposed during the wrecking of his ship and who suffered great mental anguish. The second group includes the mixed hysterical cases, which are by all odds the most common ; and there is a third in which, after a preparatory state of nervous suffering, symptoms indicative of a disease of the central nervous system appear. Osier does not believe that such a cen- tral invasion has occurred unless optic atrophy, bladder troubles, and signs of sclerosis are well established, indi- cations either of degeneration of the lateral columns of the spinal cord or of multiple sclerosis. The Neurasthenic Type. Assuming that the expression of the so-called trau- matic neurosis may be of the neurasthenic or hypochon- driacal types, it is perhaps better, before proceeding, to consider the first, especially with relation to its exact meaning ; for a mere glance at the literature of the sub- ject will show how much confusion has arisen from the use of terms to express vague affections of the neuras- thenic form. " Neurasthenia" was first coined by Beard, of New York, who, in 1869, endeavored to gather the symptoms of all forms of functional nervous weakness. The use of this word did not possess the merit of origi- nality, however, for it was but a synonym for the more homely ones of " nervous exhaustion," " nervous debility," and " nervous prostration," and did not describe any state that had not been already fully pictured many years be- ACCIDENT ABOULIA. 21 fore by other writers. Bouchut, Sandras, Borguinon, Brachet, Andral, and Briquet in France and others in England — notably Skey and Hanfield-Jones — had pretty well covered the ground. Even as far back as 1794, Pomme had given a graphic account of the maladies vaporeuses. Since Beard's time " neurasthenia " has become popular, and has been large- ly used in Europe to define what our German critics call "American nervousness" — whatever that may mean — although from the mass of reported cases in foreign liter- ature, it would appear that there are at least a few neuras- thenics abroad. We should regard neurasthenia as a condition rather than an absolute disease, and one incident to fatigue of any kind or due to toxemia ; or following many varying forms of depletion. The tendency to-day is to class it as a disease from many causes, having characteristic and striking features, and as a rule appearing in persons of congenitally weak organization. An acquired form — the neurasthenie vraie of Gilles de la Tourette — is recog- nized, which includes all those examples of simple nerve exhaustion in non-neurotic individuals. This, however, is not so common a sequence of trauma — that is, where it is persistent and manifested by a more or less complete breakdown — as is the constitutional kind, and the pres- ence of hereditary predisposition is universally conceded to be the basis of the serious and prolonged disorder. "... It must be conceded that the hereditary taint is the all-important factor, and that constitutional disturb- ances, trauma, intoxication, or other conditions, are after all in the majority of examples only provocative agents. A sound nervous system is an inheritance that only the 22 RAILWAY AND OTHER ACCIDENTS. most strenuous provocation can overturn for any length of time ; and even when an upset has been accompHshed, a restitution to the normal is soon obtained under favor- able circumstances" (Berkeley). The neurasthenia of to-day is therefore a disease of the ill-prepared and badly organized who are liable to go under through the operation of causes that would certainly not have much effect upon the stable and nor- mal individual. It is admitted that it may appear at any age, and the " neurosis " of childhood, described by Maudsley and Clouston, is doubtless a form. Neuras- thenia is hydraheaded with an etiology of the most com- prehensive kind, trauma perhaps being of minor impor- tance. It is associated in a large number of cases even with arteriosclerosis, and is common in presenile indi- viduals as the result of overwork and breakdown.' This vascular degeneration may also be due to toxemic con- ditions due to alcohol, coffee (de la Tourette), tobacco (Lavillain), lead, or syphilis; or it follows cardiac and arthritic diseases, dilatation of the stomach (Bouchard), intestinal autotoxis (Smith and Herter), and lithemia. It is also a sequence of influenza, malarial poisoning, or toxemia from a variety of diseases. Syphilis and gout, diabetes and nephritis, are all at some time manifested by the symptoms of neurasthenia, while sexual excesses of various kinds, and in fact any and all causes that exhaust and destroy the integrity of the nervous tissue, induce the disorder. It is therefore disingenuous to magnify the influence of trauma, which ' This relationship was recognized in 1794 by Pomme : " Plusieurs sont incommodds du battement des artferes temporales et ont des sifflements d'oreilles, des vertiges, des frayeurs, des tremblements, des lassitudes, des douleurs, et des engourdissements dans les membres." ACCIDENT ABOULIA. 23 is but one of the least important causes, and persons of ordinary neurological experience will recognize the symp- tom complex, which is so often held to be due to an accident, while after all it is the familiar outgrowth of depraved states or bad habits. Dana, in speaking of traumatic neurasthenia, further says : " Careful research, however, often tends to elicit the fact that previous to the injury the patient was an alcoholic, syphilitic, or neurotic and perhaps already had the beginning of his alleged trau- matic disorder. In no part of clinical medicine is a care- ful and searching examination and weighing of symptoms more urgently called for." This somewhat prolonged consideration of the general etiology of ordinary neurasthenia is perhaps necessary when we bear in mind the tendency in medico-legal pro- ceedings to ignore the ordinary clinical features of an affection dependent upon so many different things. Symptoms. — After an accident when the honest pa- tient consults his physician, his recital of symptoms usu- ally includes a long list of subjective ill feelings in which disturbances of sensation are the most important and per- sistent. While these are vague, and vary greatly at differ- ent times, a peculiar headache and backache are more or less constant. Physical weakness, functional atony of the digestive organs, insomnia and mental depression or unrest figure. The patient's psychic attitude, which will later be more fully considered, is very conspicuous, and is sometimes in marked contrast to a previous condition of mental health, although those who are familiar with his history are probably aware of other occasions when, under the effect of inconsiderable stress, he has not shown an expected resisting power, and has had " nervous prostra- 24 RAILWAY AND OTHER ACCIDENTS. tion." He shows his weakness by different kinds of indecision, and therefore finds it difficult to reach a conclu- sion and act upon it. Sometimes he is emotional, burst- ing into tears without apparently sufficient reason, or show- ing his demoralization in other ways which may sometimes cause his friends great anxiety. There is a varying degree, not only of physical weakness, but mental as well, and the former is due to insufficient muscular innervation, and its psychic character is evident. The hands are tremulous and the slightest exertion or idea of required effort may produce a more or less general agitation or surrender. What would be an inconsiderable effort for another per- son produces in him prompt and disproportionate fatigue, which begins even early in the day, or even after a good night's sleep. The patient therefore gives up most of his ordinary work and so far as possible seeks rest, which is usually insufficient to relieve the constant tire of all the muscles, but especially those of the extremities. There is never, even in serious cases, what might be called paraly- sis, but only a functional weakness or an amyosthenia, the electrical reactions being conserved. Sometimes he takes to his bed, making no effort to use his arms or legs, although he might if he so cared, or retain the power to believe that he could. In some cases there is more or less general rigidity of a light grade which is modified by changes of tempera- ture, thus resembling the phenomenon which is observed in certain kinds of depressive insanity. This, however, is not a familiar symptom, but is seen sometimes in pro- tracted cases. In a certain proportion, especially if they be of the hysterical type, the reflexes will be found to have undergone a change, there being an increase of the knee- ACCIDENT ABOULIA. 25 jerks. The appearance of the confirmed neurasthenic is largely one indicative of malnutrition, and this undoubted- ly follows the changed conditions of life and habits. Ab- sorbed by his fears and worries, it is with difficulty that he is made to take a sufficient amount of proper food ; and we therefore find a resulting pallor and general asthenia, with loss of flesh and constipation. Some patients of this kind, however, remain comparatively well nourished, and even the most wretched are apt to recover their ordinary health and spirits when the distressing worry is removed. The Mental Condition. — The mental condition of the neurasthenic is notably one of depression and des- pondency; and if at all confirmed, there is a striking apathy, which is shown in listlessness and the slowness of his movements, which in some measure are due to the actual asthenia, and in greater part to the disinclination to exert himself. As Mathieu says: "It is less a symptom than a tendency to lowering of tone in the commissural union of different spheres of cerebral activity. It is in truth an enfeeblement of the personality, a diminution of the co-ordinated reactions which constitute the ego. The lowering of volition is the most important phenomenon." There is a condition of doubt and an irresolution which is nearly always shown about the simplest details of every- day life. To this belongs the development of morbid fears of a familiar kind, which in a measure affect the individ- ual's responsibility, rendering him incompetent to exercise his judgment, so that he becomes helpless and restless, or is worried by his own inability to come to a conclusion, or even to meet the simplest demands upon his judgment and volition. 26 RAILWAY AND OTHER ACCIDENTS. In the cases in which indecision is a feature, it is not often that it arises to the dignity of a genuine or a con- tinued " folic de doute," but sometimes insistent ideas are so strong as to tincture the whole conduct. Case I. — A person who had fallen from a street car and had subsequently, under improper influences, lapsed into a condition of morbid introspection and general ill health, consulted the writer among others. This man became so possessed with his inability to go near the street where the mishap occurred that he changed his place of abode and took lodgings near my oiBce, which was in a different part of the city, so that he could be near me without approaching the scene of the accident. Nothing could induce him to go near, much less cross the road even with an attendant, and serious urging simply precipitated a childish and tearful state. On one occasion without his knowledge he was driven across the street several times and subsequently told of the proceeding, but even the accomplishment of this did not remove the morbid fear and doubt of his own capacity, and the dread of an impending calamity should he make the attempt voluntarily. Subsequently, however, he recovered entirely after a year spent abroad. Obsessions of this kind are common, and another neu- rasthenic, now under the writer's care, has a constant dread that he is being injured or made worse in the most improbable ways. One of his chief complaints is that he has been exposed to syphilis by shaking hands with this person or that, or by smoking a cigar which has possibly been handled by one who is perhaps infected; and for weeks he has neglected to wash his eyes, fearing that they may become the seat of disease irom contact with con- taminated water. The physical appearance of this pa- tient, largely induced by his own disregard of soap and water, and his red eyes, which are the seat of a blepharitis — the result of frequent rubbing and accumulated dirt- would be likely to impress an ignorant person with the ACCIDENT ABOULIA. 27 idea that they were all a part of a serious illness. The patient is often irritable and resents his wrongs. It has been said that these subjects are occasionally impelled to commit suicide as a result of their depression (Defendorf, Hirt), but of such cases the writer is unaware. Sometimes there is a condition of mental erethism which is expressed in active ideation, and the subject is impressionable and irritable to a degree. The evolved ideas, however, are closely connected with the subject's condition and take their coloring from his suffering. It must be admitted that emotional instability of a depressed kind is the rule, and accounts for the lachrymose tenden- cies ; there is also a kind of morbid timidity, of which the case just related is an illustration, and the patient dreads to do anything to increase his alleged serious condition, and frequently comes to the physician for reassurance just as do the syphilophobics and other sexual hypochon- driacs. It is common for these patients to visit the doc- tor several times a day to show him an imagined change in color, a spot of eczema, or a pimple, or some equally trifling thing which is alleged to be a new development. These symptoms are highly characteristic of the hypo- chondriacal type. While the power of attention is dis- tinctly weakened in traumatic as well as other forms of neurasthenia, memory is as a rule unaffected, which, how- ever, is not the case in hysteria. (See Traumatic In- sanity.) The fades of the neurasthenic is most striking ; in fact it may be looked upon in obstinate and protracted cases as something that points very strongly to the pos- sibility of a mental trauma (but not necessarily a serious one) and perhaps an impending litigation. It can be 28 RAILWAY AND OTHER ACCIDENTS. compared more properly to the expression of the mendi- cant one sees so much of in Latin countries. There is an habitual drooping and flaccidity of most of the lower facial muscles, while the brow is corrugated, sometimes unilaterally — as depicted by Kirchoff in his plates of in- sanity — or traversed by numerous wrinkles. Those who Fig. I.— Facies Mendicans. remember one of Duchenne's cuts showing the results of facial electrization will appreciate what is meant, for this is so persistent as to suggest the existence of an ever- present mental image of pain rather than suffering which actually exists. This expression is more often seen in litigants whose cases are in process of arbitration or suit, and is as a rule an unconscious exhibition and therefore not to be controlled; it does not by any means imply, ACCIDENT ABOULIA. 29 however, that there is a corresponding amount of suffer- ing. Case II. — H. S , aged 50. The alleged accident occurred July 30th, 1896, and according to his story the car started while he was getting out, throwing him upon his back in the street. He remained unconscious for several hours ( ?), and when he recov- ered found that there were bruises upon his head and right elbow. After a bad night he awoke the next morning suffering from frontal pain and was quite dizzy and tremulous. During that day and sub- sequently there was much pain in the back and this increased. He walked upstairs with difficulty, and on the 28th of August sent for his physician, who has treated him ever since. His power of ap- plication is so affected that he cannot read or perform any men- tal work without becoming dizzy. According to his statement it sometimes takes him four or five hours to read -one page, but this is probably an exaggeration. When seen several months after the accident he appeared to be unsteady and tremulous, the oscil- lations of the tremor being about six and one-half to the second, and both hands were affected when he was excited. The pupils were even and reacted normally ; there was no contraction of the visual field, and his hearing was not dulled. There were no paraly- sis and no analgesia. His skin was moist, and he perspired very readily, even in a cool room. Although his physicians had pro- nounced his symptoms to be due to some form of sclerosis, there was no difficulty in making the diagnosis of neurasthenia of a familiar kind ; and subsequently, after settlement of the 'case for a small sum, he recovered entirely. In this patient there was a great deal of mental tension, and it was evident that the impend- ing suit had added to his anxiety and uneasiness. Insomnia. — Sleeplessness is one of the most familiar symptoms of all forms of neurasthenia, and is usually complained of in that under consideration. It is due to many things ; and while generally resulting from an irri- table and badly nourished brain, which is unduly suscep- tible to irritation from without, it is frequently the prod- uct of a fixed idea. In other cases possibly much of the 30 RAILWAY AND OTHER ACCIDENTS. wakefulness of the neurasthenic arises from his failure, either through inability or fatigue, to take the necessary exercise, and as a consequence there is more or less toxe- mia, due to retained waste material which is not excreted. It is rare for the pain which such patients experience to keep them awake, for as a rule the headache and the other sensory disturbances are relieved by the supine position and rest. There is ample reason to believe, and many cases support such a conclusion, that a great deal of the insomnia of neurotic patients originates in, and is fostered by an obstinate and continued belief that sleep is impossible. Janet reports several interesting examples of more or less prolonged sleeplessness of this kind, and one, a wom- an of thirty-seven, complained constantly of being very fatigued and sleepy because she could not sleep at night. She remained extended on her bed, with her eyes open, tossing restlessly from side to side for many nights, and no one could see that she slept. She was watched at the Salpetriere by the patients, nurses, internes, and others; and so far as their testimony was concerned, it does not appear that she actually slept for a period of two years. Many cases of this kind are familiar to the writer, and in some the simplest kind of sug- gestion — the most efHcacious being contact of some kind — would effectually overcome the insomnia. As a rule the wakefulness of these patients occurs during the early part of the night, and others cannot sleep after a very early hour in the morning. Sensory Symptoms. — Two kinds of pain are usually complained of by neurasthenics — a peculiar headache (cephalalgia), or a backache (rachialgia). Their frequency ACCIDENT ABOULIA. 31 in other neuroses in which the general nutrition is lowered, and in which more or less cerebral and spinal ischsemia ex- ists, suggests that in the present instance they have some such causation. The headache, which is an early and harassing symptom, occurs in the majority of cases, and Lafosse has found it in forty-one out of forty-five cases. Like all anemic headaches, that of neurasthenia appears in the morning and improves toward night when the re- cumbent position is sought. It is not modified by the full or empty condition of the stomach, but is aggravated during digestion. It is often paroxysmal, and may be attended by flushing of the face and hyperemia of the blood-vessels of the surface, the temporal arteries being distended. It is probable that the feeling of head ten- sion, of which complaint is often made, has led it to be compared to the pressure of a helmet. There is also bitemporal pressure, which the patient compares to that which might be produced by an encircling iron band. Sometimes the pain extends down the back of the neck to the shoulders. Like that of migraine it is usually unilateral, but there is neither a chilly stage nor the nausea of the latter. It is associated with musccB volitantes or flitting visual spots, illusions of sight and hearing, one of the latter being a peculiar subjective crackling or explosive noise first described by Searle many years ago. The backache, when not due to sprain or injury, is sometimes very distressing and irregular in its situation and char- acter. Although the patient may complain of deep pain, there is ordinarily a lively superficial hyperesthesia, the slightest touch causing as much discomfort as forcible pressure, if not more. The skin over the vertebral spines is especially sensitive, and the bony eminences themselves 32 RAILWAY AND OTHER ACCIDENTS. are more tender than other parts of the vertebra that may be subjected to pressure. In women the seventh cervical spine is especially intolerant. The ideational character of much of this pain may be demonstrated by remitting the pressure, without the patient's knowledge, over a point where great distress has been caused, and applying it at some new point, to which his attention is di- rected. Although the same force may again be applied at the original spot, the subject will declare that the most pain is at the fresh point of contact where the finger may barely touch the skin. There is some disinclination to move or twist the body, but none of that seen in lumbago, sprain, or more serious and deeper troubles, such as men- ingitis. Sometimes complaints are made of general mus- cular soreness. Vague sensory disturbances with no ade- quate explanation are common in neurasthenia, which are known as dys- or paresthesia. These consist of numbness, tingling, formication, and other disorderly perversions of sensibility that may be localized or general, and are rarely distinctly unilateral or defined as in hys- .teria. The patient may claim that the contact of ordi- nary clothing produces great discomfort and aggravates his suffering, and is often fussy and imaginative. Occa- sionally the tongue may become the seat of a dysesthesia, which may be associated with a refusal to eat for a long time, and as a result the patient suffers resulting malnu- trition. hitercostal neuralgia and coccyodynia are common, and Huchard and Weil have described fulgurating pains that have resembled those of tabes. Coccyodynia is very frequent, and is often exaggerated by the patient, who is usually a woman and who complains of many derange- ACCIDENT ABOULIA. 33 ments of her pelvic organs. Sometimes the subject whose complaints are the most frequent, may, while the attention is diverted, sit squarely for a long time in one position upon an uncomfortably hard seat in court, ab- sorbed in the proceedings without showing any sign of distress or making any change. In women it may be an exceedingly painful symptom of trauma, and may persist for a long time, as it does under other circumstances. The study of the painful manifestations of neurasthe- nia from a psychic standpoint will explain the origin of much of the pain which is so often imperfectly under- stood, especially where there does not appear to be any sufficient original injury. The torturing introspection, to which allusion has been made, has much to do with the complaints of the individual, and his constant tendency to call up disagreeable mental images. Prince has invented the term algonesia (pain generation) to define this process by which the neurasthenic brings into the higher field of consciousness painful ideas that have per- haps been formed at some distant time. The instances are familiar enough when trivial injuries have produced mental impressions that have obstinately influenced the recipient for years. The writer has seen a patient to whom in childhood a leech was applied, and she is em- phatic in her avowal to this day that she still has pain at the precise spot. The unstable individual is often prone to connect certain peripheral sensations with those of a grosser kind; pressure on the umbilicus, for instance, causing pain at the back of the neck or at some remote ' point. Neurotic patients who receive trauma in this way learn to treasure and dwell upon painful impressions which were originally connected with some slight bruise or 3 34 RAILWAY AND OTHER ACCIDENTS. strain, and later become dominant fixed ideas ; so that an old and insensitive scar, quite removed from any sensory nerve, may become the seat of imaginary pain. " The phenomenon of producing pain in one region of the- body by a slight irritation (as by scratching) of the skin of a distant area is not unfamihar; likewise the intense pain in the back sometimes excited in neurasthenics by simply tapping the patellar tendon. The writer is familiar with one case, a man in whom during mental fatigue the forced effort of silent reading caused an intense tickling in the larynx. ... In normal individuals the. excitation of pain areas by muscular effort is of necessity, on principles of evolution, uncommon ; but pathologically, especially in neurasthenia and hysteria, examples of this are of com- mon experience" (Prince). To the, patients upon whom sensory images act in this way. Prince has applied the terms "visuals," "auditives," " olfactives," etc., with refer- ence to the kind of impression that has been recalled. In a normal condition many individuals are annoyed by reminiscences of this kind, which are forced from the sub- conscious field into a higher mental sphere, and always depend upon the formation of an early disagreeable asso- ciation. These may not rise above the line of idiosyn- crasies, but in neurasthenic and hysterical subjects pos- sess a graver importance. Recalled or unconsciously projected sense memories, when at all intense, often form the basis of quasi-hallucinations. What is a mere fancy or eccentricity in one, becomes a false perception in an- other ; and in chronic neurotic invalids the complaint of the subject is often regarded as neither absurd nor improb- able, because it is consistent with popular and conventional . belief. The declaration of the imaginative neurasthenic ACCIDENT ABOULIA. 35 does not therefore seem unreasonable to the layman, who often cannot understand how any one can complain of pain and not have it ; while to the psychiatrist, what may be the product of a morbid mental process is perfect- ly clear. The term akinesia algera, or pain palsy, may be spoken of in this connection, as it is used to express a form of helplessness which amounts to a paralysis, and is induced simply by the fear that intense pain will be caused by any muscular movement, as may be the fact. This condition cannot be considered in any other way than a psychopathic connection, and it undoubtedly arises in the manner above alluded to. In some patients the mere idea of taking food produces pain, and the same complaint is often associated with the use of one of the organs of special sense. Nervous mimicries are occasionally found as traumatic neuroses, and it is common to find not only pseudo-joint affections, but a number of inconsistent painful expres- sions when the fear of moving or required exertion is present. Such a case was that of Mr. R , seen by the writer about ten years ago. Case III. — This gentleman was a rich retired merchant who, after having gratified his desire as a collector, or rather an accumu- lator of art objects, passed his days in idleness without sufficient resources to keep his mind busy. One night upon getting up for some purpose he came into light collision with a piece of furniture, and although there was no abrasion over the spot, which was lim- ited to the third dorsal spine, or pain at the time, he sent for his family physician, who, instead of reassuring him, ordered him to bed and made sundry applications. After this his "pain increased and became unbearable," and a few days after he "noticed a growing loss of power in his legs." At this time he consulted another physician, who told him that he "was in danger of infiam- 36 RAILWAY AND OTHER ACCIDENTS. mation of the spinal membrane, and should keep quiet." Al- though it does not appear that he had any actual paralysis or any symptoms whatever except those of a subjective nature, he developed a fear of exertion, and a morbid concentration which kept him absorbed, and the occupation of invalidism took the place of the earlier fad. He had a suite of rooms at an expensive hotel, which were some distance from the dining-room, and he pro- cured a wheeled chair with which to propel himself. Subsequent- ly he discarded this and had a much more conspicuous small cart made with low wheels, which he used in the crowded corridors. During all this time, according to the story of his wife, he was able to move his legs and walk when he chose in his own room, but was always apparently helpless when in the presence of other people. Within the next year he chartered a special car and went from city to city consulting many of the available neurologists of repute, who, as a rule, took a serious view of his trouble, some of them diagnosing an actual affection of the cord, and others re- garding it as a hopeless psychopathic condition. He complained always of the persistent localized pain, and through reading medi- cal books after a time enlarged his list of symptoms. When I saw him at the end of the third year of his invalidism he was in bed supported by a cumbersome metal and leather cuirass, which was declared necessary to enable him to sit upright for a few hours daily. When this was removed by the two trained nurses I discovered no evidence of vertebral disease. The skin over the four or five upper dorsal vertebrae was red from friction, but no projection and no real rigidity were to be found. He complained of pain when pressure was made over the alleged spot of disease, but when it was made elsewhere he changed the situ- ation. The legs were flabby from disuse, but there were no atro- phy and no morbid electrical reactions. The reflexes were slightly exaggerated. There was no loss of sensation of any kind, nor retinal anesthesia. His manner was martyr-like and suggestive of a long-standing hypochondriasis, and being unable to find any symptoms whatever that were definite, I felt sure his case was a neuromimesis and treated it accordingly, with the re- sult that in a few weeks he was up and about, a mental revulsion having taken place. He discarded his crutches, discharged his attendants, and ceased to complain of pain or anything else for the first time in several years. Thereafter his chief pleasure was in ACCIDENT ABOULIA. 37 presenting himself to his former physicians and chaffing them on their mistaken diagnosis. He is tonday well. Neurasthenic patients are, then, noted for the vinstable nature of their aches and pains, their headache and back- ache being comparatively constant; but the peripheral disorders of sensation rarely resemble those of any other conventional kind of disease because they are superficial and irregular, and do not exactly correspond with the course and distribution of special nerves or deep-lying organs. Visual Changes. — Neurasthenics are ordinarily more or less asthenopic, and rarely able to read or write for any great length of time. Many of them are naturally hyper- metropic ; and as this defect is met with in neurotic in- dividuals generally as a congenital defect, it need have no significance. In some patients photophobia may exist to .. such an extent as to induce them to spend much of their time in a dark room ; but this, like any of the other sen- sory disturbances, is apt to be notional. True contrac- tion of the visual field is not found in vmcomplicated neurasthenia, even though it be traumatic, but is a very frequent symptom in hysteria, as are a perversion of the color sense and various affections of smell, taste, and hearing. A form of contraction, known as Forster's " shifting type," has, however, been found, and depends upon the susceptibility of the outer part of the visual field to fatiguing impressions, while vision in the cen- tral part remains acute. If a perimeter be used and objects be brought into the field of vision from with- out, it will be found that the impairment of the peripheral field increases in extent toward the centre. Changes in 38 HA/LWAV AND OTHER ACCIDENTS. the retina other than of a functional kind are never found, and the absence of atrophy of the optic nerve may be considered an important diagnostic fact in those advanced cases which are supposed to be connected with organic disease. Should hyperesthesia of the organs of special sense exist, it is nearly always a purely irregular psychic state which leads the individual to call up false memories of previous sensory impressions, or to associate them im- properly. Neurotic though comparatively normal individuals are constantly prone to associate some new and fanciful sen- sation with a disagreeable impression received at a remote period ; but neurasthenics carry this to a morbid extreme, practically surrendering to their new troubles, and de- claring that various sights, sounds, tastes, and smells are so disagreeable to them that they prefer to isolate them- selves and undergo self-denial to a damaging degree. These subjects are also annoyed by ringing in the ears and other subjective noises. The pupils do not show any constant change, but are usually dilated and sluggish. It has been claimed that inequality has been found, but this must be regarded as quite apart from the disease, and is probably a congenital or occupation defect. Possibly this mistake may also be made in paresis in which a neu- rasthenic debut is not at all uncommon. Vertigo. — Vertigo is a familiar and disagreeable symp- tom of neurasthenia, and varies from simple dizziness to a serious condition, which causes the patient great alarm. He may even be unsteady, or go up and down stairs with difficulty, but not in the way familiar in tabes and some other spinal diseases. It may follow or be associated with headaches, or occur after inconsiderable exertion. It is ACCIDENT ABOULIA. 39 often attended by tachycardia, and relieved when the patient Hes down. Motor Symptoms. — Fatigue finds an important place in the symptomatology of the condition, and is as often a psychic manifestation as an actual tire due to the effect of muscular toxemia, which belongs to the ordinary form of exhaustion. Undoubtedly there are cases in which the very inaction through the fear of exertion so interferes with the excretion of waste body products that the reten- tion of toxins acts injuriously in this way. An analysis of most cases will show that the fatigue is of mental ori- gin. What is known as the " feeling of fatigue " exists rather than an actual physiological condition, and is closely connected with emotional activity. Not only will an in- considerable emotional excitement prostrate the subject, but a severe shock will, as every one knows, lead to com- plete inhibition, so that the volition is suspended, for a time, when there is virtually a functional paresis. In many of these cases through diversion, suggestion, or the necessity for action (possibly through a selfish need of the subject), this feeling of false fatigue is very easily over- come. In neurasthenics there is never what may be called true paralysis; and even in the occasional rare cases in which the will has been suspended for a long time the apparent lifelessness and rigidity of the extremities is after all an ideational paralysis, which is curable. Tremor. — There are but few cases in which tremor is not present to some degree, and though constant becomes more noticeable when the patient is worried or excited. Unlike that of multiple sclerosis or hysteria, it is not in- creased by the attempt to perform any particular muscu- lar act and is not cumulative. The oscillations are about 40 RAILWAY AND OTHER ACCIDENTS. five and a half to six and a half per second, and less fre- quent than those of Graves' disease, where there are in addition goitre, as well as tachycardia, and various neuras- thenic symptoms. Some cases of this affection are trau- matic in origin and may closely resemble traumatic neu- rasthenia ; but usually the element of time as a factor in the development of symptoms should make the diagnosis easy. Other forms of tremor with which that under con- sideration may be confused are those of alcoholism, par- alysis agitans, and senility. The fact that in most of these the agitation is a gradually extending one, and is associated with other distinguishing symptoms, should make its nature clear. In alcoholism the tremor is finer and worse in the morning, while in paralysis agitans there is nearly always the apposition of the ball of the thumb with the distal phalanx of the index finger. While the oscillations of senile tremor are from four to six a second, it is more constant than that found in neu- rasthenia, and there should be no difficulty in distinguish- ing it unless the patient be presenile, which is rarely the case. In some neurasthenics the tremor involves the tongue and lips, so that speech is more or less embar- rassed, and occasionally a mistake is made in a diagnosis of paretic dementia. The reflexes are of little importance in neurasthenic states. In these as well as other affections in which the cerebral inhibitory power is diminished, the deep reflexes are usually more or less exaggerated, and in hysteria par- ticularly to a conspicuous degree. Although unilateral exaggeration may be found, and is regarded usually as a symptom of central disease, I have found it once or twice ACCIDENT ABOULIA. 41 in cases of this kind in which there was clearly no degen- eration, as a phenomenon. The reflexes are never lost, and in this connection it must be borne in mind that in a small proportion of per- fectly healthy persons it is impossible to evoke the knee- jerk at all. Although Preston and Bailey have claimed to have found the ankle clonus in hysteria, it is never present in neurasthenia, and even in the former disease when it is seen there are probably overlooked organic lesions. Circulatory Disturbances. — The most important objective cardiac derangement is recognized in accelera- tion of the pulse, this tachycardia in some cases being re- markable. It is not unusual to find an average pulse of 120, and after inconsiderable excitement it may reach 170, while the arterial tension is lowered. In some cases we find irregularity and intermissions. Symptomatic brachy- cardia is unknown. Vasomotor disorders consist not only of obstinate flushing of the surface, but there may be spots of cuta- neous hyperemia, or peripheral coldness and lividity. The condition of the skin found in certain cases of men- ingitis, and described originally by Trousseau, may exist, so that when the surface is lightly scratched or drawn upon there is a resulting red mark or tache, sometimes with elevation, which corresponds to the particular con- tact, and is known as dermography. This is often more marked in hysteria, and has been regarded in other times as a supernatural manifestation by credulous religious hysterics ; it has also formed the basis of many a con- juring trick. There is often profuse sweating, which occurs even without exertion in the coldest weather. 42 RAILWAY AND OTHER ACCIDENTS. Subjective sensations of cold and heat are common as is palpitation; and in inactive cases some of the cya- nosis, so characteristic of old spinal disease, may be found, especially if there is rigidity. In rare cases hemor- rhage and hematemesis take place without any apparent causation or sufficient injury in connection with circula- tory changes. Case IV. — Such a case was that of Mr. W. W. R , seen in consultation by the writer with the late Dr. C. E. Lockwood, of New York. Mr. R while travelling from Washington to New York on a train of the Pennsylvania Railroad on the morn- ing of November 30th, 1881, had occasion to enter the water-closet of the car. While in a standing position a collision occurred with another train, and he was thrown forward and then backward, striking without great force the edge of the cover of the water- closet. He vomited blood mixed with bile for about two hours, suffered much from pain and faintness, and was bathed in a cold perspiration which saturated his underwear. He then came over to New York, and feeling a craving for food ate some, which he soon brought up. Upon his return to his boarding-house he endeavored to write several letters, but was compelled to give up and go to bed, owing to the pain in his back. When seen De- cember I St he was suffering from general hyperesthesia over the whole body, but especially over the arms, legs, abdomen, and back, severe aching pains in abdomen and back, and was unable to move from the recumbent position without nausea and retching. He had passed his urine, and there was no paralysis or loss of sensa- tion, and there had been no movement from the bowels. For the next few weeks he continued to have subjective feelings, such as a slight cramping in his toes (" as though one were crossed over the other"). There was gastric irritability, and he passed his urine only once in twenty-four hours, and then only eight ounces. An examination of the same was negative. His pulse, which was before regular and not particularly rapid, began to intermit, there being from three to ten intermissions a minute. He was dull, and his sleep was light. There were some confusion and inability to con- centrate. Further subjective sensations were those of tingling of ACCIDENT ABOULIA. 43 the finger-tips, prickling, and what he termed a " buzzing sensation in fingers and toes," twitchings of the muscles of the calves, espe- cially of the right leg, burning, aching sensations in the back, especially that portion between the shoulder blades and over the lumbar region. Subnormal temperature, but not below 97" F. at any time. He stood and walked with difficulty, and had to be sup- ported ; the knee-jerk in both legs was increased ; the pupils were unequally contracted, but this was found to be an old condition. Upon two occasions, it was subsequently learned, he had vomited blood without any seeming effort. A short time after this, during the year 1882, his case was settled, and he gradually recovered, so that he was able to return to his duties as consul in a Central American city. There was a gradual subsidence of his nervousness and bad symptoms, his pulse became regular, and most of his subjective feelings disap- peared. It should be stated that for many weeks the urine was irregularly passed, sometimes not more than once in thirty-six hours. We had no reason to believe that he had an internal in- jury, and the vomiting of blood was regarded as the result of a vasomotor disturbance. It has been stated by Dana and others that in neuras- thenia the amount of hemoglobin is not lessened. This may be true in some cases, but it cannot be disputed that in those in which much malnutrition exists, there is not only a decided decrease in the percentage of the coloring matter of the blood, but the red corpuscles are notably deficient. In women, after shock, the menses are some- times suspended for months, and in traumatic neuras- thenia there may be a permanent irregularity, or at least one lasting until the mental uneasiness and suspense are terminated. Disturbances of Digestive Functions. — What is popularly known as " nervous dyspepsia " is a natural se- quence of trauma. Sometimes this is brought about by the patient's state of mind, or by the enfeeblement of the 44 RAILWAY AND OTHER ACCIDENTS. organs of digestion, which are insufficiently innervated, and the symptoms are varied and are what may be ex- pected in analogous cases from other causes than trauma. The derangement may be both gastric and enteric, and the symptoms may be those of both. There are generally present an atonic condition, want of appetite, or one that is capricious or at times even ravenous. The digestion is decidedly slow, and as a result there are often flatulence, acid eructations, or actual regurgitation of food, epigas- tric pain, colic, and general distress. There is in some cases an increase in the amount of chlorhydric acid in the gastric juice, and sometimes a diminution, although in this as in other forms of neurasthenia the latter is apt to be the case. Intestinal autotoxemia, shown by an in- crease in the amount of indican excreted; diarrhea, which is usually of an irritative character, or constipation naturally connected with a torpid condition of the lower bowel, are all likely to be present. The amount of urine is scant, and, as in the case just reported, may be passed irregularly. Instead of the proportion of uric acid to urea being from i to 45 or i to 60, as it is in health, it is reduced from i to 30 or i to 40 (Dana). The phosphoric acid is increased, and sometimes the urine contains traces of sugar, but never albumin, unless there is arterial scle- rosis, which cannot be said to have any direct connection with the trauma. CHAPTER II. ACCIDENT ABOULIA (THE HYSTERICAL TYPE). As has been said, the association of hysteria with neu- rasthenia is common in those persons whose symptoms develop after a railway collision or other accident. While of course it does not follow that neurasthenics must be hysterical or vice versa, the condition under consideration is, as a rule, one of general ill health with hysteria added thereto. Ordinary hysteria is so protean in its manifesta- tions that it would be a difficult task to elaborate them all, but for convenience the excellent division of Fraenkel may be quoted : " From a general clinical point of view hysteria could be separated in three principal groups, which, however, like all things in nature, are not marked by fixed boundary lines, and can show many interchanges and mutual displacements. As belonging to these groups can be enumerated: (i) Predominantly mental forms, hysterical psychoses with more or less pronounced somatic symptoms. (2) Predominantly cerebro-spinal forms. Symptoms of this group are mainly composed of phenomena of irritation or paralysis of motor or sensory apparatuses supplied by the cerebro-spinal system (mono- plegias, hemiplegias, paraplegias, tremors, contractures, ocular symptoms, etc.). (3) Predominantly splanchnic forms. The symptoms of this group are composed main- ly of phenomena of irritation or paralysis of motor or sen- sory apparatuses supplied by the splanchnic or sympa- 45 46 RAILWAY AND OTHER ACCIDENTS. thetic nervous system (vomiting, constipation, diarrheas, meteorismus, tympanites, phantom tumors, ulcerations, edemas, etc.)." The so-called traumatic hysteria is rare- ly expressed by symptoms of the third division, but more often by the first two, especially the first, for it, like trau- matic neurasthenia, is a psychosis rather than a neurosis with which we have to deal. The symptoms that belong to the hysterical type of the disorder under consideration are mainly those of a cerebro-spinal kind, and in a rough way at times super- ficially resemble those of actual cerebral or spinal disease. It now remains to describe the picture that is so familiar in subjects of traumatic neurosis, and particularize the symptoms. As has been said, there is quite apt to be a condition of preparatory ill health which varies greatly, and is not impressive ; but this may be entirely absent, the symptoms sometimes appearing suddenly. However, when there is a group of symptoms they commonly have a neurasthenic basis. What has already been said of the genesis of the latter disease may be repeated. Hysteria is, perhaps more than neurasthenia, an affection with a vicious constitutional preparation. Many of the subjects present physical defects suggestive of imperfect develop- ment, and are liable to characteristic disturbances. And their degeneracy shows itself in an unstable emotional temperament, poor judgment, and poorer will power; precocity, sexual irritability or perversion, moral delin- quency, morbid appetites, the formation of drug habits ; and physical anomalies. Trophic alterations of the central incisors may be found among hysterics, as well as certain mental disabilities, to which reference will be made hereafter. ACCIDENT ABO U LI A. 47 Hysteria of any kind is noted for the eccentricity of its symptoms, their pecuHar sudden appearance, and at times equally prompt disappearance. Among these are amyosthenia, suddenly developed paralysis, spasm and tremor, and irregularly distributed cutaneous anes- thesia which affects the organ of special sense, as well as some of the deeper parts of the body ; hyperesthesia and dysesthesia, besides certain bizarre disturbances of respi- ration, digestion, and micturition. Motor Disturbances. — Amyosthenia or muscular weakness often precedes complete paralysis, or the latter may suddenly occur, which is the rule. It is often shown by an unexpected loss of power, which, how- ever, is temporary, and may cause the patient suddenly to drop to the ground, his knees giving way; to let fall what he may have in his hand, or to collapse in some other way. Hysteri- cal paralysis is ordinarily confined to the voluntary muscles, especially those of the extremities, although it is held that the muscular coats of the intestines, as well as other mvomntary mus- cles of deeper parts, may be sometimes involved. Both lower extremities (paraplegia), one upper and one lower extremity on the same side (hemiplegia), or sometimes a single member, muscle, or group of muscles (mono- FlG. 2.— Hysterical Paralysis. (Raymond- Janet. ) 48 RAILWAY AND OTHER ACCIDENTS. plegia) may be involved. The hemiplegic form is perhaps the most common, especially in women, and at times closely resembles true hemiplegia of a more serious kind, dependent upon a lesion of the brain or spinal cord. There is, however, none of the involvement of the facial muscles that is found as a symptom of the first variety, and the left side of the body is more often affected than the right. Babinski gives a diagnostic sign which helps in differ- entiating between hysterical hemiplegia and that of an organic nature. This is obtained by making the subject lie on his back with his arms folded in front, when he is told to rise to a sitting position, his arms remaining folded. When this is attempted it will be found that if his paralysis is hysterical, the extremity will remain flac- cid and parallel with its fellow ; but in the organic form the affected limb will be flexed at the thigh, and extended at the knee and raised. Paraplegia is said by some writers to be uncommon, but this is a mistake, especially in the hystero-traumatic •examples. The paralysis of one extremity is apt to be mistaken for a peripheral kind due to neuritis, or some other form of disease causing nerve degeneration, which disconnects the peripheral muscles from their source of central innervation. All forms of hysterical paralysis are characterized by the flaccidity of the muscles and by the apparent profound loss of power. There is evi- dent greater helplessness seemingly than in true organic paralysis, especially hemiplegia of central origin ; for there are few cases of the more serious affections in which the patient is not able after a short time to make some move- ment. In fact, the muscles do not act, simply because ACCIDENT ABO U LI A. they are not directed to do so. One is impressed immediately by the limpness of the limb; and when the patient walks, the paralyzed leg and foot are not swung around, as in cerebral par- alysis when the toe touches the ground, but are dragged along, the whole side of the foot perhaps scraping the sur- face. In the paraplegic form the feet are usually kept in contact in a like manner and trailed in the same way (Fig. 3). There is not only the objective ap- pearance of great weight, but the patient himself mentions it as one of his disa- bilities. As has been said, an important diag- nostic point is that the face is never really paralyzed, but mistakes have been made by those who have been led astray by an asymmetry due to a cer- tain kind of cramp or tic, which may be unilateral and produce a distortion. The tongue, which in true cerebral hemiplegia usually points to the side of the lesion, when protruded by the hys- terical patient inclines to the paralyzed side; but this is not because of par- alysis, but as the result of a lingual spasm. Another diagnostic sign referred to by Dana is that when the hysterical hemiplegia follows a blow to the head. 49 . Al f.^ FIG. 3.— Gait in Hyster- ical Paralysis. (Cine- matograph by Author.) 50 RAILWAY AND OTHER ACCIDENTS. the latter has been inflicted on the side corresponding to the paralysis, and not on the other, as would be the case were it the cause of a cerebral lesion resulting in paralysis. As has been said, the condition of the muscles is one of flaccidity, and should there be atrophy and con- tracture, these two appearances would differ very greatly from those found in central disease, the atrophy being a result simply of disuse rather than a destruction of the large cells in the anterior columns of the cord, while the contractures are not dependent upon a descending pyram- idal degeneration. Such contractures, like the atrophy found in associa- tion with paralysis, are sometimes features of inaction, and best seen in those subjects in whom a fixed position has been maintained for a long period. Unlike a form of contracture to be described, there are sometimes left a de- formity and a residual shortening, even after the paralysis has been cured. The fact that hysterical paralysis is associated in most cases with a peculiar loss of sensation and other stigmata demonstrates its peripheral and func- tional character. Through the use of the induced and galvanic currents we learn that though quantitative re- sponse to electricity is perhaps impaired — that is, that the muscles do not contract to minimum currents, there is no " reaction of degeneration." The integrity of the ner\'e connecting the muscles with the nerve centres is therefore preserved. A peculiar hysteroid motor disor- der, in which certain voluntary acts are possible and oth- ers are not, is known as astasia abasia. In this condition the patient, when recumbent, can freely move and kick his legs, but in the upright position is unable to walk or even stand ; the muscular power therefore is not gone, but in- ACCIDENT ABOULIA. 51 yiervation is perverted. In such cases there is rarely an- esthesia. Of fifty recorded cases nearly one-half were be- lieved to be hysterical, and the writer has seen one case in which it followed a railway accident, complete recovery ensuing in a few months. This condition suggests an- other in which the patient can only do certain things with the upper extremities. He can raise his arm perhaps, but cannot write, or perform other delicate acts. Spasms and Contractures. — All hysterical patients are apt at times to present contractures of widely different kinds. While many of these are clearly the result of mental perturbation, or follow causes which are psychic, it sometimes happens that after an insignificant injury, a kick, twist or puncture perhaps, an extremity may become the seat of a spasm or contracture ; and in the latter case it may obstinately endure for some time, perhaps suddenly disappearing after a second shock or profound mental impression, or through the agency of hypnotic suggestion. Hysterical contraction may sometimes be overcome by the Esmarch rubber bandage, and usually disappears dur- ing the administration of ether. While grand hysteria, as it is called by French writers, is apt to be sympto- matized by extensive tonic or clonic contractures, perhaps of recurrent nature, the cases that interest us most are those in which a limited contracture, clearly traceable to trauma, involves perhaps an arm or a leg. They are often of so peculiar a character as to be recognized at once by proper tests without much difficulty. The form of inac- tion contracture, which involves the paralyzed extremi- ties, to which reference has been made above, occasion- ally resembles very closely certain serious kinds of central disease, and is often mistaken for that of the so-called 52 RAILWAY AND OTHER ACCIDENTS. combined sclerosis following hysteria, amyosthenia, pro- found anemia, and prolonged decubitus, or Thomsen's disease; but the tremor is peculiar. Those contrac- tures involving perhaps the fingers or hand, toes or feet, Fig. 4.— Hysterical Contractures. (Richet-Preston.) have the explanation referred to above, and the defor- mity may take place after a scratch or wound which is insufficient in itself to produce neuritis and essential con- tracture or tissue changes. The hysterical contracture is attended by freedom of the wrist, with bending of the first phalanges upon the metacarpal bones. The others present but a slight degree of flexion. The appearance of the hand is striking, the fingers being uniformly bent and crowded together so that a sort of cone is formed, the apex of which corresponds to the extremity of the last ACCIDENT ABOULIA. 53 phalanx. The thumb is adducted and strongly forced against the index finger, and the whole hand is flexed quite strongly. Sometimes there is a greater degree of flexion so that the phalanges and metacarpal bones are strongly flexed, the fist being doubled as in the illustra- tion (Fig. 4). The articulations and ligaments are not affected; and not only can the deformity be easily re- duced when the patient is placed under an anesthetic, but it becomes less during sleep. Both extensors and flexors are involved, and in this respect are the criteria of spas- modic contraction. The contracted extremities of these patients are cold, the skin is livid, there is no real atrophy, Fig. s.— Hysterical Contracture of Foot. (Richet-Preston.) no true maivren-griffe, such as belongs to injury or disease of the ulnar nerve or progressive muscular atrophy. Like the paralysis^ such contractures are as a rule associated with the sensory symptoms of hysteria. 54 RAILWAY AND OTHER ACCIDENTS. When the leg and foot are contractured, we find a condition of extreme extension extending from the thigh down. The appearance of the foot is quite different from that belonging to any other form of paralysis or contract- ure, and the deformity is that of equino-varus, the toes being sometimes extended or again are rigidly flexed (Fig. 5). In some cases the distortion in a way suggests that which follows advanced poliomyelitis, but of course there is none of the atrophy of the latter. Case V. — Janet, among a number of cases of hysterical con- tractures due to fixed ideas, reports that of a woman, aged 31, who presented a permanent emotional state, hemianesthesia, amyo- sthenia followed by hemiplegia and left-sided varus. The patient between the ages of seven and nine sustained an injury of the left foot, which consisted of a sprained ankle due to a fall from a swing ; and bandaging and retention for some time in an iron instrument were sufficient to develop a spasm and condition of varus. This disappeared, but reappeared with hysterical hemi- plegia after an interval of many years. In this connection attention may be called to the fact that in hysterical subjects the injudicious use of retention ' apparatus or unnecessary braces may not only perpetuate contracture, which would get well if let alone, but will actually induce such conditions where some simple blow has been received. With both hemiplegia and paraplegia there are apt to be contractures of a spasmodic nature, which must not be confounded with that before men- tioned under the head of paralysis. The appearance of the extremities is that just described, and there may be associated with it -an obstinate contraction of the muscles of one side of the trunk (Plate I.). When the trapezius, and those muscles at the back of the neck are in spasm, there will be added a forcible retraction of the head. Railway and otiiek A(( idi;xts. PLATE I. Contraction ot Trunk, tlie Result of a Fixed Idea. (iModilied Irom Kaymond'Janet.) ACCIDENT ABOULIA. 55 An inspection of a large number of the French cases shows that permanency of contracture is the exception, and that contractures of all kinds, especially those which are limited to one or more extremities, are apt to take place as a phase of a general hysterical state in which amyo- sthenia largely figures. According to Axenfeld and Huchard, Raymond, Richet, Janet, and others, the com- mon types of hysterical contracture occur in the follow- ing order of importance : I. Monoplegic form, the leg being more often involved than the arm. II. The paraplegic, both legs being paralyzed and contractured together or consecutively. III. The hemiplegic form, the left side being the most frequent site. Rarer varieties include an affection of the four extremities ; the crossed type, one leg and arm being affected on opposite sides of the body; and in addition to these come the localized affections, such as torticollis and the like, which, however, rarely follow injury. Certain hysteroid conditions, in which there are tonic muscular spasms attendant upon voluntary effort, belong to what has been called the Thomsen symptom complex, and may follow fright or mental stress. These conditions are of interest because of their chronicity, and for the rea- son that they have an undoubted psychical origin. The writer has described a case of this kind which at the time reported was compared to Parkinson's disease without the tremor, so closely were the other symptoms copied. There were the station and gait of the latter disease, some- thing of the speech disturbance, and a striking rigidity which was permanent, but followed the attempt to walk, and many other voluntary movements. This myotonic S6 RAILWAY AND THER A CCIDENTS. condition hardly comes under the term myotonia acquis- ita, which it resembles very much, for it is evidently a grave psychopathic state marked by a persistent volitional loss. Chronic spasms and tremor are common in all kinds of hysteria, and the various tics, choreiform move- ments, tremors and shiverings may be local or more or less irregular, in this respect resembling the paralyses and contractures. A paralyzed or contracted extremity may be the seat of spasm, in some respects like a hemichorea of organic origin, but its real nature may often be determined by the trial of suggestion. Whole groups of muscles are perhaps involved in tremor, or separate muscular bundles may as a result of trauma become the seat of twitchings or lively spasms, and even the involuntary muscles may be agitated. Two forms of spasmodic af- fection have been found in connection with traumatic hysteria, which may be particularized as myokamia (Schultze) and paramyoclonus m,ultiplex (Friedreich). The former consists of muscular quivering of isolated muscles, and, according to Walton, does not involve the entire muscle at any time, but group after group of fibres. It resembles the fibrillary twitching of progressive mus- cular atrophy, and it is conceivable how a false diagnosis may be made in early cases of the latter. The muscles of the calf, thigh, and the glutei, and sometimes those of the shoulder are involved, and there is an increase of electric irritability for a time. While such tremor may occur as a result of tobacco, alcohol, or other toxic agents (Wal- ton), trauma is known to be a frequent cause. Several interesting traumatic cases have been reported, among them one by King, who found it after a blow on the ACCIDENT ABOULIA. 57 groin. The writer has seen one case in which it chiefly affected one quadratus as well as the posterior muscles of both legs in an old alcoholic who had had a rather heavy fall upon his buttocks, and was greatly benefited by static electricity and other suggestion treatment. The condition is by no means a serious one, but is evidently a purely peripheral disorder. What is known as paramyo- clonus multiplex consists of suddenly developed and severe clonic spasms, chiefly of the larger muscles of the body, those of the leg and feet being affected in a lesser degree; it usually follows violent emotion. "The pa- tient without warning is seized with sudden and light- ning-like contractions of the trunk and hip muscles, which cause his body to be alternately flexed and extended, so violently that he is often thrown from the chair or couch on which he is lying" (Dana). This is followed by tremor when the particular attack ceases. There are cases due to trauma in which myoclonus \\zs, lasted for several years, and such a one is reported by Prince. Case VI.— In this patient " the spasms were confined to the legs and developed as a traumatic neurosis following a carriage drive, during which the carriage was overturned after being struck by a trolley car. That same night there developed marked spasms of the legs, confined almost entirely to the quadratus femoris, but also extending over the back of the legs when an attempt was made to move. The spasms persisted for forty years." Prince tried nerve stretching by bending the legs backward and upward as far as possible toward the shoulder. Immediately following this there was a change in the spasms, which continued during the night, but the next morning finally disappeared. Other cases have been benefited or cured by mental therapeutics. Tremor, either fine or coarse, is found in hysterical subjects, and differs from that of traumatic neu- S8 RAILWAY AND OTHER ACCIDENTS. rasthenia, in which there is present a general and constant tremulousness. In hysteria the agitation mimics that of some of the more serious diseases of the nervous system, which differ greatly so far as the presentation of this symp- tom is concerned, and in many litigated cases it may often be claimed that multiple sclerosis exists. It has not the true character of the tremor of the latter, although it re- sembles it closely, and is hardly an " intention tremor," though varying in intensity under emotional influences. The distinction has been made that in both affections the tremor is cumulative, but that as soon as the object is seized or the effort is accomplished, the tremor stops if it be due to multiple sclerosis ; but if it is hysterical, the disorderly agitation continues. In a measure this is true. There is a form of paralysis agitans of hysterical origin which may closely counterfeit the central affection. In this, as in so many other mimicries, we find hysterical stigmata which make the diagnosis comparatively easy. Janet reports two cases developing under the same con- ditions, in both of which there were dreams, obsessions, and subjective sensations ; and under some circumstances both could easily be mistaken for the real malady. Hysterical tremor somewhat resembles those tremors due to the toxemia from metallic poisoning, especially lead and mercury; there is a confusing anesthesia in the latter, however, which is not so irregular and peculiar in its situ- ation as in the former, when it may be found in distinct and characteristic areas. In the latter, too, the reflexes are lowered or abolished, and there may be wrist-drop or other forms of paralysis, and finally some atrophy. In both hysteria and neurasthenia there is general bodily un- ACCIDENT ABOULIA. 59 steadiness, that may be recorded by Dana's ataxiagraph, which is placed above the patient's head and registers movements attending the swaying of the body. It is a question whether the general inco-ordination found in some of these cases is not due rather to indecision, clum- siness, and timidity than to anything else, so that the ataxia- grams obtained do not always possess diagnostic value. The Reflexes. — Should there be anesthesia which is at all marked, it will be found impossible to evoke some of the superficial reflexes if the stimulus be applied on insen- sitive skin. The deeper reflexes may be absent in hys- terical hemiplegia, or unaltered, thus enabling us to dif- ferentiate it from that due to a central lesion with a subsequent degeneration of the spinal cord, where there is an exaggerated knee-jerk. They are, however, present and sometimes increased in hysterical paraplegia of trau- matic origin. Ankle clonus is very rare. Bailey refers to one case, but the writer has not seen it except when some coincident central disease existed. Sensory Symptoms. — Peculiar disturbances of sensa- tion are eminently characteristic of hysteria in general ; and in the traumatic variety these are usually abundant and luckily so well marked as to enable us to differentiate a functional affection from one of central origin. This is not always a thing, however, that can be easily accom- plished, and numerous attempts have been made to draw some sort of close line between the hysteroid loss of sen- sibility and that dependent upon an organic disease. Such anesthesia may be associated with hysterical at- tacks, 'amyosthenia, actual paralysis, or contractures, remaining or disappearing with or after the motor symp- toms. The peculiarity of these forms of sensory disturb- 6o RAILWAY AND OTHER ACCIDENTS. ance is that they are very irregular in their appearance, do not correspond to regions supplied by particular nerves, and have a disposition to appear suddenly in spots or to affect certain areas, the limitations being sharp and well defined. In traumatic hysteria we find anesthesia of three kinds : that of touch, or tactile anesthesia ; insen- sibility to painful impressions, ox analgesia; insensibility to heat and cold, thermo-anesthesia, as well as occasion- ally the impairment or loss of the stereogenesic function, which prevents the patient from distinguishing form in association with weight. Increased susceptibility to tac- tile impressions is known as hyperesthesia, and to actual pain impressions as hyperalgesia. In addition to these there are the dysesthesia -asi.^. par- esthesia, to which allusion has been made in speaking of neurasthenia.- Analgesia is by all odds the most important kind of sensory disturbance; and while all three forms of anes- thesia may at times be lost, it is unusual to- find them conjointly affected. This insensitiveness to painful im- pressions may be said to be the kind of anesthesia that gives the disorder its occasional dramatic interest, and has played a part in many an historical episode of a religious nature, developing often as the result of a fixed idea, or in consequence of some intense emotional exaltation. We find instances in the history of every faith where martyrs have gone to the stake in a condition of auto-suggested insensibility, or have uncomplainingly submitted to the crudest tortures. The performances of the fanatical Assouai, when live coals are held in the unprotected hands, or snake bites and ordinary painful injuries are borne without discom- ACCIDENT ABOULIA. 6i fort, come under this head; while a certain number of persons for gain are able to induce such a condition of insensibility that they may introduce pins and needles into their tissues with impunity. Profoundly anesthetic areas are often bloodless ; and in certain ordeals to which suspected witches were subjected, if the surface was pinched and no blood appeared, this was often considered conclusive proof of guilt. Doubtless there are cases of Fig. 6.— a, Hemianesthesia ; B, C, segmental (gauntlet form) and disseminated forms ; jsr, 0, indicates hysterogenic zones. (Dana.) anesthesia due to fixed ideas. It is the writer's experi- ence, and doubtless that of many others, that litigating subjects can, through expectant attention, engender a cutaneous want of feeling, submitting to the wire brush and the induced current or even the platinum cautery. These, however, when expectant attention is present, are not strictly the conditions which we are called upon to discuss, although there is a general relation in all the cases. Hysterical anesthesia is of several forms. First, 62 RAILWAY AND OTHER ACCIDENTS. irregularly distributed spots or zones in which the anes- thesia is more or less complete. Second, the gauntlet-like or glove variety, where a hand or foot or perhaps a whole extremity may be anesthetic, there being a sharp limita- tion between the sensitive and insensitive regions. Third, what is known as hemianesthesia, where one-half of the body is in- volved, the insensitiveness stop- ping sharply at the median line. Under the first head may be grouped the affections which lead to the alteration of function in the organs of special sense. Spots of anesthesia of variable extent may also involve the buccal mu- cous membrane, or that of the anus or vagina. These spots are very much modified by certain kinds of contact; and the fact that they are not dependent upon any local or even deep disease, but are rather a psychical phe- nomenon, is proved by the experi- ments of Burcq and Charcot, who showed that it was possible to clear up anesthetic spots or trans- fer the area of insensitiveness to some other part of the body by the mere application of coins or magnets to the surface. Perkins' tractors, which were used nearly a hundred years ago by the quacks of the time for the purpose of " drawing out pain," probably acted in the same way. Analgesia sometimes extends to Fig. 7.— Sieveking's Esthesi- ometer. ACCIDENT ABOULIA. 63 the deep parts, so that a pin may be introduced almost to the bone without producing much discomfort. Hemianesthesia, as has been said, is as a rule con- fined to the left side of the body, and this is a matter of considerable diagnostic interest in connection with cere- bral lesions. In some cases it is doubtless dependent upon disease of the internal capsule on the right side of the brain ; and Seguin and Charcot many years ago con- sidered the significance of the hysterical symptoms of organic disease, and the condition is now generally re- garded as an occasional feature of a deep-seated organic change, or a concomitant, so that care must be exercised in making a diagnosis, especially when a trauma is re- ceived by an individual who already presents some form of central disease. For the purpose of testing anesthesia we may utilize several instruments and appliances di- rected to the detection of the particular form ; and it is best to blindfold the patient before proceeding. Tactile anesthesia may be determined by the use of the esthesi- ometer, which is used to determine the subject's ability to recognize two points at a certain distance of separation. Where this loss has occurred the distance is increased. Weber's table, which is in general use, may be utilized ;^ > Table of Weber. Point of tongue >^ line Red surface of lips 2 lines Palmar surface of third finger : line Tip of nose 3 li^es Metacarpal bone of thumb 4 Skin of cheek 5 Mucous membrane of hard palate 6 Dorsal surface of first finger . . 7 Dorsum of hand over heads of metacarpal bones 8 Mucous membrane of gums 9 Lower part of forehead 10 64 RAILWAY AND OTHER ACCIDENTS. oooo for the same purpose a camel's-hair brush enables one to make a rougher test. A needle, or an electrode with a sharp point, which is connected with an induced electric apparatus, will show the analgesia, should it exist, and two test tubes, one of which is filled with warm and the other with cold water,' are all that are needed to determine the condition of the thermic sense. In hys- teria there often exists a dry and insensitive condition of the skin, quite unlike the moist cutaneous surface of the neurasthenic,which not only interferes with the passage of electric- ity, but may minimize the value of tests with a needle, or the other ways suggested. The organs of special sense are involved in the same anesthesia, and suffer more or less extensive losses of function. Chief among these is the limitation of the field Lower part of occiput 12 lines Back of hand 14 " Neck under lower jaw 15 " Vertex 15 " Skin over the patella 16 " Skin over the sacrum 18 " Skin over the sternum 20 " Skin over cervical vertebrae 24 " Skin over middle of back 30 " Skin over middle of the arm 30 " Skin over middle of the leg 30 " Fig. 8.— Meyrowitz's Recording Perimeter. ACCIDENT ABOULIA. 65 of vision and the loss of the color sense. By the aid of the perimeter it will be found that one or both eyes are the seat of concentric limitation, perhaps one more extensive- ly than the other, and as a rule the loss is greatest on the side corresponding to the bodily anesthesia; that is to say, if there be a left hemianesthesia the reduction of the visual field will be correspondingly greater on that side. The simple method of testing by gradually bringing some object, either a white or colored one, into the field of vision, or removing it from the centre, may be adopted ; or we may cause the person to look at a central point on a large square of black cardboard or black cloth, the oper- ator moving pins with large colored heads into the field of vision, to be left in position when perceived by the subject. The perimeter, of which there are several kinds, should be used if possible, and is preferable to coarser tests. It will be found that central vision may be acute, but that of the peripheral field is diminished or gone. While absolute hysterical amblyopia or blind- ness is rare, it sometimes occurs, is often crossed, but may disappear rapidly before a hypnotic suggestion or shock.^ It is an uncommon consequence of trauma, or as a developed fixed idea. A variety of amblyopia, which the writer has found as an occasional result of the excessive use of tobacco as well as hysteria, is known as the " tubular field of vision." As the result of constric- ' It may throw some light upon the nature of this loss to show that in the hypnotic state the patient with hysterical limitation of the field of vision may be made to see objects within the blind limit. Sidis and White also found that a helpless subject of hysterical paralysis when hypnotized could perform acts that wtre impossible when he was fully conscious. If a pair of scissors wefe placed in his paralyzed and anesthetic hand he could use them ; and he would also use a pencil. Of course nothing of this kind is possible in incapacitating central disease. 5 66 RAIL WA Y AND THER ' A CCIDENTS. tion, " though the absolute area of the field is the same no matter at what distance it is measured, the patient sees the world as if looking through a tube of infinite length." The loss of the color sense, which may be tested by the perimeter, is one of the most interesting of hysterical anesthetic phenomena, and has not always the same method of progression. Sometimes all the primary colors gradually disappear until the perception of red alone re- Jtii/M ^1 ., Fig. 9.— Crossed (functional) Amblyopia. (Purves-Stewan.) mains; again the last color to remain is blue. When none can be distinguished, the patients see " everything gray." The loss is commonly concentric, and it is pos- sible with proper apparatus clearly to mark the different lines of limitation and the distance at which the colors are lost. The worsted is also available. Monocular troubles are significant and unilateral, and hemianopsia or diplopia which have no serious central ex- planation are among these. In certain subjects there is a peculiar loss of power of binocular cmtvergence without any single ocular muscle being paralyzed. A woman who had ACCIDENT ABOULIA. 67 been injured in a collision recently, and who was seen by the writer, could not converge or focus her eyes on any object inside of twenty-four inches. Some hysterical per- sons see objects held in front of them much smaller than they really are (micropsy), or larger {megalopsy). Monoc- ular polyopsia consists in the perception of two objects, one usually above the other. This may be found when one eye is covered, and the subject is asked to look with the other at a pencil or some other object. Vague ocular pains which radiate are highly suggestive of hysteria, and are anything but constant. Hysterical deafness is one-sided or symmetrical, and of course is found without any change in the bone or Fig. 10.— Gallon's Whistle. auditory apparatus, unless it be the subjective one of anesthesia. It may be tested with the tuning fork or by the aerial method. While the former, if held between the teeth or applied to the bones of the head, will not be heard in the deaf ear, the subject will readily perceive the watch tick at a normal point. Galton has discovered that certain subjects cannot hear very high notes, but can those of the medium regis- ter, and has invented a whistle to demonstrate this. With this the normal individual should hear a note produced by ten thousand vibrations per second, which corresponds to 8 mm. on the scale of the instrument. Persons with an- 68 RAILWAY AND OTHER ACCIDENTS. esthetic defects of hearing do not appreciate high notes. Hysterical deafness or diminution is more common than aboHtion of smell or taste, and Preston finds it usually as- sociated with actual anesthesia of the external auditory meatus and the tympanum ; in fact, the lowered sensibility of all the organs of special sense bears a general relation to the presence of cutaneous anesthesia elsewhere. Loss of taste (ageusia) and loss of smell {anosmia) are, if found, commonly unilateral, and in almost every case in connection with hemianesthesia; and these may be tested with appropriate apparatus. The former is limited to the back or front part of the tongue, and is accompanied by local anesthesia of parts in the vicinity.' ' Zwaardemaker (" Les Sensations Olefactives," L'Annde Psychologique, 1899, p. 202) has invented olefactometers for testing not only the intensity of smell, but the subject's selective and differentiating power. These are con- structed with the idea of gradually exposing an increasing surface which has ' ' ' ' 1 • — ■ — ' — I I 9 • '«„« ,5 • » 2 ' I 01 fact I es {-I — I r 290 — I — I 1 1 — I I I I '00 „ -"" 'o* 'S «<> *» OlFacties ^ Fig. II.— Zwaardemaker's Olefactometer. been coated with a perfume. A cut of the simpler instrument is appended. In those of more elaborate construction there are two tubes instead of one, and porous cells surrounded by a reservoir of glycerin, with which the par- ticular odor has been incorporated. The acuteness is determined by " ole- facts." Zwaardemaker has a classification of odors : I . Etheric odors (Rimmel's fruit series). II. Aromatic odors (terpenes, camphor, spices, herbs, roses, almonds, chemical subdivisions of cineol, eugenol, anethol, geraniol, benzal' dehyde). ACCIDENT ABOULIA. 69 Care should be taken to differentiate this kind of altered function from the loss which is due to central disease; notably to tumors or lesion about the uncinate gyrus in which is located as well the sense of smell. Case VII. — A case recently tried in which the writer testified was that of a woman who had been thrown down by a car and who was rendered unconscious. She was taken to the Roosevelt Hos- pital when her immediate symptoms of shock disappeared, but she developed erysipelas of the head and arm, with high temperature and delirium, and it was a month before she was discharged, when she was taken to a friend's house and then to another hospital. It was claimed that she had a hemiplegia of the left side, due to cerebral hemorrhage and complete loss of taste, but not of smell. There was no fracture of the skull, and the hemiplegia was clearly hysterical, disappearing suddenly and reappearing on the other side. At one time it was claimed she had a crossed paralysis with contracture, — the left leg and right arm being affected. There were spots of dysesthesia, and a great spinal hyperesthesia. Ageusia and anosmia may of course be due to various other causes; among them true central disease, nicotin- ism, plumbism, alcoholism, or are a result of cocainism and other toxemias with local effects, or they follow tumor. Sometimes the latter is the ordinary consequence of a local affection of the mucous membrane. In these in- stances it is double. III. Balsamic fragrant odors, jasmine, violet (terpinol, ionon, vanillin). IV. Ambrosiac odors (amber, musk). V. Alliaceous odors which embrace the cacodylics, vulcanized rubber, a mixture of gum ammoniac and india-rubber, asafetida, ichthyol. VI. Tarry odors. VII. Valerian. VIII. Narcotics. IX. Stinks. The recently invented coal-tar synthetic perfumes should be covered by classes II. and III., but they really are not. In this connection the writer has recently seen a case in which a peculiar perversion of smell for all these existed, which did not extend to their natural analogues. yo RAILWAY AND OTHER ACCIDENTS. Conditions of hyperesthesia are of far less importance than those of anesthesia. The areas are rarely as exten- sive ; in fact spots of superficial increased sensibility are characteristic of this kind of sensory disorder. These areas may be in close juxtaposition with the anesthetic regions, with absolute anesthesia perhaps of a leg and foot and hemihyperesthesia of the rest of the same side of the body; but this widespread hyperesthesia is un- usual. It is not uncommon to find this distribution in association with hyperzones and dysesthetic areas else- where. What has before been said as to the sensitiveness of the vertebral spines may be again referred to, for it is present both in neurasthenia and hysteria. It may be added that when firm pressure is made on one of these, or some other painful point, there will be a decided acceleration of pulse rapidity (Mannkopf's symptom). From the fact that when hyperesthetic spots are pressed or irritated, other symptoms of hysteria may be induced; these have been called hysterogenic zones. Sometimes an hysterical paroxysm may be stopped by cauterization or firm pressure over the ovary, or by compression of the testicle. The writer has elsewhere reported such a case seen with Robert Abbe.' Case VIII. — The man who was a morphine taker was the subject of an attack of grand hysteria attended by rather general anesthesia (analgesia), unconsciousness, nystagmus, contraction of the trapezius so that the head was retracted, violent clonic spasms of the thoracic muscles, exaggeration of the reflexes, and a condition of mental excitement somewhat akin to those reported by the French writers. Forcible compression of the testicles effected a prompt subsidence of all the symptoms after they had lasted twenty-four hours, and there was no return. ' Brain, June, 1886, p. 528. ACCIDENT ABOULIA. 71 The terms " ovarian," " supra- and inframammary," and " spinal " and " testicular " are used to localize these zones. An interesting form of hypersesthsia is that which counterfeits joint disease, and which often leads to errors of diagnosis. The determination of hysterical joint affec- tions is possible by the recognition of the fact that the psychic element is always present, and that pressure of some remote point will cause as much, if not more, alleged suffering than when the actual joint itself is disturbed. This hysterical arthralgia is ordinarily unattended by any degree of swelling, and there is no redness. A significant peculiarity is that rough handling does not produce as much distress as when the surface is lightly touched, especially when the patient watches the manipulations. The knee- and hip-joints are commonly affected, espe- cially the former. To dysesthesia rarely belong the well-defined distri- butions of disturbed function that are found in anesthe- sia and hyperesthesia. It is vague and sometimes is seemingly connected with true organic changes, and has then an apparently reasonable explanation. Other dys- esthesiae are associated with contractures, and a third kind is found in anesthetic subjects when the analgesia is not complete. It is observed that when anesthesia is advanced and complete, the patient makes few if any complaints ; but if the sensibility is simply enfeebled, he is annoyed by pricklings and other disagreeable sensa- tions. Dysesthesia under certain circumstances may, as the result of a fixed idea, assume a new character leading to the development of hysterical hallucinations.' A sim- ' Probably this is tiie explanation of certain sensorial delusions in paranoia. 72 RAILWAY AND OTHER ACCIDENTS. pie pain in the thorax may lead the normal individual to believe in phthisis ; but in such a case as that presented by Janet, there was not only the obsession growing out of a pain in the chest, but hysterical contractures of the inter- costal muscles of the left side of the chest and other stig- mata existed. Fixed ideas of local pain after laparatomy must be familiar to every surgeon, and in this connection attention is called to the dysesthetic conditions in litig- ants, who refer much of their vague pain to harmless scars and depressions, especially of the scalp. Persistent ideas of cold and heat are found among hysterical subjects, and • their unilateral character conveys their true nature. Janet also speaks of a man who presented cold areas in the left foot, outside of leg and thigh, and on the shoulder of the same side. These spots were slightly hypoesthetic and did not extend. They were associated with hypo- chondria, and the condition had lasted for sixteen or eigh- teen years. Case IX. — A personal case occurs, the patient being an hys- terical woman who had been in a railroad wreck and although not injured herself, saw others burned by steam. She developed almost immediately after the accident a fixed idea that she had been scalded by escaping steam, and for many years would call attention to the tingling and smarting of certain spots which were larger than those in Janet's patients. Of course she had never been injured at all. There was no tactile loss. Her visual fields were contracted, and her left hand and arm anesthetic. Subse- quently neurasthenic symptoms appeared. In certain forms of hysteria the senses of smell, taste, and hearing may become intensely hyperesthetic, certain odors producing great discomfort and the patient being able to hear high notes of Galton's whistle, which are in- audible to others. Railway and other Accidents. PLATE II. Various Types of Functional Anesthesia. (Purves Stewart.) ACCIDENT ABOULIA. 75 Aphonia and mutism are found in accident aboulia of the hysterical kind, and the latter is most important and interesting. These disturbances are too often re- garded by the ill informed as symptoms of organic dis- ease, and in some ways resemble the losses due to central affections. The aphonia or mutism may follow shortly after the accident or appear coincidently with the shock,, and last a variable time, or be cured by an electrical ap- pHcation to the vocal cords, or even externally to the neck. Again, they often disappear when a new and violent mental impression is made, or yield to suggestion. The following case, which is of unusual interest, may be re- ported somewhat in detail. Case X. — Mrs. H. W , an elderly woman who while waiting to take a street car was so demoralized by the approach and pas- sage of another that she fell to the ground, but with the excep- tion of a slight bruise over the upper and posterior parietal re- gion sustained no serious injury. This was in September, 1900. When taken to the house of her friends in the vicinity, she becaine unconscious and was treated by her family physician, who was unable to get her to talk. She remained in this con- dition for at least two months, and then, according to another physician, became delirious and talked foolishly. She subsequently was paralyzed and without sensation, so that a pin could be thrust into her legs without causing discomfort. She was mentally de- ranged, and said that her "head was gone," and that it had been appropriated by physicians. I examined her in December, 1900, about four months after the alleged accident, and again a year later. When watched and deferred to, her manner and behavior were highly suggestive of hysteria with a certain amount of associated malingering. She kept her eyes firmly closed, rolled her head from side to side, and talked " baby talk," saying " Mittit " for " Mrs.," and clearly affecting the manner of a child of three or four years of age. There were absolutely no genuine aphasia and no objective signs of any kind, nor any paralysis. Her reflexes were slightly exaggerated. Her pulse when first taken was 84, 74 J^A/LWAV AND OTHER ACCIDENTS. and in fifteen minutes afterward, during which time she was ques- tioned rather rapidly, it increased to 102. At the second visit I was still more convinced of her interest in what was going on about her, although she would not at first speak. When sharply cross-examined, she opened her eyes and replied to my questions, getting out of bed and making every attempt that I suggested, and showed that she was the possessor of fair amount of muscular power. Although she finally declared she could not see, and firmly shut her eyes, I found a pair of eyeglasses by her side which she admitted she had used. After her irritation she be- came loquacious, although keeping up her silly manner at times, and resorting to the baby talk. She spoke freely at others, calling attention to the vague pains in her head, forehead, and back. I found the latter to be hyperesthetic. She claimed that she could not walk and that the left leg and hand were without power ; but there was something very suspicious about this alleged loss, for she made an evident voluntary effort to keep the fingers flexed when I held the hand, and subsequently allowed them to relax ; but when she got back to bed after sitting in a chair, she not only grasped the back of her daughter very forcibly, using the left hand as a well person would, but the left leg as well, without embarrassment. The jury in this case gave a verdict of between two and three thousand dollars — after her appearance on the wit- ness stand. Although a well-known neurologist had testified that she was demented, she had no difficulty in answering the majority of questions intelligently in a low voice, occasionally mispronounc- ing a word when she became annoyed or confused, evidently by the purport of the question. There was nothing in her appear- ance in the court room that indicated the alleged paralysis, and she certainly was not aphasic. The v^friter has seen cases of word bHndness and word deafness, but the hysteroid character was revealed by re- peated examinations which showed their inconsistency. All psychomotor acts of the hysteric are noted for their inconstancy. Troubles of respiration are more marked in hysteria major, and are rarely seen in the traumatic form. In a ACCIDENT ABOULIA. 75 small proportion of cases, especially when there is a neu- rasthenic admixture of symptoms, there is a decided acceleration of respiratory efforts, the normal rate being often increased three times. Osier reports a case in which the respirations were 130 per minute, and the subject himself had counted 150 at another time. The patient is habitually apt to count, as was the case with this indi- vidual, and doubtless the rate of respiration is increased by the expectant attitude that is cultivated. In the ex- cited conditions a myographium tracing will show a great disproportion between the action of the abdominal and thoracic muscles, especially in splmtchiic hysteria. The rarer symptoms of this variety may be found in traumatic examples. While I have never seen that form of ab- dominal distention known as meteorism or some of the other phenomena of a disturbance of the sympathetic or splanchnic nerves, it is not unusual to find persistent vomiting, neurotic edema, and hematemesis hysterica. In one case the writer found that the disorderly collec- tion of symptoms was augmented by that of chromi- drosis ; but in all except this there had been attacks of hysteria major. Allusion has already been made, in speak- ing of neurasthenia, to the case of Mr. R , and the vomiting of blood was undoubtedly here a hysteroid com- plication. Bernhardt and Kronthal report the case of a man who had lived three years after an accident, and be- sides his hystero-neurasthenic symptoms he occasionally had attacks of hematemesis, but no internal lesion was found at the necropsy to account for it. What is known as neurotic edema is a rare symptom in traumatic hysteria. Case XI.— A case of hystero-neurasthenia which fell under the notice of the writer was that of a laboring man who fell from 76 RAILWAY AND OTHER ACCIDENTS. a street car of the Third Avenue line, in the month of December, 1 895, striking the back of his head and left hip. He was dazed and nervous, and was taken to Bellevue Hospital, where a slight bruise was found at the back of his head, but no other external evidence of trauma. After a stay there of less than an hour he went home, and remained in bed about a week, and in his house about a month and a half. He engaged a lawyer the next day to bring suit against the railroad company and was seen be- tween this time and March, 1898, by not less than four physicians. His complaints were that his left arm and hand were first swollen, that the left leg was dead and cold, and that he could not bend the arm, "and had no ambition to raise it." His voice was weak and had been so ever since the accident, and he " saw stars " when reading. There has been persistent insomnia and "he awoke nearly every hour." He has not been able to walk ten blocks since the accident, although about this there has been a conflict of opinion. He could not cohabit with his wife, though he had the desire. His several physicians testified that they were able to thrust pins into both legs and " into the substance of the pros- tate gland " without any pain being produced. From the time of the alleged injury until March, 1898, he said that he had lost thirty-four pounds, and there had been a state of continued inval- idism up to that time, with constant vomiting, so that he could not retain any food — ^not even milk ; in spite of this, however, he looked fairly nourished. His appearance was characteristic, his forehead being wrinkled, and his expression was one of resigned grief. According to his physicians he was unable to use the mus- cles of the left side and there was diminished reaction to the faradic current, and according to them his skin was insensitive to strong currents applied to the surface of the left foot, leg, and thigh ; the entire back being sensitive. A physician of the com- pany who made an examination was unable to find any indication of organic disease, flatly contradicting the physicians of the plain- tiff. There was certainly no embarrassment of motion when he took the witness stand, for at different times he apparently used his lower extremities without difficulty and it is probable that he had recovered from any previous motor weakness. When he raised his trousers it was found that there was an uneven, pro- nounced edema of both extremities with shiny skin, and this ex- isted without any renal disease or history of alcoholism, so that. ACCIDENT ABOULIA. 77 taken with the vomiting (about which the testimony was most emphatic), there was probably some splanchnic hysteria. He obtained a heavy verdict, and I was informed by his counsel two years after the trial that his condition had improved but little. Hysterical suppression of urine has been described fully by Charcot. This irregularity, which in a minor degree existed in the case of the hystero-neurasthenic Mr. R when the urine on one occasion was passed only once in thirty-six hours, may be a much more pro- nounced symptom. This ischuria may consist of periods of suppression, which in Charcot's cases apparently lasted for weeks, and is often followed by polyuria, when the patient passes large quantities of limpid fluid. In these cases there is often vomiting or profuse sweating or sali- vation, and the urea is thus probably gotten rid of in other ways. The Mental Condition. The mental state of the hysteric is notably one of dis- equilibrium, implying the most disorderly kind of con- cept association, a riot of sentient impressions, and more or less absolute weakness of will, which is shown in the abasement in the exercise of all the intellectual functions. In the hysteria major of the French we are furnished with a bouleversement of an extravagant character shown by varying disturbances of consciousness, a state of ecs- tasy, " beatitude," and alternations of emotion. Conditions of double personality are referred to by Richet, Janet, Myers, and others, and occupy a prominent place in neu- rological literature, and the religious exaltation and the connection with hysteria are doubtless due to racial and local peculiarities. Its hallucinations are rare outside of France, and this religio-sexual tinge is due in a measure to 78 RAILWAY AND OTHER ACCIDENTS. the environment of the patient. In America and Eng- land these cases are rare. The mental condition is rather that of the so-called " interparoxysmal state," the ordinary feature of which consists in a peculiar emotional and moral instability which is seen in perverted ethics and morals, lying being easy and habitual. There are the con- stant demand for sympathy, the love of notoriety, and the martyr-like bearing which may be quiet or obtrusive, with vacillation, and weakness of judgment. Tears or laugh- ter are so near the surface that without adequate cause the subjects are as likely to weep as to laugh for the same reason. They sometimes make charges against others so shallow that they should see the certainty of exposure and detection which they do not. Sometimes, as Lefevre has shown, the charges of assault are made by irresponsible young girls as the result of unconscious auto-suggestion. Memory is apt to be deficient, or may be lost in hysteri- cal subjects about certain occurrences; but there is no rule about this, and there is often simulation for obvious reasons. The hysteric may, and often does, lapse into a state evidenced by mental symptoms of an irregular kind. These departures are appreciated in a measure by the subject, but he cannot escape them, and they take the form of obsessions, which are perhaps fleeting and short- lived, phantasms and hallucinations of memory. Case XII. — L. G , a woman of thirty-one years, was one of the occupants of an elevator which fell a short distance in a department store. No one was injured but herself, and she was only shocked and demoralized ; she claimed she was for a few moments unconscious. She was taken to her home in the upper part of the cit}', and the next day had an apparent hysteri- cal convulsion with unconsciousness, and after recovery passed a large quantity of urine involuntarily; she subsequently be- ACCIDENT ABOULIA. 79 came aphonic, but this disappeared as suddenly as it came. There were subsequently backache, cephalalgia, and various dysesthesiae. When seen for the second time, October 13th, 1901, she was apparently in a condition of profound ill-heal,th, and was unnerved and aboulic. She complained of shortness of breath and gen- • eral weakness, and ascended the stairs with great difficulty. She was pallid, had a weak pulse, and had a melancholic facies. There were areas of hyperesthesia on the right side of the body, and especially on the scalp, which was so tender that the weight of her hat caused her great pain. She could not read without great fatigue, and if she persisted had an hallucination of see- ing smoke. At times she was nauseated and had hysterical vom- iting. From time to time she had hysterical contractures of the left side of the body, with anaesthetic spots. At the time of the accident she was menstruating, but it stopped and has never but once reappeared. About three months after the accident she de- veloped morbid fancies, some of which became obsessions, and she had an impulse to spring at and injure her husband, to whom she was devoted. When holding her child upon one occasion she had a loss of consciousness following an obsession and impulse to kill it. At other times she had visual hallucinations when she saw the figure of a man in black who laughed at her ; she, how- ever, recognized that it was merely a phantasm, but was neverthe- less frightened. At the time of the last visit she slept badly and was tortured by dreams. Her case was settled with the in- surance company, but I was informed a year later that her condi- tion had not improved to any great extent. Major or grand hysteria, to which reference has been made, is occasionally met with in connection with trauma, but in such cases there have undoubtedly been previous convulsions and manifestations due to other agencies. When a consequence of the accident, it is purely the result of fright or developed brooding. The acces are occasional and general, and the patient is appar- ently unconscious, although not always so, for she may subsequently recount what has taken place. Sometimes the attack may take a cataleptoid phase and last for a «0 RAILWAY AND OTHER ACCIDENTS. long time. Even with those who are supposed to be hon- est there is deception and lying, perhaps a pretended inability to take food, or to do certain things they are perfectly able to. To this class belong the examples of alleged continued unconsciousness which often find their way into the newspapers. Sometimes these states occur in males as well as females, and the following case, in which the writer appeared, may be quoted : Case XIIL' — W. S was a boy who, during the year 1896, was employed in a trunk store, and it is claimed that he was one day assaulted by two employees of the city because he refused to re- move from the sidewalk certain trunks which should not be there. Almost immediately after the assault, which does not appear to ■have resulted in any great immediate injury, he became uncon- scious at his home in Brooklyn, and remained so until after the examination by the defendant's physicians on December 4th, 1897. He appeared to be nineteen or twenty years of age at this time. He was lying in bed on his back with head turned to the left, the left forearm bent at the elbow, while the arm itself was extended at a right angle with the trunk ; the left leg was bent at the knee and abducted, the right arm was bent at the elbow with the forearm lying over the chest ; the right leg was extended ; the eyelids were closed and tremulous. There was considerable tremor of both legs. He was apparently unconscious, and insensible to all ordi- nary external impressions. The pulse was 140, soft and feeble, the respirations were 60 and very shallow ; on raising the eyelids it was found that the eyeballs were strongly rotated so that both pupils were turned upward and to the left. So extreme was this rotation that the pupils could not be examined. The conjunctiva was apparently insensible. There were incomplete hemianesthesia on the left side and hyperesthesia on the right side, and tremor followed the irritation of the surface of the needle. The face was flushed and the general surface was moist and warm, with the ex- ception of the extremities which were cool. There were no vol- untary movements of any kind. The right side presented in a ' The history of this examination is largely drawn from the report of Dr. Austin Flint. ACCIDENT ABOULIA. 8i most marked degree the waxen flexibility and immobility when the arm or leg was put in a position requiring sustaining muscular contraction characteristic of catalepsy ; but the upper eyelids fell immediately after having been raised so as to expose the globe. When the body was raised to a semi-erect position in bed this was maintained for several minutes, when there occurred violent gen- eral tremor, and he was restored to the recumbent posture to avoid possibly dangerous nervous disturbance. The same phenom- ena were presented when the right arm or leg was raised. The members on the right side were easily put in any desired position ; on the left side there was rigidity amounting nearly to tonic spasm. The muscular contractions on the left side were over- come with some difficulty, and the arm and leg when moved soon regained nearly their original positions; the waxen flexibility, so marked on the right side, was but slight on the left. The plantar reflex was absent on the right side and delayed on the left. The knee-jerk was absent on both sides. During the examination he was given some milk from a feeding spoon or small dish. It re- quired a fevir seconds to separate the teeth. A little milk intro- duced into the mouth in this way was swallowed after a few sec- onds, but the feeding as done at the examination was very slow, and it did not appear that it would be possible to introduce enough nourishment by this process to sustain life for any considerable length of time. The body, however, was apparently fairly well nourished, and there was no emaciation. Shortly after this, in 1898, his case against the city was tried, and he received a small verdict. In a few days he recovered consciousness and told his doctor that he had "been in a place too horrible to describe, where he had been constantly tormented by the employees of the Bureau of Incumbrances " ; it was alleged by his physician that the hystero-cataleptoid state has returned, and that his condition has altered greatly for the worse. Yet it appears that the young man subsequently went abroad and returned sufflciently well to become a party to fresh legal proceedings. Despite the fact that hysteria is one of the most dra- matic and common nervous disorders, no attempt so far has conclusively fixed the existence of a central morbid state. In the form under consideration the post-mortem 6 82 RAILWAY ANE OTHER ACCIDENTS. findings have been equally unsatisfactory. Evidences of arteriosclerosis have been discovered by Bernhardt in two subjects on whom necropsies were made ; but the question at once arises as to whether this vascular change was not due to something else which had no connection with the accident. It seems to be a favorite theory of those who -i'vak* 1 Motor ^Centers m general whicli ai about tbe Bolandic Fissure, Fig. 12. — Scheme of Conscious and Sub-conscious Fields with Psychic Mechanism and Idea Formation. (Modified from Lefdvre.) have written most extensively about traumatic neuroses that the morbid appearances are dependent upon mul- tiple hemorrhages throughout the nervous substance. Artefacts are so commonly found that one is inclined to look upon their discovery with suspicion, especially as they are so often produced by careless manipulation, or are due to other causes, such as rough handling or ex- treme changes of temperature, the findings in the Guiteau case being an example of this. ACCIDENT ABOULIA. 83 The term hysteria should imply an inactivity of the higher centres and the enfeeblement of co-ordination and will power, while there, however, remains a certain amount of volitional activity of another kind which is part of the subconscious self. The conservation of this latter for the performance of certain actions that may have become to some degree habitual is possible, and be actuated by simple suggestion ; or a disorderly expres- 3ion of ideas that do not enter the higher sphere of con- sciousness sometimes takes place. Certain organs that become hysterically anesthetic, when the subconscious self is appealed to, are even able to functionate in a con- ventional way. Sidis has in this connection called attention to the ex- istence of the operations of the subliminal self, and has by suggestion been able to induce the subject of hemianesthe- sia and hemiplegia to do many things that were seemingly impossible when the already inhibited upper stream of consciousness was in vain relied upon, and when the superior will was dormant. " The law of suggestibility in general," says this writer, " and those of normal and ab- normal suggestibility in particular indicate a coexistence of two streams of consciousness, of two selves within the frame of the individual : the one, the waking conscious- ness, the waking self ; the other, the subwaking conscious- ness, the subwaking self. But although the conditions and laws of sensibihty clearly point to a double self as constituting human individuality, still the proof, strong as it appears to me to be, is rather of an indirect nature. We must therefore look for facts that should directly and explicitly prove the same truth. We do not lack such facts. We turn first to those of hysteria." 84 RAILWAY AND OTHER ACCIDENTS. The recognition of this process enables us to under- stand many of the extraordinary phenomena of hysteria, not only in its purely psychic manifestations, but in more material expressions which are ordinarily in antagonism with our preconceived ideas of responsible consciousness. It explains why an individual will deliberately and honest- ly make a declaration in regard to a subjective condition which does not really exist, for a perversion may be en- gendered as the result of a sufficiently strong shock or mental impression to inhibit the higher brain centres. The dependence of the motor and sensory symptoms of hysteria upon some disorder of the psychical equilibrium in contradistinction to the symptoms which follow a structural disorganization of the elements of the cerebro- spinal system is characteristic of the disease. This is abundantly proved by several things. First, that all of its physical expressions, no matter how apparently real they may be, may not only be produced by suggestion, but are often the product of what are known, and what Berkely refers to, as " dream ideas associated with the defective capacity for co-ordination of psychic processes." Hysterical monoplegia, hemiplegia, paraplegia, con- tracture, or tremor may be thus accounted for, and the genesis of sensory disturbances, such as hemianesthesia in its various forms and limitations, is none the less diffi- cult to understand. The fact that it is possible to restore or modify lost sensation by the application of magnets, coins, or other objects to the surface of the body where anesthesia has been found, or to transfer sensation (allo- chiria), must show that this lost function does not de- pend upon a lesion, or any destructive pathological proc- ess, but to an actual abeyance of function. Attention has ACCIDENT ABOULIA. 85 already been called to experiments that have been made which establish the fact that two streams of consciousness exist, but that it is possible to cause an individual in the hypnotic state not only to use an hysterically paralyzed limb, but to enlarge an hysterically limited field of vision, or to modify the individual's powers of perception by suggestion. The second and more readily understood proof of the unstable nature of the cerebro-spinal mani- festations of hysteria consists in the fact that they may often be caused completely and suddenly to disappear under the influence of a profound mental impression. This possibility is as old as the history of medicine, and it has, it is unnecessary to say, entered into the creation of most of the marvellous and supernatural cures and miracles. Paget was the first writer who more than thirty years ago described these psychoses as imitative disease, or neuromimeses as he called them ; and to-day skilful orthopedic surgeons and neurologists readily rec- ognize the fact that the subjects of neurasthenia or hys- teria may unconsciously present the symptom of real affections, especially those of the joints or the muscular system. These diseases may be so closely counterfeited, as the result either of slow and continued suggestion or of sudden shock, that the families of the patients and even skilful physicians will for a long time be deceived. In this connection we must recognize what modern psy- chologists have called the "disaggregation of subcon- sciousness " to explain the complete upsetting sometimes of the ordinary mental regulation, as well as the primary personal judgment— the preservation of the faculty of the estimation of the individual relation. It is hardly necessary again to refer to the contributing 86 RAILWAY AND OTHER ACCIDENTS. factors other than the trauma itself ; and while Dejerine, Dorliat, and some writers agree that a hereditary soil is not necessary for the growth of the traumatic neurosis, the actual experience of those who investigate these cases most constantly would seem to contradict this. It is alleged that stout, healthy laboring men are as apt sud- denly to become neurasthenic or hysterical after an acci- dent as those about whose predisposition there can be no earthly doubt ; but in these a diligent or even a superficial search may sometimes disclose a bad family history in which tuberculosis, alcoholism, or some such factor finds a place. It is a somewhat curious fact that since Jewish immigration has increased to such a degree during the past decade, many of the plaintiffs in accident cases are of this race ; and it is well known that the predisposition of the Semite to insanity as well as nervous diseases of every kind is very great. Men seem to outnumber the women. Naturally children do not develop the so-called traumatic neurosis ; but, when injured, suits are brought in their behalf for material injuries of more or less conse- quence. So far as the alleged source of injury is con- cerned, it would appear that falls backward are more common than others. It need hardly be said that the so-called traumatic neuroses not only follow general injury, when there is no recognizable wounding of the nervous organs themselves, but may develop when there is literally no physical trauma. CHAPTER III. INJURIES OF THE CRANIUM AND ITS CONTENTS. External violence to the head is, of course, under certain circumstances, apt to be followed by widely vary- ing disturbances of function, or by actual disease of the brain and its membranes. When subjected to direct and sufficient injury, the scalp ordinarily presents contusions, ecchymoses, and wounds of different kinds.' While fractures and depressions may perhaps be found beneath such scalp wounds, the outer table being involved, ' I. Blunt edges sometimes produce scalp wounds having straight out- lines and sharp clean edges, which in these respects could not be distin- guished from wounds produced by sharp cutting instruments. 2. Scalp wounds, which exhibit entire hair bulbs projecting from the surface of their sections, have been produced by a blunt instrument. 3. Wounds exhibiting nerve filaments or minute blood-vessels bridging the interspace between the lips of the wound, toward the middle of the depth of the section, while the tissues have receded all round them below as well as above, have been produced by blunt non-penetrating instruments. 4. When a wound, even with sharp, well-defined margins, bears in con- tour a resemblance to an osseous ridge in close proximity, there is a proba- bility that it was produced by a blunt instrument through forcible impact against an underlying osseous ridge. 5. Cut hairs found in the immediate vicinity of a wound are valuable aids in determining whether a sharp or a blunt instrument has been made use of. 6. As to the diagnosis between wounds produced by instruments of the knife kind and other sharp-edged substances, such as glass, earthenware, etc., no dependence can be placed on the mere regularity of outline or sharp- ness of edge, or the reverse. 7. Sharp clearly defined wounds in certain cases present peculiarities in their terminations which may be sufficient to enable a probable diagnosis as to whether they were produced by a knife or a portion of glass or earthen- ware (Macewen). 87 88 RAILWAY AND OTHER ACCIDENTS. injury to the cranial bones may be confined to the inner table, with possibly resulting symptoms of irritation and compression, and subsequent obscure but serious mani- festations dependent on destruction or degeneration of the brain substance. The case again may not be seen until a much later time, when cicatrices and depressions, due to fracture or erosion of bone, alone remain ; or, on the other hand, there may be more or less indication that the deep parts have been wounded or contused without any discoverable external appearance. Severe injuries often do little damage, while slight ones may, by trans- mission of force, lead to laceration of deeper parts and possibly abscess. Surgeons generally hold that the amount of damage done to the brain is apt to be inversely proportionate to that inflicted upon the skull. It would appear that the head is more liable to injury than the spine, not only be- cause of its position, but from the fact that the latter is so much more securely invested by protecting tissues. In some ways the skull is admirably adapted by nature for the care of its delicate contents ; and, like other spherical bodies, often escapes the full force of a blow. It is for this reason that there are comparatively so few serious injuries as the result of so many seemingly dangerous exhibitions of force. Glancing blows, so common and frequent, are less likely to produce serious trauma ; but, of course, the chance of injury from falls is greater. Much depends upon the age of the subject, the condition of his bones, and the possible existence of increased fria- bility. Old people, as well as the insane, and those who are subjects of trophic disease, are especially liable to fracture when considerable force has been exerted. On INJURIES OF THE CRANIUM. 89 the other hand, even when there is no fracture, a skull may be subjected to a very great deal of violence and compression without any very dangerous results. In the young subject considerable bone displacement, with re- sulting pressure upon the brain, is possible, but the con- sequences are not necessarily serious. Case XIV. — In this connection Dennis reports the case of a child who fell to the basement from the third floor of a tenement- house, striking upon the head and sustaining an indented fracture upon the side of one parietal bone. The indentation was very marked, and the depressed bone caused cerebral compression to such an extent as to produce hemiplegia of the opposite side of the body. The child was taken to the operating room, and while in deep coma and still hemiplegic, the sides of the head were ma- nipulated so as to cause a bulging out of the elastic bones of the skull, causing the indentation to disappear and consciousness to return at once, with instant relief of the hemiplegia, and subse- quent complete recovery. CONCUSSION. Much confusion has arisen in connection with a con- sideration of what is known as concussion, which is the result of shock. It is produced in so many different ways, and the disturbance of the physiological condition is so variable, that there is often great want of exactness in defining its expressions and method of production. This disturbance of cerebral function is either very sudden and short-lived or lasts for some time. It is commonly due to falls or blows upon the head ; but does not follow, as is often alleged, the sudden stoppage of a rapidly moving railroad train, being rather a direct and local exhibition of force. The protection afforded by the arrangement of the three investing membranes of the brain and the cere- 90 RAILWAY AND OTHER ACCIDENTS. bro-spinal fluid is quite good enough to prevent any harm, or at least any lasting disturbance, even after con- siderable cranial injury ; and as a rule simple concussion is likely to indicate a mere disequilibration. . The term concussion then need not, of 7iecessity , imply a serious or dangerous condition, its phenomena being usually transi- tory and consisting of symptoms due to the sudden de- pletion of the vessels of the head. There are, however, fatal cases of concussion, death being preceded by a rise of temperature and an increased rate of pulse and respiration, which are ordinarily sup- posed to be due to impairment and final extinction of the functions of the vagus and other nerves regulating the respiratory centres. Kocher reports a case in which a patient died on the third day. He found no morbid appearance in the pons, medulla, cerebral peduncles, or cerebellum, but minute extravasation in the corpus callo- sum, walls of the left ventricle, anterior part of the left optic thalamus and frontal lobe, and in the anterior part of the right optic thalamus. He therefore believes that in fatal "concussion" there is really a widespread and minute laceration due to the distribution of an impulse by both brain substance and cerebro-spinal fluid. Mental disturbances, extending from slight vertigo or confusion to complete loss of consciousness, which rarely lasts for more than a few days, more often a few minutes ; perhaps vomiting ; dilatation of the pupils, pallor, and car- diac weakness expressed by a small rapid pulse, are famil- iar to most persons. Under some circumstances there is a relaxation of the sphincters with involuntary dis- charges from the bowels or bladder. If the unconscious- ness is protracted, it may be looked upon as the expres- INJURIES OF THE CRANIUM. 91 sion of some hysteroid state, or else of a far graver com- pression of the cerebral mass. Concussion is, after all, a sudden change of balance between the cerebro-spinal fluid in the ventricles, perivascular and other spaces, and the blood contained in the vessels themselves. To this is added a more or less general derangement of cell function. An important medico-legal fact is the relation of this state to consciousness and intelligence ; and it has been held that without consciousness no concussion can occur. That is to say, if a person while descending a lad- der has an attack of syncope and becomes unconscious, and then falls in consequence of his unconsciousness, he may not suffer from concussion of the brain at all. If he falls while conscious, he is certain to receive concussion of the brain, if he does not sustain a more serious injury. Dennis, from the inspection of a large number of cases, has come to the conclusion that there is a decided difference as to the susceptibility to nervous accidents, especially concussion, between persons of high and low organization, a conclusion which has a bearing upon cer- tain well-recognized facts familiar to criminologists. In this connection he reports the case of a dull, backward boy of sixteen, who could not read or write, and who fell six stories through an elevator shaft, sustaining a fracture of the skull without any apparent concussion, for he im- mediately arose and climbed up the five or six stories to the place from which he had fallen. He therefore re- gards persons of fine nervous organization and cultiva- tion as those most unstable and susceptible to shock. 92 RAILWAY AND OTHER ACCIDENTS. LACERATION AND CONTUSION. These forms of injury are always of moment, and serious after-effects are likely to follow. They may or may not be associated, but are usually accompanied by a certain amount of concussion, and are productive of lesions of a destructive character, such as minute extravasation, edema, or rupture of some intracranial vessel with subse- quent increased tension and tissue disorganization. The formation of a lesion in this way is often basal, even when the force is transmitted from above, as it may be. Under some circumstances the effects of a severe blow, inflicted upon one side of the head or on top, may be exerted upon an opposite point, provided the density of intervening tis- sues be favorable, and there be no interposing cushion of cerebro-spinal fluid, or by "cone bulging."' Such in- stances have been possible where there was no disturb- ance at the point of impact, and where a mistaken diag- nosis has been made. In most cases, however, there often turns out to be a transmitted or radiating fracture from a superior point. ' Miles, of Edinburgh, made a number of experiments which consisted in the delivering of blows of varying force upon different parts of the exterior of the cranium. The result was a " cone of bulging " usually at some point opposite the point of impact, there being a determination of the cerebro- spinal Jiuid or a temporary change in the shape of the skull. In reality his results were an explanation of the older contre coup. Frontal and vertical blows caused the most serious results, the violence being expended at the base ; and if sudden death did not occur with tetanic convulsions there were lesions of the ventricles, and the medulla and upper cord suffered. Occip- ital blows were less serious, while violence directed to the lateral aspect of the head was the cause of general disturbance, and the intraventricular pressure was decidedly modified, giving rise to a less serious train of symp- toms suggestive of irritation. Some years ago Duret in the same manner experimentally produced a lesion of the fourth ventricle by striking the fron- tal bones forcibly, the explanation being that the cerebro-spinal fluid was driven violently back through the lateral ventricles into the fourth. IN/URIES OF THE CRANIUM 93 In laceration especially the occurrence of hemorrhage IS usually immediate and sometimes extensive, leading to increase of intracranial tension, the meningeal arteries being most often ruptured. Laceration is a far more serious condition than contusion, and its effects are as a rule shown more quickly. Confusion of the brain is looked upon as a very common effect of trauma, even of a Fig. 13. — Contusion of Brain. (Vibert.) slight kind, and most writers emphasize its importance, some perhaps unduly. The most serious cases are those which are basal (Fig. 13). A certain number of obser- vers consider what is known as coinmotio cerebri as but a form of contusion, although a distinction is made by those who would explain all persistent cases of traumatic neurasthenia in this way, especially those of the doubtful kind, in which there are suspicious expressions of central disease. When there is no fracture, but serious indica- 94 RAILWAY AND OTHER ACCIDENTS. tions of a suspected cerebral contusion or laceration, an examination of the cerebro-spinal fluid, drawn by lumbar puncture, may clear up the real condition. In such a case, when a man had been hit upon the head, with re- sulting mental symptoms of a light grade with aphasia, and it was believed that no fracture had occurred, the cerebro-spinal fluid, when drawn off and submitted to cen- trifugal action, showed the presence of a minute blood clot ; ' and further microscopical examination demon- strated that there were many red corpuscles. There can be no doubt that in obscure cranial or spinal fracture this procedure will prove of immense diagnostic value in the future. It is needless to say there is much exaggeration and misconception regarding cerebral commotion, and many purely functional examples are given undue impor- tance. CEREBRAL COMPRESSION by blood, purulent formations, or depressed bone, or by the products of slow meningitis or hydrops, is manifested by evidences of increased blood pressure which continue until relief is afforded by an opening or until the case ends unfavorably. If extensive enough, the respiratory centres may be quickly overpowered and death occurs. In this connection attention may be called to the more or less authoritative statement that if one-twelfth of the intracranial space is encroached upon by a foreign body, death will certainly ensue. Even when serious second- ary symptoms develop and continue for some time, the relief of the pressure may, in exceptional instances, be fol- lowed by a rapid and complete cure ; but much depends upon the nature of the morbid process. ' Verbal communication by Dr. C. L. Dana. INJURIES OF THE CRANIUM. 95 Cases of interest are reported in which bilateral pressure upon the upper third of the anterior and posterior central convolutions, wherein the motor centres for the lower ex- tremities are located, produced a paraplegia which almost immediately disappeared when the gauze packing which had been introduced was removed. In one of these cases lowering of the radial-pulse pressure was recognized by the Oliver instrument, and noted from day to day as the im- pinging foreign body was withdrawn, the patient ulti- mately recovering. Cases of compression, as the result of head injury without external wounds, but with internal laceration, may present coma and convulsion, increased pulse press- ure, Cheyne-Stokes respiration, dilated and slowly acting pupils, and apparent blindness. Sometimes there are to be found a number of lymphocytes in the cerebro-spinal fluid and other evidences of a commencing inflammatory condition; but it is even possible some days or weeks after an accident, with such increased intracranial tension, to effect an astonishing restoration by giving relief to the impinged brain in the manner indicated. In the event of such neglect the coma continues, vomiting occurs, paraly- sis supervenes with rectal and vesical incontinence, the temperature falls, and the signs of vital dissolution ensue. In this connection it may be remarked how tolerant the cerebral cortex may sometimes be to in- terference in the absence of serious compression. Sev- eral cases are recalled in which extensive comminution and depression of bone about or above the motor centres with laceration existed without any grave or lasting paralysis, or those sequelae that might naturally be ex- pected. 96 RAILWAY AND OTHER ACCIDENTS. Case XV. — Dr. Lewis A. Stimson has communicated to the writer a case of this kind which in a way is somewhat unusual, but is an illustration of what has been said The patient was a healthy man of fifty who, while engaged in the cellar of a building, received a head injury. A hammer-head fell from the tenth story, the prongs being driven through a Derby hat he wore and through the scalp and bone He was unconscious for two or three min- utes only, sustaining slight shock, and almost immediately talked rationally on his way to the New York Hospital. There was complete motor paralysis of the right arm and leg. The right knee-jerk was much exaggerated, as was the Babinski reflex on the same side; a,nd there was a corresponding ankle clonus. The wound was small and consisted of two openings corresponding to the claws of the hammer, side by side, one at the median line and another a trifle to the left and half an inch below the vertex ; the other three-quarters of an inch to the left of the first wound. There was penetration with comminution and depression of the inner table. Broken bone was removed and the dura found intact ; a small incision was made and a blood clot removed This was on November 19th, 1903. The rise of temperature did not exceed loi ,5° F. at any time, and it was in no way notable The next day found him in excellent condition, the paralysis persisting with dysesthesia. November 24th there was a marked tingling sensa- tion in the finger and hand; at 6:15 p.m. a partial return of power in thumb and forefinger. November 25th, again some power in hand and forearm. November 26th, there was a return of power in hip and knee and in shoulder November 30th, the patient could touch both ears and place paralyzed hand on top of head. In early December, pronation was possible; toes and feet were still paralyzed, and he was discharged improved. FRACTURE OF THE SKULL, Cranial fractures are usually divided into two kinds so far as location is concerned — namely, those of the vertex, and those of the base ; and both may coexist, the fracture of the upper part of the skull frequently extending down- ward, although its detection is not always an easy matter (Fig. 14). R.UI.W.W ANIl llTUKK At (_ lUli.Nl s. PLATE III. i- ^v>i.; |«4J A. Fracture of the Base of tlie Skull from Antero-posterior I'ressure. The patient, a man aged thirty-five, sustained a fall of ten feet on his head. At the autopsy this fracture, passing through the foramen magnum, was found. (Hutchinson's" Illustrations of Clinical Surgery," vol. i., Plate .xxx.) B, Transverse Fracture of the Base of the Skull, produced experiment- ally on the dead subject by forcible pressure exerted across the skull, the result being precisely analogous to that shown in Fig. .1. (Helferich.) INJURIES OF THE CRANIUM. 97 The immediate recognition of the first kind should be made, if diagnosis is at all possible, by touch or inspec- tion ; but we must rely upon far less direct means for the detection of those at the base of the cranium, and, conse- quently, the chance for error is very great. In fact, these fractures are sometimes detected only after death, the patient perhaps succumbing to some other disease, his Fig. 14. — Depressed Fracture of the Skull with Extension. real trouble being unsuspected. The immediate recogni- tion of fracture of the vault is possible by manipulation, or when a wound is present, by the direct examination of the exposed skull. Sometimes this is very difficult, espe- cially when no comminution or depression exists where the scalp is intact, and the fracture is linear or stellate, or where it involves comparatively thick bone, or is con- cealed by dense tissue or muscular covering. Under some circumstances a compound fracture may be indi- cated by the peculiar tumid lump, which is known as 98 RAILWAY AND OTHER ACCIDENTS. Pott's puffy tumor, the scalp being intact. In the case of a basal fracture a diagnosis is largely inferential, the sig- nificant indications in such cases being the escape of blood or serous fluid from some of the openings of the head, when we are able to judge with some accuracy as to the situation of the fracture. Phelps has collected a very valuable series of his- tories, and in 286 of these there was a hemorrhage from the ear in one-third of all the cases, in which, after death, there was found a fracture of the petrous portion of the temporal bone ; and hemorrhage of the nose in one-fourth of all his cases, in which fracture of the anterior fossa and anterior part of the middle fossa was found. In six cases in which hemorrhage from the conjunctiva occurred the anterior fossa was found to be the seat of the fracture, and in three cases in which buccal hemorrhage occurred the fracture involved the same situation. Fracture in the posterior fossa was connected with a subcutaneous ex- travasation behind the ear, and fracture of the mastoid process of the temporal bone caused the same local hem- orrhage. The blood may come from the vessels of the diploe, or from the sinuses of the dura that may be opened, or from some implicated vessel. The escape of serous fluid from the ear was not found to have the great diagnostic importance that is popularly attached to it. Unless of immediate occurrence and in very large quan- tities it may mean nothing, and even then be due to other causes. Of course, the escape of brain matter from the meatus is a grave and indisputable indication of frac- ture, as is a true hernia cerebri. Edema of the tissues over the mastoid region is gen- erally recognized as an important result of fracture of the PLATE IV. K.ViLW.W AMj ii]lli:K .\l I IlilCXTS. .1 , / . ] Ini-i/(jinal Section tbrouyli tlie Skull with tlic Contained linnn, >lw>\vii)L;" a laii;"c ext)'a\'asation of liloixl from llie niidillc nn;iiin;j;"eal artery lielweeii tlie liiaiii ami dura. This has been caused l>_v a fracture through Ihe temporal bone. The brain is compressed and displaced inward. n lutcliinsciii's " Illustrations of Clinical Surgery," vol. ii., f'late liv.) />'. l'"ractui-e of the .Skidl with Rupture of the Middle Meningeal Artery, I mm a workman, aged twenty, who fell from the fourth story of a house. < )n admission to tlie hospital there was an extravasation of blood in the left temporal region, as well as a perceptible fracture of the sciuamous portion of tlie left temijoral bone, followed 1)_\' escape of cerebro-spinal fluid from the left e.ir, and parahsis of the left side of the face and of both arm and leg on tlie right side. Death resulted from tetanus due to infection of a ciMitused wound in the thigh. The drawing sjiows the position of an ex- tra\asation of Ijlood fnini tlie posterior branch of the middle meningeal artery, together with the bifurcation of this arter)', llie line of fracture, etc. (Helferich.) INJURIES OF THE CRANIUM. 99 walls of the posterior fossa, as well as the temporal bone. Another important result of fracture of the base, which may be immediate or of later appearance, is the involvement of certain cranial nerves, and it is not uncommon as a con- sequence of a secondary meningitis to find implication of several of the important nerve trunks at the base of the brain. Those immediately injured, however, are the olfactory, trigeminus, optic, and the auditory nerves, for they all pass through delicate bony parts which are very liable to fracture. Cranial injuries, if of sufficient extent and severity, are likely to be followed by hemorrhage, contusion, and laceration of the brain and its membranes, and by thrombosis of the sinuses ; and secondarily, by a variety of inflammatory conditions, to some of which ref- erence has been made. Besides these there are certain in- determinate mental changes that cannot be regarded as occasional or mere psychological curiosities. Among these are moral perversities, peculiar phases of disturbed con- sciousness, and certain dramatic hysterical, and epileptoid states, as well as affections of speech. The immediate effect of the violence that produces the fracture and the shock are so familiar that they may be dismissed with few words. There may be a varying loss of conscious- ness and a depression of the vital forces, which is shown in a lowering of respiration and a fall of temperature if there be hemorrhage and compression.' Considerable elevation of temperature after fracture is an exceedingly bad sign, although a rise to 101° to 102° if not continued may mean nothing. ' Phelps held that the slowing of pulse and respiration found in most forms of compression is absent in that due to middle meningeal hemor- rhage, which is often followed by spastic paralysis. 100 RAILWAY AND OTHER ACCIDENTS. Facial asymmetry, exophthalmos, unilateral or double, oculomotor symptoms, facial paralysis or spasm, are occa- sional objective evidences of the effects of fracture ; while anesthesia, hemiplegia, or neuralgia of parts supplied by the fifth nerve ; deafness, loss of smell or taste, or speech disturbance are central indications of deep mischief, which may last for some time, disappearing gradually as the process of repair takes place and the fracture is healed. Certain permanent residual conditions of a last- ing nature follow the destruction of nerve tissues or the pressure of exudates. Beside these, we may find various general motor and sensory conditions which will hereafter be particularized. Under some circumstances the diagnosis of fracture is complicated by other diseases that may develop through its agency; for example, tuberculosis and syph- ilis. Fraser reports such a case. Case XVI. — The patient was a man who had received a frac- ture of the parietal bone by a brick that had fallen from a great height. He was at first insensible, but was able in the course of three weeks to return to his work. He suffered, however, from occipital headache of a severe character, and during the next fifteen months was deaf, and with this there were some amblyopia and a variety of symptoms suggestive of mental enfeeblement. He was stupid, of slow thought, and greatly depressed. A few months later his gait became ataxic ; he had an inclination to fall backward, and presented the " circus movements " described by some authors as suggestive of cerebellar disease. In addition, there were double optic neuritis, with vertigo and vomiting, and difficulties in co-ordination. Subsequent examination revealed the existence of well-marked syphilitic indications, such as nodes, eruptions, and cicatrices, and it was determined to try the effect of specific treatment. Under the use of large doses of iodide of potassium his trouble diminished . in severity and he rapidly re- covered. In this case it is very probable that the blow was an INJURIES OF THE CRANIUM. loi exciting cause of cerebral syphilis. Although the situation is not favorable for a contrecoup that would give rise to cerebral disease, it is possible that a diffused meningeal inflammation and deposit of gummatous matter took place as an extending lesion. Case XVII. — A personal case in which no fracture was found is that of M. R , who received a severe blow upon the back part of the head some time in 1876, which rendered him unconscious. He, however, revived without any apparent serious consequences, and six years afterward was seized with sudden vertigo, nausea, and vomiting, which lasted several days. Six months later his legs became weak, and there was double vision. Three months after this his speech became affected, there being considerable awkwardness in enunciation, with diiBculty in co-ordination of the movements of the right upper extremity, and he walked with a tottering gait, spreading his feet far apart. When seen by the writer in December, 1883, he presented the motor symptoms above enumerated, with added facial paralysis on the right side and increased knee-jerk on the same side; his tongue protruded, pointing to the right. His hearing was good, and there was some ptosis on the left side. On April 23d, 1884, there was hemianes- thesia of the right side of the body, and the hearing had become dull in the right ear. Since his last visit there had been right facial neuralgia, and increase of the ataxia and unsteadiness, and exophthalmos of the right eye, with no sugar in the urine. He was seen by Dr. C. S. Bull on April 21st, 1884, who found a rotatory nystagmus, a paresis of the right external rectus and left internal rectus. He could not contract the right orbicularis palpebrarum alone, though he could in connection with the left orbicularis.' The palpebral aperture on the right side was wider than on the left, through excess of action on the part of the levator. The pupils were normal in size and reaction. The nystagmus was more marked when he was not fixing any object with his eyes, and when he looked toward the left it was accompanied by a marked clonic spasm of the right internal rectus and left external rectus. There was also deficient action of the right inferior oblique ' This phenomenon, which has recently been called the " orbicularis sign," has been advanced as a diagnostic test, it being found by G. W. Jacoby (American Neurological Association Report, 1903) to exist in hemi- plegia of central origin. 102 RAILWAY AND OTHER ACCIDENTS. muscle. He was hypermetropic. The field of vision was normal, and there was no special pathological change in the retina or nerves. The patient's symptoms increased, and he died June 20th, 1 884, of exhaustion. Two weeks before death there was an increase of occipital pain, which was only controlled by morphine. The lungs were healthy. At the autopsy there was found in the left lobe of the cerebellum beneath, a tumor the size of a small egg and consisting of apparently broken-down tissue. The pons was not involved, save as it might have been from pressure. Some fluid was found in the lateral ventricles. Other parts of the brain were healthy, except that the entire bulk of the brain seemed increased. Dr. Lyle Smith, who was present at the autopsy at the patient's home in Hudson, N. Y., informed me that there was not only a family history of phthisis but every evi- dence that the growth itself was tuberculous. It is to be re- gretted that no more extended examination was possible, and that the microscope was not used, Occasionally in the determination of death from alleged violence the arterial degeneration, due to alcohol- ism and other factors, must be taken into consideration, and it does not do to be arbitrary or to dismiss contribut- ing causes of various kinds, among them old cardiac affections and epilepsy. A delicate medico-legal point may also arise in those cases in which the patient dies from tetanus after a severe wound. Localization and Symptomatology. The localization of cerebral disease necessitates a knowledge of experimental physiology of the nervous system, as well as the appreciation of the teachings of pathology and clinical neurology ; but anything more than a mere presentation of a suggestive synopsis of symptoms and their relation to definite lesions for the purpose of diagnosis would be out of place in a book of this kind, INJURIES OF THE CRANIUM. 103 and the reader is referred to any of the standard neuro- logical text-books. The locahzation of function in the cerebral cortex and the expression of destruction or injury of particular parts may be made with reference to motor and sensory areas, the nature of which is now pretty well understood (see Appendix, Charts i and 2). Motor Areas. — Larynx, lower jaw, pharynx, tongue, lowest quarter of both anterior and posterior central con- volutions. Face, anterior and posterior central convolutions im- mediately above the preceding centres. Upper extremity, middle half of anterior and posterior central convolution, reaching a little higher up on the anterior than the posterior one. The centres for the thumb and index finger are at the lower end of this region ; the centre for the shoulder at the upper border. According to some authors, the centres for the extensor muscles are on the anterior and those of the flexors on the posterior convolution. All agree that the anterior convolution is of greater importance for the motor func- tion. Lower extremity, upper quarter of central convolution and paracentral convolution. Opinions as to localization of central parts differ ; it is generally assumed that the hip and knee centres are located in the lowest part and the foot centre in the highest part, and in the paracentral convolutions. Thorax, posterior part of superior frontal convolution. Some authors localize the muscles of the thorax in the cerebellum. Motions of head and eyes (conjugated), posterior part 104 RAILWAY AND OTHER ACCIDENTS. of first and second frontal convolutions. It is generally- assumed that this centre effects a voluntary turning of the head and eyes toward the opposite side. There are a few other centres for the innervation of the eye muscles, ?.^., in the lower parietal and in the occipital convolutions. Some authors claim that the gyrus angularis has special relations to the eye muscles, and that lesions in this region may produce disturbances in accommodation. According to some writers, there is a centre for the con- tralateral pupil in the gyrus angularis. Vasomotor centres are supposed to be in the central convolutions, especially for the opposite half of the body. These, however, are found only in apes, and are very uncertain in man. Sensory Areas. — No uniform view has been reached regarding the localization of sensation. Some authors identify the centres of sensation with the motor centres (Munk). Others enlarge the sensory area and ascribe this function especially to the gyrus fornicatus (Ferrier, Horsley, Flechsig). Others, again, deny the relation of this region to sensation (Hitzig). Speech. — Motor, posterior part of third frontal convo- lution. Sensory, posterior two-thirds of first temporal convolution. Sight. — Occipital lobe, especially fissura calcarina, and cuneus. Some authors add to this the first occipital con- volution, gyrus fusiformis and lingual is. The rest of the occipital lobe as well as the gyrus angularis is claimed to play a role in turning optic sensations into conceptions. Hearing. — Upper temporal convolutions. Smell. — Gyrus uncinatus. Taste. — Anterior part of gyrus fornicatus. INJURIES OF THE CRANIUM. 105 The frontal lobes, especially the left, are those in which intellectual processes originate, and as a result of more or less extensive disturbance we find resulting- impairment, which may vary from simple dulness and hebetude to absolute dementia. Although Beevor, Starr, and others have found mental failure in their numerous collated cases of tumors affecting both frontal lobes, Phelps is inclined to consider from his own analysis that it is the left in which intellectual function originates. In this he says: i. " The more absolutely the lesion is limited to the left prefrontal lobe the more positive and distinctive are the symptoms of mental default." 2. " The integrity of the mental faculties remains unimpaired in right frontal lesion, though it involves the destruction of the entire lobe, or even extends to the entire hemisphere." 3. " The exceptional instances in which seemingly opposite conditions exist are always reconcilable on more careful examination with the assertion of an exclusive control of the mental faculties residing in the prefrontal region of the left side." In the lowermost frontal convolution on the left side is the limited region known as the Island of Reil, or Broca's convolution, in which is situated the centre for motor speech, and the discovery of this preceded by many years that of the numerous cortical motor and sensory regions enumerated above which play so import- ant a part in modern pathology. Its involvement leads to motor aphasia, agraphia, and loss of speech co-ordina- tion, and of smell sometimes, as well as the most widely differing disturbance of consciousness. Case XVIII. — J. A. Y , an army officer, forty-four years of age, was seen by the writer on March 6th, 1883, the patient being io6 RAILWAY AND OTHER ACCIDENTS. referred to him by the late Dr. C. R Agnew, under whose care he had been. In 1863, at the battle of Gettysburg, he received a head wound, a bullet entering the left orbit, leaving on the right side after passing obliquely behind the ridge of the nose and out of the right orbit between it and the eyeball. There had appar- ently been no injury of the right eye. He was unconscious and delirious for seven days, became blind, and lost the sense of both smell and taste, the former permanently. In October, 1863, the left eye was removed, the operation being followed by an agonizing headache, which lasted for months, -by numbness -of. parts supplied by the lower branch of the fifth nerve on the right side, and at times by severe pain of the scalp and in the upper frontal region. By this time attacks of vertigo, with confusion of memory, oc- curred when he also had hallucinations of smell, perceiving odors that were not unpleasant. At these times there was contraction of the field of vision, but no diplopia or hemiopia. At times he talked thickly, and there was an apparent temporary amnesia. These attacks occurred occasionally, but in the interim his mind was clear. His wife said she had noticed twitching of the left side of the face. His hearing was good. He could not detect the difference between cologne, ammonia, camphor, or acetic acid, yet he said he could distinguish between the odor of an apple and a pear, or of a peach and an apricot. The centrum ovale as well as the corpus callosum may be involved without any conspicuous or distinct symptoms, except in the former case, when the lesion is in possible close proximity to the cortical centres. Tumors in the corpus callosum often give rise to mental dulness, delu- sions, and dementia, and to vague and inconstant motor symptoms, notably a hemiplegia which shifts. Should the internal capsule be the seat of a lesion at all extensive there will be hemianesthesia, hemiipleigia, possibly hemi- opia, and paralysis of muscles supplied by the facial and. hypoglossal nerves. Various limited forms of trouble are connected with focal lesions in this locality and there may be a paralysis of the facial and hypoglossal nerves PLATE V. Railway and other Accidents. HoRiZDXTAL jAIiu-Section of Braix. LV. Lateral ventricle; Vc^, fifth ventricle; CC, corpus callosum ; CS, corpus striatum; LX. lenticular nucleus; /C, internal capsule; OT, optic thalamus; /«., insula; d.p.f., anterior pillar of fornix; Pi, pineal gland; CO, corpora ciuadrigemina ; C, cerebellum. INJURIES OF THE CRANIUM. 107 alone. Of course double lesions produce a correspond-" ing diplegia. Lesions of the optic thalamus are associated with occipital headache, disturbances of a mental kind, and with muscular inco-ordination, rotatory movements to the side of the lesion, and optic neuritis. Should there be a posterior lesion, there is likely to be hemiopia. Lesions of the corpora quadrigemina give rise to a peculiar ataxic gait, to loss of appreciation of change in the position of the limbs, and to oculomuscular paralysis. If the " tegmen- tal " fibres beneath are involved, it is quite probable that there will be hemianesthesia. Lesion of the crusta will give rise to a crossed brachiocrural hemiplegia. As some of the fibres of the optic nerve take their origin in these parts, it is quite likely that under certain circumstances there may be a complicating hemiopia or atrophy of the optic nerve, and possibly association of some disturbance of hearing, the auditory nerve being involved as well. Crossed hemiplegia with paralysis of the third nerve on the side of the lesion and with paralysis of the extremi- ties of the other side is also to be looked for. Disease of the pons is characterized by " crossed " or alternating pa- ralysis if the lesion be in its posterior part, when the hemi- plegia will be on one side of the body and the facial pa- ralysis on the other. Focal lesions are usually followed by disturbance of some of the nuclei of the cranial nerves or by fibres of others which pass through them — among them the fifth, sixth, and seventh. Such lesions are manifested by facial paralysis and by pain or anesthesia if the seventh and fifth nerves be involved, and there is a paralysis of the external rectus in addition to a hemiplegia. If the sixth nerve be implicated, the eyes in consequence turn toward the paralyzed side. Tonic spasm of paralyzed limbs in io8 RAILWAY AND OTHER ACCIDENTS. connection with diseases of the pons is not unusual. If there be a bilateral lesion, there is double paralysis not only of the face, but of all four extremities, with contrac- tion of both pupils. Lesions of the cerebellum, both extra- and intramedul- lary, are indicated by disturbance of equilibrium. The patient staggers and suffers from vertigo when in the upright position, and vomiting is common. Headache in the occipital, frontal, and temporal regions is commonly associated, nystagmus often occurs, and optic neuritis oc- casionally. There is often in the extramedullary variety weakness of the face and limbs, which is hemiparetic. The unsteadiness referred to causes the patient to totter or fall; but there is no rule about this. It is rare to find cerebellar disease without some implication of the cranial nerves. Case XIX. — E. C. M , a mail clerk, received a basal frac- ture with evident injury of the cerebellum. He was engaged sorting mail in a car attached to a train of the New York and New Haven Railroad Company on July 25th, 1893, when the car swerved from the temporary track and collided with a passing train, the result being that much of the side of the car was crushed in and the man was seriously injured. " There was a scalp wound about two and one-half inches in length on the back of the head running horizontally, just below the occipital protuberance. Profuse hemorrhage was taking- place from the right ear, and there was hemorrhage into the right orbit, the eyeball being much discolored from extravasated blood. During the forenoon the patient was only partially conscious; hemorrhage still continued from the right ear. " There was a spot in the back, in the middle dorsal region, where there seemed to be some tenderness, and it was a question whether there was a depression there or not. No fracture or dis- location of vertebrae was diagnosed, and there was no paralysis of any kind. A diagnosis of the fracture of the base of the skull INJURIES OF THE CRANIUM. 109 was made, and his recovery was considered doubtful. His mental condition varied greatly, and at times he was semiconscious, being roused with some difficulty, while at others he was delirious, and again slept naturally. Gradually this subsided, and on the 27th he was comparatively rational, answered questions quite well, al- though slowly and hesitatingly. " From July 28th he complained a good deal of pains in the right side of his head. These persisted for two or three weeks with varying intensity, and not yielding readily to treatment. " On August 3d his eyes were examined. He had an ulcer of the right cornea with slight conjunctival injection and remains of a conjunctival ecchymosis. There were neuroparalytic keratitis and paralysis of the internal recti with crossed diplopia. . " The afterpart of Mr. M 's stay in the hospital was un- eventful, gradual improvement taking place. There were two symptoms, which during his stay were noticeable: hesitating speech and unsteady gait. The hesitating speech was as if the word wished for came slowly at his command, but rightly. The unsteady gait was at the time ascribed to weakness from confine- ment and consequent disuse of the muscles of locomotion. He left the hospital September, 1893. "On March 6th, 1894, Mr. M was examined again. The same unsteadiness of gait was noticed as during his stay at the hospital, but it was decidedly less marked. He could not stand erect with eyes closed without swaying unsteadily. The same was true when the eyes were fixed on the floor at his feet. " On examining his head there was found a linear horizontal cicatrix about one and one-half inches in length and about one- quarter to one-half of an inch below the occipital protuberance. No special tenderness of the scar. " There was no indication of any abdominal trouble ; no tender- ness in the pit of the stomach, no cough. There was complaint of some pain in the lower scapular region on the right side, but no localized tenderness was found. " Examination of the eyes : There is a slight macula of the cor- nea of the right eye. The pupil is slightly dilated, and is not so responsive to light as that of the other eye. Vision of the right eye is 0.7. There is .75 dioptre of hypermetropia. Vision of the left eye is the same. There is at times double vision, and with a red glass before one eye there is at once a crossed diplopia. no RAILWAY AND OTHER ACCIDENTS. " There is an insufficiency of the internal recti of one degree at twenty feet and of ten degrees at fifteen inches, by both Stevens' and Maddox's tests for insufficiency of the ocular muscles. After repeated testing and consequent exercise of the muscles the diplo- pia at twenty feet disappeared, but remains the same at the near distance. The ophthalmoscopic examination was made with a di- lated pupil. Right eye: Disc is markedly cupped with edges of excavation fairly well marked, and about five dioptres deep. No other notable condition was found. Left eye normal in appearance. Tension of each eye normal. Field of vision normal. " Right ear : Hearing distance normal. Drum membrane is normal in appearance, but slightly hyperemic, and with a red- dened scar extending downward and forward from two lines an- terior to the tip of the manubrium to the annular ring. Left ear : Hearing distance for watch 0.06 ; voice twenty feet ; whispered voice eight feet. Drum membrane is dull and retracted, but freely movable. Reactions to tuning forks of vibrations from 128 to 2,048 show no deviations from the standard. " In our opinion the patient suffered from concussion of the brain, with a fracture of the base of the skull and severe shock, narrowly escaping a fatal termination. " As a result of the general physical examination, we find, what with the exception of subjective symptoms, as pain, loss of mem- ory, etc., which are incapable of demonstration, there are but two which would indicate any probable permanent injury to the general system — namely, hesitating speech and unsteady gait." ' "The patient consulted the writer May 7th, 1895. He was a broken-down, unhealthy looking man who walked with some diffi- culty and slightly dragged the right foot. He was exceedingly pale, and tired easily. He lacked concentration, and had been unable expeditiously to sort his letters, and continued application was likely to produce headache and some mental confusion. He could formerly do twice as much without trouble, and had gone to work again, as he said, to reassure his wife, who had been suf- fering for some time with some depressed form of mental disease manifested by anxiety in regard to his welfare. Both eyes were ' Examination by Drs. J. T. Rogers and Godding at the Rhode Island Hospital, from whose reports these notes are taken. INJURIES OF THE CRANIUM. in red and suffused. He presented a depression at the occipital region with some loss of substance of the scalp, and beneath this spot he said there was constant pain, which was increased by men- tal exertion, and was aggravated when he lay down when he be- came dizzy. When the head was retracted, there were also pain and a tendency to fall backward, which he had to resist. His speech was decidedly affected, there being motor aphasia, and at times he was at a loss for a word, or paraphrased. There were occasional double vision and ocular pain, and when pressure was made over the eyeballs there was some tension indicative of commencing glaucoma. Both optic nerves were to some de- gree excavated and both eye fields congested. The right pupil was larger than the left, and there seemed to be inability com- pletely to close the right eye. His vision was decidedly affected on the right side, and he complained of haziness and blurring, which, however, was not always constant. Hearing in the left ear was impaired. There was some anesthesia of the right side of the face which involved the gums, as well as a loss of smell, which,* however, was not marked. The reflexes were increased on the right side, and the patellar tendon reflex especially. He could not stand with closed eyes without swaying to a very decided degree. There were no disturbance of co-ordination in the upper extremities and no pathological atrophy. The functions of his bowels and bladder were also unimpaired, and there was nothing to indicate spinal disease. The case was settled for a comparatively small sum. This man, I believe, subsequently became blind. Case XX. — A case of cerebellar tumor of traumatic origin was seen by the writer in consultation with Dr. L. R. Morris, November 4th, 1898. The patient was a little girl of six, who in March, 1897, had fallen violently, striking the head over the occip- ital region. There was no loss of consciousness, vomiting, or subsequent headaches, and the only external mark was a large hematoma. A month later she had another fall, unattended as well by any immediate evil consequences. In the spring of 1898 she complained of occasional morning headaches, and in May or June her mother and aunt noticed a " cast in one eye " and certain motor difficulties and strange attitudes, the head being seemingly "pushed forward and fixed." The child became thin, 112 RAILWAY AND OTHER ACCIDENTS. listless, and had "a tired look," and in August had morning nausea and vomiting, with severe headaches, photophobia, and there was a marked internal strabismus of the right eye, with lateral nystagmus, dilatation of the right pupil, the ocular de- fects being inconstant; but later there was a fixed crossing. The tendon reflexes were slightly exaggerated and the pupillary reflexes sluggish. In October, 1898, there were tremor of the hands, static ataxia, with tendency to fall forward, and a peculiar rigidity, which prevented her from bending forward from the hips, so that she could not pick objects from the floor unless she planted her feet well apart, flexed her thighs, and threw back her head ; then with the left shoulder slightly raised and the muscles of the neck rigid she could with her right hand grasp articles placed in front of her at her feet. Her head was not rigid except when walking or sitting; she had cramps in the right leg and clonic convulsions lasting about a minute each, when there would be a " kicking motion." No pain was produced by pressure over the scar. She shortly afterward became apathetic ; there were shoot- ing pains in the head, radiating from the occipital region, delirium, and shouting. The bowels moved only by enemata; the urine was voided involuntarily at times at first, afterward constantly. Finally she could not speak nor could she be aroused. Her hands and fingers were flexed and thumbs turned in, most constantly on the left side ; her feet were extended and her toes flexed. On November 20th there were two general convulsions, with clonic movements of the feet, legs, hands, and arms, lasting half an hour and not preponderating on either side. During convulsions both eyes were drawn inward and downward. There were subsequent loss of deglutition, Cheyne-Stokes respiration, increase of trem- bling and contraction, and death from respiratory failure Decem- ber 13th. For almost a month she was fed by enemeta. Dr. John R. Weeks, who saw her, found a slight loss of power of the externi, which subsequently became marked, especially on the right side ; there was sluggishness of pupils to artificial stimula- tion on November 6th, with moderate dilatation, and later, No- vember 2 1 St, the eyes were fixed and the iridesdid not respond to light. There was almost complete ophthalmoplegia externa and in- terna, which lasted until death. At Dr. Weeks' first visit ophthal- moscopic examination of fundus disclosed papillitis in both eyes with elevation of about two-thirds of a millimetre (Fig. 15). There was INJURIES OF THE CRANIUM. 113 serous exudation on the temporal side and below the disc in the right eye, wAxh engorged and tortuous veins and small arteries. From the ocular symptoms — vomiting, headache, uncertain gait, pitching forward, convulsions, apathy, and general s)'mptoms, I made a diagnosis of a median cerebellar tumor, with hydrops ventriculi. At the autopsy the convolutions were found to be flat- tened, the pia rather more injected and drier than usual, and when a longitudinal incision was made through the corpus callosum and the hemispheres were separated, there was found a brownish-red Wi f 4 . ^ ^ 1 I ^ _^ „ Fig. 15. — Papillitis with Detachment. tumor about the size of an egg lying in the median line and touching the cerebellum. The mass, about 4.5 cm. in length, 4 cm. in width, and 4 cm. in depth, was situated in the cavity of the third ventricle and reached forward and downward into the optic recess and infundibulum. Separating the thalami, it displaced upward the roof of the third ventricle and obliterated the pos- terior pillars of the fornix ; it here lay in contact with the corpus callosum. Extending backward and downward it destroyed the pineal gland, overrode the lamina quadrigemina, compressing under it the acjueduct of Sylvius, separated the corpora quad- rigemina, and reached to the tip of the valve of Vieussens. The fourth ventricle was intact, and the aqueduct still patulous, but very small. The lateral ventricles were found full of a thin red- 8 114 RAILWAY AXD OTHER ACCIDEA'TS. dish fluid, and their surfaces were stained yellow. Projecting into the right ventricle from the foramen of Monro was a cyst formed by the ^-elum and filled with a bloody fluid. There were about six ounces of fluid in the cranial cavity. On section of the tumor a dark-red surface is apparent, looking for the most part like clotted blood. A considerable area near the superior surface is Fig. i6, — Cerebellar Tumor. ^ lighter in color and of a spongy texture. There is the appearance as if several hemorrhages had occurred at different times splitting up the new growth and forming clots. The structure of the tumor is that of a small round-cell sarcoma augmented by repeated hem- orrhages. Disease of the medulla is expressed by symptoms in- dicative of irritation or destruction of the cranial-nerve . nuclei at the floor of the fourth ventricle, and paralysis of the extremities on one or both sides. When death is not immediate, the cranial-nerve symptoms are progressive and develop slowly. Disturbance of function of the cranial nerves must be studied with relation to their deep origin, course, and ' This and preceding cut from Medicine, July, 1900. INJURIES OF THE CRANIUM. "5 peripheral distribution, and at the same time with relation to the complete or partial decussation of their deep fibres; for instance, the olfactory nerve has no crossed fibres, while the course of those in the optic nerve is most complicated and incomplete. Injury of the former is unilateral so far as loss of smell is concerned, while if one of the crura of the optic nerve be injured, we are fur- nished with the so-called homonymous heinianopsia which is attended by loss of vision of the same side in both eyes. Disturbance of the sense of smell may follow falls with shock as well as from destructive disease, the loss corre- sponding to the side upon which the lesion is situated. It may also be due to meningitis at the base of the frontal lobe. When the optic nerve is involved, we or- dinarily find neuritis and choked disc, due to in- terference in the return of venous blood through pressure (Fig. 17) or dis- ease, or with destruction or irritation of the deeper parts and nerve nuclei; amaurosis and amblyopia are produced. Some- times the papilla is the seat of inflammation and swelling when the appearance depicted in Fig. 16 is found. In cerebral sclerosis and as the result of various deep structural lesions we find atrophy of the optic nerve and its ocular expansion. Hemianopsia may be due to dis- ' From Medicine, July, 1900. Fig. 17. — Distention of Optic Nerve Sheath and Compression of Nerve. ii6 Ji AIL WAV AND OTHER ACCIDENTS. ease of those nuclei which are situated in the occipital lobe as well as other parts before referred to. This form of disturbed function may be temporal or nasal. If the temporal halves of both eyes are blind) it is bitemporal ; or if both nasal halves, binasal hemianopsia, which, however, is rare. The form known as homonymous., to which refer- ence has been made, is perhaps the more common, and is the result' of a lesion of the chiasm. A functional disorder is known as " flitting scotoma," which is bilateral and con- sists of the sudden perception of dark, crescent-shaped A LettKyt Fig. i8.— Rig:ht Homonymous Hemianopsia. (Purves-Stewart.) spots, which are fringed with dazzling colors. They last for a time and disappear in the direction of the periphery of the visual field. The oculomotorius or third nerve is concerned in the reflex movements of the iris, the inner- vation of the levator palpebrarum, as well as all the muscles of the eyeball, with the exception of the superior oblique, which is taken care of by ^hepatheticus or fourth nerve, and the external rectus, which is supplied by the abducens or sixth nerve. As a result of paralysis of this nerve we find various kinds of strabismus, diplopia, and ptosis, as well as pupillary changes, and also difficulty of accommodation. PLATE VI. Railway and other Accidents. Base of Brain. I(oI), Olfactory nerve; l/io), optic nerve; ///, oculomotorius ; IV., patheticus or trochlear nerve; V, trigeminal nerve; F/, abdvicens nerve; VII, facial nerve ; VIII, auditory nerve ; X, pneumogastric nerve ; XI, spinal accessory nerve; PI pineal gland; ca, corpora albicantia; P, pons; mo, medulla oblongata; c, cerebellum. INJURIES OF THE CRANIUM. 117 It is rare for these three nerves to be affected together, and in such a case the general paralysis of the eyeball is known as ophthalmoplegia ; but this condition is rather due to alcoholism or some other form of general brain disease than trauma.' The trigeminus ox fifth is a mixed nerve containing sensory, motor, and trophic fibres. It is concerned in the innervation of the muscles of mastica- tion, and has as well wide and important sensory offices, for its fibres supply not only the gums, tongue, teeth, ear, face, and part of the pharynx, but the scalp as well, and it is in a measure concerned in the trophic supply of the cornea. As a result of irritative or destructive lesions we find spasm or automatic movement, or perhaps paralysis of the masseters, anesthesia of the face, corresponding to the distribution of the three branches, vertical or facial neuralgia, loss of taste in the anterior third of the tongue, noises in the ears, or sometimes ulceration of the cornea. The injury may of course be superficial or deep, and in the former there are usually areas of incomplete anes- thesia, while in the latter it is not unusual to find that other cranial nerves are involved as well, with additional special symptoms. Case XXI. — An illustrative case is that of a man who came imder the writer's notice in October, 1890. He had been injured in a railroad wreck on the Hamilton and Dayton Railroad, and was picked up unconscious, remaining so for several hours, and for a long time suffered from shock and acute pain confined to the right side of the head; there was much irritability of temper, as well as periods of nervous excitement, and more or less insomnia. The patierit, when he came a year after the accident, presented two .scars, one about two and one-half inches ' Oirfithahnoplegia may be external or internal, depending upon the muscles, involved,. ii8 RAILWAY AND OTHER ACCIDENTS. long over the frontal bone a little to the right of the median line and about an inch above the superciliary ridge. The latter bore the traces of slow healing, due to the escape of pieces of bone, which were exfoliated from the outer surface of the -skull and had been removed from time to time. There was ptosis of the right eye, which existed almost from the time of the accident, and he had complained of diplopia depending upon a paralysis of the muscles of the right eye ; his right pupil was in- sensitive to light and somewhat dilated. There was a limitation of the field of vision on this side, the constriction being almost half that of the other eye. Disturbance of the seventh nerve was manifested by slight paralysis of the right side of the face, which was apparent in a grade of deformity when he laughed or per- formed other suggested acts, and injury of the fifth nerve was shown by anesthesia of the gums of the upper jaw on the right side, and he had already lost several teeth as a result of trophic change. There was an apparent loss of the sense of smell, although his taste was but little affected, and only in the front part of the tongue. His motility was slightly impaired on the left side of the body, especially the left leg ; but the reflexes were unaffected. In this case there was evidently a transmitted fracture of the base with meningitis and involvement and injury of the third, fifth, and seventh nerves. The case was settled for a large sum, and there is no doubt of its seriousness or progressive character. The facial or seventh supplies all the facial muscles, except those innervated by the fifth and third nerves. As a consequence of deep disease, it is not rare to find an extensive loss of function, which may be due to periph- eral changes, and consist of spasm and paralysis. The auditory or eighth is the nerve of hearing, and its injury is followed by deafness as well as by certain minor disturb- ances of hearing. The paralysis, if central, may follow a cortical lesion or injury of the other central nuclei. A peripheral injury of the seventh will result in complete fa- cial paralysis, for the central variety is apt to be expressed only by a loss of power of those muscles supplied by the two INJURIES OF THE CRANIUM. 119 lower branches of the nerve, the patient being able to close his eyes and wrinkle the forehead, and there is no reaction of degeneration, as when the terminal branches of the nerve are paralyzed. In the central form the reflexes are preserved, while in the peripheral they are lost. With paralysis of the auditory nerve alone we some- times find subjective noises, which are constant and dis- tressing. The glosso-pharyngeal or ninth nerve supplies the posterior third of the tongue, and, therefore, loss of taste in this situation may be found. It is contended, how- ever, that the back of the throat derives its sensory inner- vation largely from fibres of the fifth pair. The pneumogastric or tenth and spinal accessory or eleventh are nerves of great importance, presiding over respiration and digestion. Traumatic cases are not com- mon, but when found are usually obscure. The trunk may be wounded, or a series of interesting symptoms may follow the creation of a deep lesion. If the spinal ac- cessory and hypoglossus nerves are involved together, we are furnished with a train of symptoms which constitutes the well-known bulbar paralysis. With injury of the vagus or sensory branch, we find anesthesia of the larynx, atro- phy, and various forms of spasm and paralysis, among them esophageal and laryngeal spasm, tachycardia, con- vulsive asthma, and angina pectoris. Graves' disease, or exophthalmic goitre, is by many recognized to be a trau- matic affection of this nerve, and doubtless many neuroses often follow shock in which it is implicated. A bulbar lesion may affect the hypoglossal or twelfth, leading to paralysis and atrophy of the tongue and twitch- ing or spasm of the jaws. 120 RAILWAY AND OTHER ACCIDENTS. Case XXII. — Hirsch reports a mixed traumatic injury of the hypoglossus, vagus, and sympathetic, the patient being a laborer who accidentally shot himself, the bullet passing through the roof of the mouth and lodging at the left of the fourth cervical verte- bra, where it was afterward found in the sternocleido muscle and removed. As a consequence of the injury, there were paralysis of the left velum palati, paralysis of the left vocal cord with loss of voice, vomiting, and paralysis of one side of the tongue. There was pronounced secretion of saliva, which accumulated under the left side of the tongue, and the left pupil diminished in size, with slow reaction to artificial stimulation. There was no loss of taste. Paresis of the muscles of the left half of the thorax was found, an increase in the rapidity of the heart's action took place, the count averaging io8; but there was at times a decided tachycardia. General Symptomatology. Brain lesions are recognized as general, indirect, and focal. The symptoms of the two former are so irregular and so often presented in a varying number of conditions as to lead to difficulties in diagnosis, but when associated may be always suggestive of cerebral disease, though they may have a widely different significance. The symptoms of general lesions are usually transitory, pass- ing away in a comparatively short time with the relief of certain conditions, or obscuring the cause of death should there be a fatal termination ; while the focal lesions are often permanent and are manifested by more or less defi- nite expressions, such, for example, as a lasting aphasia or paralysis. General symptoms, then, usually mark a widely ex- tended disturbance, and include changes in the pulse- pain, vomiting, delirium, loss of consciousness, lowering or increase of temperature, respiratory changes, etc., which, for instance, may follow compression or shock, there possibly being at the same time a local destruction INJURIES OF THE CRANIUM. I3i of tissue, which afterward makes itself known in per- sistent expressions of mischief. Indirect lesions include, for instance, such symptoms as hemiplegia, which may disappear quickly, while the hemiplegia of a focal lesion may imply the permanent destruction of a specific motor tract. It is therefore often a matter of great difficulty to localize by means of symptoms, and we must take into account their mode of onset as well as their association with others, and, perhaps, the existence of a previous con- fusing symptom, due to a lesion that has existed for some time. Hirt says in this connection : " That even apart from the mode of onset the symptoms are not of equal value in the localization. Some, it is true, as hemiplegia, together with crossed lateral oculomotor paralysis, are almost pathognomonic of a lesion of the crus, and their simultaneous appearance is felt, therefore, to be extremely important; while others, as conjugate vision in severe hemiplegia, are found in different lesions, and are there- fore less significant. Still others, as optic neuritis, all general symptoms, headache, vertigo, and unconscious- ness, are absolutely valueless." Lesions may be roughly classified as those of the cor- tex, of the midbrain, and of the basal ganglia and cranial nerves. The former, thanks to the labors of Fritsch, Hitzig, and Ferrier, as well as of those who have followed them, is comparatively easy. The symptoms may be regarded as due to irritation and destruction, the latter being more serious. Considerable difference exists be- tween the extent of function of the areas of the cerebral cortex of the right and left sides of the brain ; but it is well known that the latter is not only, as well as the right, the seat for motor areas, which occupy the central con- 122 RAILWAY AND OTHER ACCIDENTS. volutions, but that several important sensory centres of the cortex are confined to this side. Motor Disturbances. — Among the commonest symp- toms of cerebral disease are spasm, convulsion, tremor, ataxia, and paralysis. Lesions of that part of the cerebral cortex in which the motor centres are situated,, and which have previously been described — or of the meninges in juxtaposition therewith — are apt, if irritative, to lead to monospasm or convulsions, which are more or less gen- eral. If there be constant pressure or destructive disease of these areas, there may be a permanent paralysis upon the opposite side of the body, associated perhaps with convulsions. The cortical motor lesions must be distin- guished from others at the lower level of the brain, where the motor tracts are simply cut across or destroyed. A destructive lesion of the motor apparatus, if sufficiently extensive, may give rise to a paralysis of the face and of the upper and lower extremities on one side of the body (hemiplegia), or if the lesion be bilateral or at some point of decussation of the motor fibres it will be double. The arm in hemiplegia is ordinarily more profoundly para- lyzed than either the lower extremity or the face, and, as a rule, the patient can use his leg long before he can his upper extremity, and in all forms of cerebral paralysis the distal parts present a more extreme loss of power than those nearer the trunk. As a late result of serious brain lesions giving rise to paralysis, there is in some cases descending degeneration attended by pain as the result of an associated neuritis, with possibly spastic contrac- tures and increased reflexes. In profound paralysis at the beginning, there is a diminution or loss of both kinds of reflex action. What is known as the Babinski sign is INJURIES OF THE CRANIUM. 123 a reflex extension of the great toe in response to irritation or tickling of the sole, and is a reHable indication of that form of degeneration which so often takes place after a cerebral lesion of the motor tract. The ankle clonus ob- tained by forcibly flexing the foot is essential and indica- tive of organic disease. Allusion has already been made to the " combined flexion of trunk and thigh reflex " of Babinski. Cerebral disease, especially if there be irritative lesions of the cortex, is apt to be manifested by convulsions either unilateral or general (Jacksonian epilepsy), or by loss of consciousness. These often originate as the result of an increase of intracranial tension, due to compression made by depressed bone, by purulent or other accumula- tions, and by neoplasms. Loss of consciousness, however, does not necessarily follow, and a form of hemiplegia, due to cortical disturbance, may be associated with vio- lent convulsions of the paralyzed limbs, with little or no appreciable loss. In other cases convulsions, due to involvement of the cortical motor centres, may end in transitory paralysis. What are known as associated ■movements take place in paralyzed limbs when some vol- untary movement is made on the other side of the body, and are automatic. For example, if a patient grasps an ob- ject with his sound hand, the act will be accompanied by a certain amount of flexion of the fingers of the other hand. Tremor occurring in the course of brain disease is often associated with multiple sclerosis, and is increased by voluntary attempts, and is general, while twitching of isolated muscles or filaments may be an expression of disease of the motor centres as well as a peripheral symp- tom of disturbance of certain cranial nerves. 124 RAILWAY AND OTHER ACCIDENTS. Ataxia, which is also found in disease of the posterior columns of the spinal cord, may be one of the indications of cerebral as well as of cerebellar disease, and may be connected with general unsteadiness, rotatory or propul- sive movements in different directions, a tendency to fall backward or to one side, and other disturbances of equi- librium, as well as vertigo. Care should be taken to differentiate the kind associated with auditory vertigo (Meniere's disease) from that of genuine cerebellar disease. Sensory Symptoms. — Head pain is an important indi- cation, is common, and varies greatly in its appearance, expression, and intensity. This is especially true if the meninges be affected, when it is often exceedingly severe, general, and persistent, and accompanied by tenderness, es- pecially when the scalp and underlying bones are subjected to pressure. The head pain is often aggravated by intel- lectual fatigue or effort, or by exposure to extreme heat, violent efforts, and other agencies that favor hyperemia or congestion. When the cerebral membranes are in- flamed, the pain is accompanied by a sense of pressure and constriction, and it is at times paroxysmal. Various forms of peripheral pain, due to neuralgia or neuritis of the fifth pair, may, as a result of trauma, follow incom- plete fracture or actual injury to the nerve trunk itself, and these morbid states may terminate in anesthesia. A fracture of the posterior fossa is quite apt to be connected with pain in the suboccipital region, and it is a more or less important diagnostic symptom of basal fracture. Obstinate neuralgia is apt to be expressed by tender points which are left after the paroxysm has subsided. Central hemianesthesia may be consecutive to lesions of the cortical sensory areas or of the internal capsule, and INJURIES OF THE CRANIUM. 125 is often found with hemiplegia, but disappears before the paralysis. Lesions of the occipital lobe are symptom- atized by the retinal anesthesia with unilateral blindness already mentioned. Much of the interest attached to the sensory disturb- ances in connection with cerebral disease is due to psy- chic defects and disturbances of perception. Not only may a pin prick at a distal point be tardily felt as the re- sult of disease of the receptive apparatus, or of belated conduction, but a sluggishness of mental recognition as a feature in itself should be recognized. The mental in- tegrity which enables the individual to respond to direc- tion, location, weight, and temperature tests may be de- ficient, and in disease perhaps of the parietal lobule there may be loss of muscular sense which prevents him from knowing the location of his limbs when he is blindfolded, and when they are subjected to certain passive move- ments and changes in position. Speech disturbance in connection with head injuries may be classed with headache and vomiting as important indications of cerebral mischief. Aphasia (which ordi- narily means the loss of power of intellectual speech, in contradistinction to aphonia and alalia, which are usually due to defects in the peripheral apparatus) is dependent, as has been shown, upon the lesion of the third frontal convolution. It is really an inability on the part of the patient to use the word-symbol, and as a result he em- ploys some other unsuitable word. He is able to recog- nize his mistake when it is pointed out to him, but is usually unable to do any better upon a second attempt if the loss be at all profound. Word blindness {alexia) and word deafness are two conditions which are also forms of 126 RAILWAY AND OTHER ACCIDENTS. aphasia, and are sensory defects; the one consisting in an inability to speak written or printed words which the individual sees and is unable to speak when he attempts to read a.loud; the other is lost ability to repeat words spoken to him. In either case these do not depend upon any intrinsic disturbance of the eye or ear, but rather upon some cortical lesion : in the one case situated in the angular gyrus (?), and in the other in the posterior part of the first and upper part of the second temporal convolu- tion. These are often associated with aphemia. There is also loss of ability to recognize gestures or signs or objects {apraxid). Sometimes the patient is unable to write, though he can speak, and this loss (which is due to a lesion which destroys the brain centre which presides over writing) is known as agraphia. These patients may be able ft) write, sing, or gesticulate when they cannot speak, and it is not common to find asemasia or asemia (Steindhal), which is an inability to understand any sign or symbol of thought, whether spoken, written, or acted. These interesting disorders of speech are usually in- dications of grave, although not necessarily incurable dis- ease. In a number of instances shock or hysteria will give rise to a spurious aphasia, which is, after all, mutism. The affection, as a rule, is due to some form of cortical degeneration, and that following thrombosis and rupture of a cerebral vessel is the most common. It is true that during Bright's disease attacks of aphasia may occur from time to time as the result of the uremia, and there are minor congestive disorders that give rise to aphasia as a functional affection. Trophic changes consecutive to disease of the brain are presented by those whose condition is one of chro- INJURIES OF THE CRANIUM. 127 nicity. The muscles become degenerated and shortened, and there are resulting contractures and atrophy, and the faradic excitability is reduced. In old cases arthropathies may develop, just as they do in posterior sclerosis. Bed- sores form as a result of lowered nutrition, differing in no respect from the kind associated with spinal lesions. INFECTIVE CEREBRAL DISEASE. Considerable medico-legal importance must be at- tached to head injuries, where, as a result of infection conveyed from without, abscess, thrombosis of the si- nuses, meningitis, or general inflammation of the brain substance may ensue. Following such paths of infection as the lymph vessels and membranous prolongations which communicate with the various intracranial serous cavities we find that through the introduction of the various cocci, secondary and grave disturbances may be a consequence of trauma. Not only may pyogenic micro- organisms lead to the development of the diseases enu- merated, but the tubercle bacillus may find its way into the body or be stirred into activity in subjects in whom it has remained latent or has infected other parts. Case XXIII. — The case of a boy about eight years of age who showed brain symptoms eleven days after a fall is reported by Schilling. In this subject fracture of the inner table of the skull with irritation by fragments of bone was supposed to exist, but the patient died before an operation could be performed. After death tuberculous meningitis was found, and it is to be supposed that the encapsulated and latent bacilli were mobilized by the trauma and set free in the circulation at the point of injury (Mc- Dill). As a rule, the infection follows the introduction of material at the point of fracture or site of the external 128 RAILWAY AND OTHER ACCIDENTS. wound ; but occasionally the claim has been made that intracranial inflammation has been due to metastatic ex- tension from a distant point. Under some circumstances this is perfectly possible and probable, but in the case of McQuade vs. the Metropolitan Street Railway the patient had sustained a compound fracture of the left forearm, which was treated successfully, the wound healing abso- lutely without any great amount of purulent inflamma- tion. Six months after the accident and after the disap- pearance of all signs of the fracture the patient developed middle-ear disease, with cerebral abscess, and died. Strange to say, the case had to be tried twice, the jury disagreeing upon both occasions. ABSCESS OF THE BRAIN, Abscess of the brain, as a result of injury, may be superficial or deep, involving the cortex in the first in- stance as a consequence of ulceration, and occupying the site between the intramedullary substance and the me- ninges, or it is more likely to be of deeper origin, invading the white substance, especially of the frontal and parietal lobes. In this respect it differs from that arising from otitis media, which is usually located in the temporo- sphenoidal lobes and cerebellum. Traumatic abscess is acute or chronic, in one case following edema and red softening and developing in from one to two weeks, while the chronic form may be of slow origin and growth, and be associated with an old suppurating wound, from which the infection extends. Thus it may be a consequence of penetrating wounds, or it may occur from pus carried to deeper parts, so that even in some cases injuries of the nose and mouth may, by the conduction of micro-organ- INJURIES OF THE CRANIUM. 129 isms through the Eustachian tubes, set up inflammation of the middle ear and estabHsh an abscess in those parts of the brain which are in such close proximity. Such an accident, however, is rare, the purulent collection develop- ing from some local condition, ordinarily without fracture of distal parts. Penetrating wounds of the orbits may be the means of introducing the materies morbi into the sub- dural and arachnoid extensions which accompany the optic nerve, or the frontal sinus may, under some circum- stances, be the starting-point of an abscess or of a serious form of thrombosis elsewhere. The symptoms of cerebral abscess are exceedingly suggestive, especially the intense headache and the cere- bral vomiting — that is to say, vomiting without nausea, which is of a peculiar explosive character, and bears little or no relation to the fulness or emptiness of the stom- ach. In conjunction there may be convulsions and other evidence of increased cerebral tension, and irritation, which is variable ; elevation of temperature and perhaps optic neuritis. In a certain number of chronic cases the symptoms may be mistaken for those of cerebral anemia, and in others a large abscess may exist in the centrum ovale and be tolerated for years without much resulting trouble. Of course no specific diagnostic signs can be invariably relied upon, and in the localization of the ac- cumulation we must be guided by our general knowledge of cerebral topography and pathology. THROMBOSIS. Usually, as a result of some injury of the diploe and the introduction of infectious material, there may be an induced thrombosis of the sinuses of variable extent. As 130 RAILWAY AND OTHER ACCIDENTS. a result, an initial inflammatory action takes place in the wall of the particular sinus, so that it becomes roughened and favors the coagulation of blood. A slow or rapid extension is manifested by stasis, coagulation, and occlu- sion of the vascular canals. Sometimes the initial factor is the occlusion of a vein communicating with a sinus or the pressure of a foreign body, or, again, it is made by the products of inflammation. The symptoms of sec- ondary thrombosis, which is a traumatic form, as distin- guished from that which is dependent upon the previous existence of other diseases, or as a result of chlorosis and anemia, follow fractures, the extension of erysipelas from superficial parts, and otitis. With the latter we have nothing to do except when we find that such inflam- mation is due to a fracture which involves the temporal bone. This form of thrombosis is a somewhat late but nevertheless sudden result of infection from a long-exist- ing wound, and is symptomatized by rigor, high fever, pro- fuse sweating perhaps, and by other evidences of septic infection. There is often a transfer of the septic material elsewhere, and pulmonary pyemia is the ordinary cause of death. Certain indirect symptoms, which are usually unilateral and later bilateral, may express the extension of the disease, and, as Macewen has pointed out, there is a variation in the severity of these symptoms: those of one side being less pronounced after a time, while the other becomes more markedly affected. Thrombosis of the superior longitudinal sinus, which more often fol- lows injury than elsewhere, is ordinarily accompanied by edema of the scalp, distention of the veins of the parietal and occipital regions, epistaxis, and perhaps squint, and by convulsions, followed by paralysis. Thrombosis in INJURIES OF THE CRANIUM. 131 this situation may also be due to caries consecutive to head injury. The symptoms of deep extension to the cavernous or other sinuses give rise to facial neuralgia, occipital or extending vertebral pain, exophthalmos, edema of the eyelids, ptosis, strabismus, and pupillary changes, which may be unilateral or bilateral. CEREBRAL MENINGITIS. («) Pachymeningitis Interna H^emorrhagica. The first variety is usually a chronic and slowly developing form of meningitis limited to the dura, or involving the dura and the other membranes, and is char- acterized by the formation of a blood tumor or hematoma. After a blow or other cranial injury a hemorrhage may take place, leading to the growth of richly vascularized connective tissue, with thickening and sanguineous collec- tions, and may be preceded by a slowly developing men- ingitis. In every case there is a thickening of the dura, with layers of imperfectly organized tissue and evidences of repeated extravasations in different stages of absorp- tion. In the non-traumatic form there is usually some pre- disposing cause, and a variety of general diseases enter into its development, among them affections of the heart and kidneys, rheumatism, alcoholism, sunstroke, and some of the infectious fevers. Traumatic pachym,eningitis may follow almost any kind of a blow, but it usually occurs after an injury of the vertex, which may or may not be connected with fracture. When associated with compound fracture there may be an extradural abscess, and Macewen reports with others the following: 132 RAILWAY AND OTHER ACCIDENTS. Case XXIV. — A man received an apparently trivial wound on the upper and back part of the head after a fall upon a sharp stone. Although the wound was healed, his immediate condition was not such as to attract attention. About three weeks after the accident, he developed a dull aching pain on the left side of the vertex, which subsequently became acute and lancinating. This was followed by mental depression and a sensation of weight, and by irritability and insomnia, with giddiness upon movement. The pain was referred to the vertex and brow rather than to the cicatrix, which was situated to the left of the median line at the posterior extremity of the parietal bone. That form of tumid- ity about the cicatrix which is known as Pott's puffy tumor was present, and the diagnosis of suppurative pachymeningitis was made. This wa!s four weeks after the accident. An incision over the cicatrix disclosed a stellate fracture of the skull with slight depression of the external table and much depression and com- minution of the internal table. When the broken bone was re- moved, about four drachms of pus escaped, and it was found that the dura was covered by a thick layer of granulation tissue. The patient made a perfect recovery. All cases by no means present the favorable prognosis found above, for through neglected or delayed surgical procedure a depressed fracture may give rise to a slow and incurable inflammation of the dura, and of the under- lying membranes as vs^ell, which in turn may lead to the expression of a large number of slowly appearing symp- toms, and a condition which resists both medical and surgical treatment. Chief among these are diffused or localized headache and cortical irritation or pressure symp- toms, which bear a close relation to the extent of the thickening. In these chronic cases not only may there be irregular paralysis, but convulsions as well, and a distinct mental change manifested by early irritability, insomnia, restlessness (which is followed by intellectual dulness), and possibly a late dementia. The headache is often in- PLATE VII. Railway and other Accidents. Old Head Injury. Softening and loss of left frontal lobe, chronic pachy- meningitis, right hemiplegia, aphasia, epilepsy, dementia. INJURIES OF THE CRANIUM. 133 creased by heat or even the slightest indulgence in alco- hol. In those cases in which there is suddenly formed hematoma, there may be at the same time a correspond- ing loss of consciousness, cerebral vomiting, and contrac- tion or dilatation of the pupils, and when the paracentral convolutions are involved, corresponding motor symp- toms. In serious and slowly developing cases, as a result of brain atrophy or porencephaly, there are the usual gen- eral and hopeless indications of extensive destruction. {b) Leptomeningitis. Inflammation of the arachnoid and perhaps the pia mater, which is traumatic, is usually infectious, following extension from other parts — the pyogenic process de- pending upon the passage of infection through the circu- lation from some focus of inflammation, as a result usually of thrombosis elsewhere. It is often purulent, and may be associated with the formation of abscess, and naturally is extremely obscure in its origin. Attention has already been called to the possible channels of infection by which pyogenic micro-organisms as well as bacilli find compara- tively easy access to internal parts from fracture and cari- ous bones, where the local purulent formation originates. In cases in which erysipelas of the scalp is associated with compound fracture and cerebro-spinal leptomenin- gitis, it is not uncommon to find streptococci pyogenes; staphylococci, aurei, citrei, and albi in the discharge. By proper cultivation it is possible under some conditions to identify the micro-organisms with those found in the pus of otitis media and other localized collections. As lepto- meningitis may also be tub'erculous, or follow the exan- themata, the patient's history must be closely scrutinized, 134 RAILWAY AND OTHER ACCIDENTS. and we must look for special germs of other troubles elsewhere. Inflammatory conditions, due to fracture of the skull, are more prone to lead to the development of leptomen-. ingitis than are those due to otitis media or other pri- mary affections. The disease usually develops within two weeks, but may be almost immediate, although, like pachymeningitis, it occurs sometimes in connection with a suppurating wound a long time after an injury has been .received. Its course is usually rapid, and if at all ex- tensive and active may carry off the patient in less than a month. Beginning with more or less diffused head- ache, which is usually intense, and by elevation of tem- perature there is restlessness, as well as rapidity of pulse, muscular twitching and extreme irritability, photophobia, intolerance of noise, and other evidences of excitement. There is at a later time cerebral vomiting, followed within a day or two by general convulsions, exaggerated reflexes, delirium, and pressure symptoms indicated by coma, want of control of the sphincters, and ultimate collapse and death. The whole course of the affection is attended by changes in temperature of a characteristic kind, there being a rapid rise toward the end. Should the inflamma- tion extend to the base, we find cranial-nerve symptoms, and perhaps optic neuritis. In some cases in which the inflammatory process is not so active, especially when the dura is involved as well, there may be a. slowly devel- oping and not necessarily fatal form of trouble, the prognosis, so far as the ultimate end is concerned, how- ever, being bad. In others the meningitis is of light grade, and is associated with slow cortical disorganization and an. irritative lesion. INJURIES OF THE CRANIUM. 135 Case XXV. — This is a case, reported elsewhere by the writer, in which a man fell from a fire escape to the ground, two stories below, striking upon his head and left shoulder. He was taken up unconscious, and remained so for fourteen hours. The only apparent injuries he received were two severe scalp wounds, one of which, in its slowness in healing, must have been attended by some bone injury. From this statement it would appear that there were puffy tumors upon the scalp, which were opened with some escape of pus. He was seen by the writer ten years after the accident, when two cicatrices were visible, one one and one- half inches long on the left side of the head, apparently over the superior part of the left parietal bone. There was a distinct point of depression, but only a slight cicatrix visible on the right side, but very superficial. In this case there was no hemiplegia, but three months after the fall the patient noticed tremulousness of the fingers of the right hand, and afterward the arm of the same side with hyperesthesia of the right side of the face. Both the left leg and arm were in no way affected, but the right lower extremity became agitated when he attempted to use it. There was some apparent anesthesia on the right side, but no loss of susceptibility to pain or temperature. When he stood with his eyes closed he swayed somewhat, but did not fall. He was for some time ataxic in walking and suffered at times from pains in the right shoulder and thigh, but there were no other sensory symptoms but those mentioned. This man continued for years in the same condition, changing very little, but gradually becoming intellectually dull and incapacitated for work. SPECIAL FORMS OF CEREBRO-SPINAL DISEASE SOMETIMES DUE TO INJURY. Several general diseases of the nervous system have been said to owe their origin to trauma, although about some of them there is much contention. Undoubtedly, under certain circumstances, as a result of head injury, we sometimes encounter a slowly developing sclerosis of brain and cord, which has been called multiple cerebro- spinal sclerosis or sclerose en plaques. In the early stages 136 RAILWAY AND OTHER ACCIDENTS. it is sometimes confused with neurasthenia, but when established there is no reason for such a mistake, for there is a close correspondence between the manifesta- tion of the train of serious and well-defined symptoms and the formation of numerous and widely distributed foci of disease, which consist in an increase of neuroglia and induration in limited spots ("islets") in the brain, medulla, cerebellum, and spinal cord, giving rise ip weak- ness and a peculiar intention trenior as well as a great deal of awkwardness and stiffness when certain muscu- lar acts are attempted. There are an increased activity of the reflexes, sometimes nystagmus, and often optic-nerve atrophy. The speech is peculiar, and becomes scanning or " shivering " in character. There are vesical troubles, such as are fourid in other forms of sclerosis,, ataxia, and bulbar symptoms if the medulla and great basal ganglia be involved, and sensation is usually unaffected. The disease is progressive and incurable. Its course is ex- ceedingly irregular, and there is great room for mistaken diagnosis. Sometimes it is confused with dementia par- alytica or general paresis, but the ocular changes and the mental symptom of the latter will serve to make the diagnosis clear. In the beginning it may be mistaken for traumatic hysteria, but the tremor of the latter is truly not volitional, and in hysteria there is never oscillation of the eyeballs. It is usually a sequel of certain infectious fevers and depraved states, and rarely an accident disease, and when it occurs is consecutive to some grave injury. PARALYSIS AGITANS There may be a traumatic form of this disease, and cases exist in which blows upon the head have preceded its INJURIES OF THE CRANIUM. 137 development. In one with which the writer is famihar, it followed a trivial injury to the ulnar nerve, which in turn became the basis of an hysteroid condition character- ized by inaction and fear of movement. It would seem almost as if, when the injury was cranial or directed to some other part of the body, that a peculiar mental state was induced, characterized by more or less inhibi- tion of movement, and after the establishment of this ap- peared the peculiar tremor which is so well known. I have seen but one case which formed the subject of liti- gation, in a man of middle age, and here the tremor had undoubtedly begun several years before the alleged ac- cident. The symptoms consist of a comparatively fine tremor, participated in by the forefinger and thumb, and afterward by the rest of the fingers and the muscles of the entire hand, the right side being the favorite seat of invasion. This may, after a period of months or years, involve the entire upper extremity, and usually the lower extremity of the same side next, and finally the whole body. Attempts at the beginning are made to control the tremor by the patient, who presses the ball of the thumb against the tip of the forefinger or some small object ; but this relief becomes ineffectual after a while. The muscles of the face are rarely involved, but the voice becomes low, harsh, and rasping, and articulation grows difficult, being interfered with by the accumulation of saliva in the mouth. The patient when attempting to rise from a chair to walk, does so with difficulty, being propelled forward in a disorderly way, so that what is known zs/estinaiion results. He usually sits or walks with the body bowed, the chin thrust forward, and the knees slightly bent. His face is expressionless, and the whole 138 RAILWAY AND OTHER ACCIDENTS. appearance and attitude are striking. Insomnia, by reason of the inability to find a comfortable position in bed, and severe pains of the joints, which follow, are later features of this distressing affection. Its progress is uninterrupted and slowly enfeebling, and death may occur after many years with little or no mental impairment. EPILEPSY. The frequency of head injury as a cause of epilepsy was emphasized by many of the older writers, but there has been a reaction since neurophysiology and chemistry have thrown so much light upon the pathology of the affection, and have shown that so many conditions have to do with its genesis. The fit itself may be said to be symptomatic of an altered state of cell equilibrium from whatever cause, and usually proceeds from some disturb- ance of local metabolism. The experiments of Mott have shown that the epileptic explosions of dementia paralytica are attended by an increase in the accumulation of cholin in the blood and cerebro-spinal fluid, as a result of tissue destruction, and doubtless the ordinary epileptic fit has some such explanation, especially when there is a morbid process, which may or not follow a trauma and resulting contusion or laceration. The surgical features of epilepsy that deserve consid- eration are: i. The influence of depressed bone or the products of inflammation in producing cortical irritation, 2. The existence of cicatrices. 3. The possible produc- tion of the disease through the crushing or injury of per- ipheral nerves. 4. The effect of violence to the head without external wound or fracture. That an epileptoid neurosis may follow injury to the INJURIES OF THE CRANIUM. 139 head without any appreciable wound or other evidence of violence cannot be doubted ; but this sequel of trauma need not necessarily be serious. A form of congestive disorder described by Andral and the older writers, and later by W. A. Hammond, may closely simulate epilepsy and is curable. A more grave disease is that dependent upon contusion of the brain, of the form described by Vibert. Nothing more need be added as to the influence of irri- tative and destructive lesion of the cortex in the produc- tion of that localizable affection known as Jacksonian or cortical epilepsy. What has been said of the awakening of dormant disease may be recalled, and sight must not be lost of the fact that syphilitic and other growths may be responsible for the paroxysms, the trauma being an ex- citing factor, and that some of these, especially the former, are amenable to treatment. In a number of recorded cases the presence of a cicatrix has been discovered. While on the one hand its site may be that of an underlying fracture, on the other there may be nothing of the kind, and the dense tissue may be the starting-point of an irritation that gives rise to fits when scalp pressure is made. Fere reports the case of a man of thirty-six who received a fracture of the skull in November, 1870, but which healed in a few weeks. Six months later he developed epilepsy of an irregular character, and had as many as five or six attacks in a day as a result of indulgence in absinthe. In the median part of the frontal region there was an irregular cicatrix about eight centimetres long, extending from left to right, and so extremely sensitive that simply shaking the hair in its vicinity pro- 140 RAIL WA V AND OTHER ACCIDENTS. duced great pain. It was impossible to make an explora- tion, for pressure was followed either by an attack or by vertigo and pallor. At various times there had been some exfoliation of bony splinters. The cicatrix did not correspond to the region of the motor centres, and the attacks were not considered to be Jacksonian. As a rule, they were preceded from twelve to forty-eight hours by a pain first confined to the cicatrix, but after- ward extending to the entire convexity of the skull, and then without warning the patient would fall suddenly after crying aloud, the limbs being extended. This was succeeded by clonic movements, mainly on the right side, and by a condition of stupor; a slight degree of right hemiparesis was found after recovery. The patient was cured by the trephine, a button of bone being removed- which was about one and one-half centimetres in front of the bregma, and no evidence of disease of the dura be- neath was found. It has been held that where there is no external appearance to enable one to localize the trau- matic lesion, if there be pain on the side opposite to the localized spasms and some loss of power on the side of the body in which the spasms appear, the inference of an injury of the cortical motor centres may be drawn. In certain diseased conditions of the middle ear so- called reflex epilepsies sometimes follow the merest con- tact or the blowing of air into the external meatus, or even a slight exhibition of force. While the claims of Brown-Sequard are often open to doubt so far as their confirmation by clinical facts is concerned, there can be no doubt that he was able to pro- duce convulsions in animals, particularly guinea-pigs, by crushing the sciatic nerve. But such injury to the human INJURIES OF THE CRANIUM. 141 subject has not hitherto given rise to classical epilepsy, although the claim has been made as the basis for com- pensation. A case in which a great deal of nerve injury in connection with an unskilful amputation was supposed to cause the epilepsy, which followed later, came under my observation, and a second.operation was ordered for the purpose of removing the degenerated nerve ends, but without result. Case XXVI. — J. M , aged 25, was a salesman in a large department store, of good habits, who never had had any head or other injusy until November 29th, 1889, when he was run over by a railroad train, losing his right leg and receiving a blow upon the left side of his head. He was about three months in the hospital, where his leg was amputated, and he recovered fully with the ex- ception of neuromata, which involved the ends of the severed nerves and which were exceedingly painful. In August, 1894, upon a very hot day, at about 11 p.m., he had a severe epileptic convulsion preceded by a shriek, and in this he bit his tongue and foamed at the mouth. The convulsion began on the right side of the body, and was followed by a disturbance of speech for several weeks, which was solely due to the wound of the tongue, and not to ataxic aphasia. He had attacks of temporary blindness and petit mal several times during the day. He had another attack a few months later, the right side being again affected with resid- ual pains, some of which were due to the dislocation of the right shoulder. He had paroxysms regularly after this, the right side being always involved, and upon one occasion the mouth seemed to be drawn to this side. They were both nocturnal and diurnal, and from 1898 until I saw him a year later he had had light par- oxysms without aurse. He suffered constantly from headache on both sides of the vertex, his sense of smell being decidedly im- paired on the right side, and he evidently suffered a certain amount of mental weakness. As his stump was painful, and the result of the first surgical operation was exceedingly imperfect, I sent him to the New York Hospital, where a fresh amputation was per- formed, the result being a great improvement in his local condi- tion ; and as a large neuroma was removed, it seemed possible that 142 RAILWAY AND OTHER ACCIDENTS. there might be some improvement, but after two months the at- tacks returned with greater frequency. There was no depression or external evidence of fracture of the cranium, and it was deemed best not to attempt any further surgical interference, although there was little doubt in the minds of those who saw him that he had an obscure focal lesion of the cortex, and possibly some injury of the base, which accounted for the anosmia. The peripheral nerve degeneration in the amputated extremity was thought at first to be the starting-point of the paroxysms in a manner sug- gested by Brown-S^quard. CHAPTER IV. TRAUMATIC INSANITY. In preceding chapters the mental alterations consecu- tive to injury or shock have been considered, so that any detailed description of traumatic functional disturbances may be here dispensed with. Meyer, whose recent con- sideration of the subject is comprehensive,' refers to the rather general disposition to misuse the term traumatic insanity. "Some writers," says he, "include — bowing ' Meyer's Classification. 1. The direct i>ost-traumatic deliria with the following subdivisions. {a) Pre-eminently febrile reactions. (b) The delirium nervostim of Dupuytren, not differing from deliria after operations, injuries, etc. (c) The delirium of slow evolution of coma, with or without alcoholic basis. (d) Forms of protracted deUria, usually with numerous fabulations, with or without senile basis. 2. The fiost-trauntatic constitution. (a) Types with mere facilitation of reaction to alcohol, grippe, etc. (b) Types with vasomotor neurosis. (c) Types with explosion diathesis. {d) Types with hy steroid or epileptoid episodes, with or without con- vulsions (such as most reflex psychoses). (fi) Types of paranoiac development. 3. The traumatic defect conditions. (a) Primary defects allied to aphasia. (b) Secondary deterioration in connection with epilepsy. (c) Terminal deterioration, due to progressive alteration of the primarily injured parts, with or without arteriosclerosis. 4. Psychoses in which trauma is merely a contributing factor. (a) General paralysis, with or without traumatic stigmata. (b) Manic-depressive and other transitory psychoses ; katatonic deterior- ation and paranoiac conditions, with or without traumatic stig- mata. 5. Traumatic psychoses from injury not directly affecting the head. 143 144 RAILWAY AND OTHER ACCIDENTS. to the crude sense of the word — all mental disorders in whose etiological constellation any traumatism plays a role ; even a surgical operation, or a totally indifferent organ, or a fracture of an ankle . . . also insolation is frequently included." Although it is popularly supposed that head injuries are the most fruitful causes of insanity, statistics do not appear to prove this to be the truth; for at the large Scotch asylum under Clouston's care there were but twelve cases directly due to these and to sunstroke, or one-third of one per cent of all the admissions during nine years.' Yet many irregular psychoses are undoubtedly traumatic. Two general forms of traumatic insanity are recog- nized, viz.: I. That which includes the cases due to direct cerebral injury and expressed by slowly developing motor symptoms, amyosthenia, varying degrees of hemi- plegia, and perhaps tremor, as well as convulsions, and by vertigo and headache, while the changes in mental health consist of excitement or depression followed by dementia, and occasionally by confusion, with hallucinations and de- lusions. These patients often give way to impulses of a destructive or homicidal character and are hard to restrain. The organic features of the disease sometimes suggest gen- eral paresis and lead to mistakes in diagnosis, especially if there happens to be one or more epileptoid paroxysms. 2. The second form is supposed to be due to shock ' The influence of head injury, however, as a factor of recurrent insanity is made much of by Bevan Lewis, who says that twenty per cent of the male recur- rent cases at Vilest Riding Asylum had suffered from falls or a violent blow, causing temporary unconsciousness without fracture or depression of bone, but at the same time there was a history of alcoholism and criminal tendencies. It is not stated, however, whether these injuries preceded or were inflicted after the development of the mental symptoms. TRAUMATIC INSANITY. 145 alone, and where there is no adequate history of any damage to the cerebral tissue or resulting coarse disease. In a small number of traumatic cases, with associated minute and general lesions, symptoms of cortical disease, due to nutritive changes, are found with or without fract- ure, and may be exceedingly complex. What almost amounts to a characteristic of this form of insanity is the intolerance of stimulants, or the susceptibility to mental disturbance under the influence of a trauma in persons who are addicted to alcohol. Case XXVII. — A boy, aged 16, who was seen in October, 1903, had about nine years previously fallen through a trap door, striking his head upon the vertex on the right side near the me- dian line, sustaining a depressed and comminuted fracture of the left parietal bone. The subsequent unconsciousness lasted five days, and he was taken to St. Vincent's Hospital, where he re- mained for six weeks. There were immediate hemorrhage from the nose and right ear and internal strabismus for three weeks. There was no paralysis or anesthesia. A diagnosis of fracture of the vault, with comminuted fracture of the bone, was made by Dr. J. D. Bryant. There was some fron- tal headache, but the history of other succeeding symptoms was unobtainable. He presented a depression of the scalp and skull about one and one-half inches long and about one-half inch wide, behind the situation of the central fissure, and local pressure pro- duced no pain or discomfort. The right pupil was slightly larger than the left, but both reacted to bright light and efforts of ac- commodation. There was commencing choked disc in both eyes, but no oculomotor symptoms. The knee-jerks, especially the left, were exaggerated, and there was left ankle clonus, but no apparent loss of power. The innervation of the left side of the face was de- fective, the tongue being protruded in a straight line, and he oc- casionally had vertigo. There was a mitral regurgitant murmur. Coincident with the injury he began to drink immoderately, and has continued to do so, although he has gotten into all kinds of trouble, having been arrested for an apparently purposeless and violent assault upon a woman. He has had at least two epileptoid attacks, 10 146 RAILWAY AND OTHER ACCIDENTS. and an attack of post-epileptoid violence, in whicii he assaulted a relative who was with him, but had no memory of this afterward^ nor did he recall his last escapade. He has always been neurotic, wilful, and hard to manage. When a child he had chorea. His present mental degeneration is closely connected with the trauma ; .and although he is bright in many ways, he has degenerated and undergone a change in disposition and morals, which has advanced rapidly. Shock may either through its purely psychical mani- festation or through a general concussion of the cephalic mass induce a notable alteration in mental health. When no structural disturbance follows — that is to say, when there are no minute anatomical changes — the subject's conduct may suffer material change in certain cases and a variety of altered intellectual function or derangement is almost immediate, or may follow within a few weeks or months after the accident. What has been termed primary traumatic insanity by Guder, Bailey, and Meyer begins often in this way, and may or not be inaugurated by a rise of temperaturCv somnolence, and delirium; and is symptomatized by- mental haziness, "variable contradictory statements of time, poor calculation, amnesia, and fabrication " (Meyer) — in fact, by a general psychasthenia. Sudden and apparently complete losses of memory- are the familiar and dramatic consequences, sometimes of shock ; but they are exceedingly rare, and are so striking when they do occur as profoundly to impress the layman as well as the doctor. They may at times blot out the pa- tient's recollection of his accident, and although the dis- position of malingerers is often to pretend not to know what has happened, thus saving themselves a great deal of trouble and impressing the jury, such simulation is more TRAUMATIC INSANITY. ii,y common in criminal cases in which the hope is to escape the consequences of an illegal act than in those under consideration. It has been alleged that a blow upon the head may suddenly destroy all recollection of past events, and that another head injury at some subsequent time may lift the veil and restore the ability to recall the past ; but these examples are rather curiosities of medical liter- ature and rank with those of mental duality, which are usually hysterical conditions, occurring in psychopathic subjects. A loss of memory usually follows a serious accident and is a part of a general disturbance and structural change in connection with a local laceration, or perhaps fracture. Case XXVIII. — A case of this kind was that of an elderly man who had fallen down the stairs of an elevated railroad station, striking the back of his head and sustaining a probable fracture of the skull, an injury of the right arm, and an inguinal hernia. There was evident injury of the cerebellum as well as other parts of the brain, for there was prompt rise of temperature to I02°-I03° F., as well as delirium, convulsions, vomiting, headache, and a tend- ency to pitch to the left. On one occasion he pitched forward from a chair in the doctor's office in which he was sitting, and when walking there was often a tendency to proceed to the left. The head symptoms subsided with the exception of occasional giddi- ness and procursive movements, although two years afterward there was some tenderness over the left suboccipital region. A feature of this case was a loss of memory for most things occurring after the accident, but with a fair retention of events preceding his fall. In fact his only account of the accident was that communi- cated to him by others, and there was a coincident weakness ; for although he had been up to the time of his fall an intelligent busi- ness man, he could not in his altered condition compute simple sums of interest, and was in every way intellectually feeble. In this case, which was tried three times, it was alleged that his symp- toms were due to old Bright' s disease, the basis for this defence being a transient albuminuria ; but several carefully made subse- 148 RAILWAY AND OTHER ACCIDENTS. quent examinations showed not only no evidences of renal disease whatever, but his arteries had not degenerated, and there were no signs of senility, although he was over seventy years of age. Concussion either with or virithout loss of conscious- ness may give rise to a loss of memory, which at first is so slight as to be little more than confusion, or of a puz- zling effort to recall, and there is a weakness interfering with reminiscent ability, the impression made by recent events being decidedly feeble. From this the patient may entirely recover in a short time, or there may be a subsequent fatuous condition expressed by delusions of identity and place and so great a degree of mental dete- rioration as to suggest the beginning of organic dementia. In a small number of persons who have sustained shock there is remaining mental confusion, which may be active or resemble the incoherence of acute mania ; or a dazed and bewildered state, which is different from that of acute dementia. Fleeting delusions, both systematized and unsystematized, hallucinations, and great restlessness are found, the confusion being sometimes confined to a species of aggravating indecision, not rising to the dig- nity of a psychosis. In such patients there are a lack of concentration and a decidedly impaired power of attention, which make their mental state quite evident to the most casual observer. From time to time the newspapers contain accounts of men who have wandered from home and who, when found, have no remembrance of where they have been or what they have done. The mental condition of these patients, as a rule, is supposed to be post-epileptic, or due to a so- called " psychical equivalent " for a convulsion, but this is by no means always true. The writer has known of a TRAUMATIC INSANITY. 149 case in which after a head injury a state of double con- sciousness was developed, and when upon at least two occasions the subject remained away for a week or two, during which in a way he appeared perfectly normal to strangers who met him. When he met his son on his return, he did not for a time know the latter, though he ultimately resumed his old personality, but could give no account of what had happened during his wanderings. He was not an epileptic, and his habits were good. These cases, which have been described by Janet, Richet, Binet, and others, are clearly examples of double or triple per- sonality, and are explained by a profound obsession, during which the subconscious self asserts itself.' If the injury be sufficient to produce a cerebral abscess or a hematoma, aphasia, epilepsy, and stupor may as a result be slowly appearing symptoms, indicating pressure and widespread pathological complications. Serious mental sequelae of head injury are found in connection with such evidence of mental disease as persistent headache, which is diffused, or bears some relation to a local injury, or to early irritability and querulousness. In the former case the symptoms of hyperemia are added, and the slightest mental effort greatly aggravates the cephalalgia. The same thing results from exposure to the sun, the use of alcohol in even small quantities, and overeating. The conjunctivae are bloodshot, and ordinarily there is some photophobia. The mental change, in addition to the expressions already mentioned, is mainly one con- nected with sluggishness of thought, dulness, and de- mentia. ' There may be a form of traumatic psychosis of a periodic and par- oxysmal nature expressed by violent impulses, the interparoxysmal interval being one of apparent sanity. ISO RAILWAY AND OTHER ACCIDENTS. TRAUMATIC INSANITY IN PREDISPOSED SUBJECTS. There is no form of insanity that at times has not been ascribed to accident; but, as has been said, the statistics show that there is exaggeration in this assump- tion. Of course, while injury, especially of the head, is a prolific cause of mental disease in persons so predisposed, or as the result of intracranial disease following blows, great care must be taken to determine the connection between cause and effect, and to ascertain whether the mental symptoms did not actually precede the alleged traumatism. There can be no dispute about the fact that occasionally long-continued worry, suffering, or severe shock may in persons with hereditary tendencies lead to the development of a psychosis of more or less gravity when the trauma may be the least part. Some unstable subjects succumb very rapidly to de- pressing causes, which would have no effect upon the normal man or woman ; and an insignificant injury with its attendant shock would favor a psychopathic decline or breakdown, as would overstudy, worry, or some other like cause. In these cases it is quite probable that there has been a preceding attack of insanity, or something very like it, and if the facilities are offered we may discover that some of the family of the patient have been or are insane, or that there is a remote history of alcoholism, tuberculo- sis, epilepsy, or hysteria. While Rigal and other French writers entertain the most catholic views in regard to the production of mental disease by trauma, it is probable that they exaggerate the cause and minimize the psycho- TRAUMATIC INSANITY. 151 pathic basis. Trauma in predisposed cases may be fol- lowed by periodic insanity, melancholia, as a rule, being a primary phase, and in several of these seen by the writer the psychosis originated in a previous state of ill health, due to brooding. A limited delusional form, which, how- ever, is not a true paranoia, because of the confusion and decided mental weakness, is occasionally seen ; but it is difficult to compare it with either the hallucinatory or simple delusional form so well known. Case XXIX. — Upon the 8th of February, 1883, the writer examined J. H. M , aged 49 years, in company with Dr. A. B. Ball. M was injured in a collision between two ferryboats about a year before, the only objective feature being a fracture of a fibula. He had re'c6ived also a blow upon the head. There were, at the time, a great deal of cerebral disturbance, irritability, and a change in disposition, which became so marked that he was sent by his physicians in Jersey City to an asylum, because he was dan- gerous and threatened his family. He was a large and active man, restless and unstable, and lacked fixed attention and insight. His eyes were bright and wandered restlessly, and he looked away from his questioners when replying; his pupils were dilated and his manner was excited. He did not finish answers, constantly turn- ing into new channels. He said that he had had personal com- munication with God, and dreamed at other times. When asked if he saw God only in his dreams, replied : " No. He has appeared to me in person, and I saw His clothes and beard." He said that he was an agent of the Almighty, and was to compel persons to do as he told them ; that his wife and children were unkind and did not care for him, that they would be better out of the way, etc. He could assign no reason for their ill-treatment except that one of his children, whom he "hated the most," had injured one of his saws ; and admitted that he had told his wife he would cut her throat and his own. He had expressed delusions of impor- tance and wealth. He denied insanity. On some subjects he could talk clearly enough, but close questioning showed that his mind was weak, and this was manifested by some more or less confusion and instability. There were no physical symptoms 152 RAILWAY AND OTHER ACCIDENTS. whatever. It was ascertained that there was an unsound family history, and he had always been peculiar. His case came to trial before his mental condition was fully recognized. On the witness stand he abused his counsel, and said he did not need damages or compensation. In this case the right of a lunatic to bring a suit was questioned, but was decided after appeal in the affirmative. There was a subsequent compromise. Case XXX. — Another case, the subject being the daughter of neurotic parents, was seen by the writer in December, 1900. She was a passenger on a train wrecked at Paterson on November 29th, 1899. Although occupying a seat in the drawing-room car, which was one of those that escaped, she was considerably stunned and shaken up by the collision, but sustained no wounds, and on leaving the car was obliged to pass through a place where" there were a number of mangled bodies and wounded people. The immediate effects of this shock were very severe, and on reaching home she was utterly demoralized, apprehensive, and constantly referred to the accident. She became nervous and timid, grew thin as she would not eat, and lost much sleep ; silence and introspection followed, and it was with difficulty that any one could get an answer from her. On December 20th she told her mother that her being on the train was a "put-up job"; that the accident happened because she was on it. Because of the increase of her ill health she was advised to consult Dr. McEvoy, one of the physicians at the Vanderbilt Clinic, and went there several times, but suddenly left because she thought that everybody was watching her and " saying things against her " ; that " the doctor had put poison in her medicine, and blown something into her nose of a poisonous nature." Her excitement increased so that it was found necessary to watch her continually. On the 6th or 7th of April, 1900, she went to the house of her betrothed, whom she accused of poisoning her, and a few days later was seen by the writer, when she manifested well-recognized delusions and hallu- cinations, believing that there was a conspiracy against her ; that she was unfit to be in the society of decent people ; that she ex- haled a peculiar and subtle odor, her father, mother, and young man to whom she was engaged having conspired to poison her, and said that they had put something upon her clothing ; that she had changed her waist three' times in one day, and the bedclothes, TRAUMATIC INSANITY. 153 so that they would not be contaminated. The coffee they gave her had also been doctored by some one. She believed herself to be absolutely immoral, and said that when she went to the dis- pensary people were trying to make improper proposals to her, and looked at her in a peculiar way. She thought that others in the street cars also had evil inten- tions. At other times she was excited and anxious, and declared she was about to die. Her delusion of self-degradation was such that she would not go to church because she imagined the clergyman was preaching at her, and because the people looked at her and knew her wickedness. She was a strong and well girl before her accident, was sensible, calm, and quiet, and her bodily functions were in normal condition. Since then her menstruation had been irregular, and she would go seven weeks at a time without any period. Although her active delusions subsequently disappeared, she was different in many ways, and lost all her former brightness, and was dull and moody, and had delusive ideas. Though the case was settled for a comparatively small sum she has not recov- ered, there being an undoubted permanent condition of impair- ment. While it is held and it is undoubtedly true that a serious hypochondriacal melancholia may follow a railroad injury and be manifested by an initial condition of neur- asthenia, ordinary hypochondriasis, and simple depression, the evolution of such a psychosis and the patient's com- plaints bear a direct relation to the accident itself — at least in the beginning, and there is more or less reference to the excitement through which he has passed, and the specific incidents which have to do with his morbid fears. When we meet with an alleged delusional hypochon- driasis where these things are absent, it usually has some other explanation. Such a case was that of Mr. S , who brought suit for damages upon two occasions, and whose friends and physician ascribed his evident insanity to trauma. 154 RAILWAY AND OTHER ACCIDENTS. Case XXXI. — Mr. S , clerk, about 45 years, claimed to liave been injured by being thrown to the ground by a street-rail- way car on the night of June 26th, 1898. The plaintiff is a He- brew, and according to his friends had enjoyed good health before the accident. It is certain, however, that several years, before, he had consulted several specialists abroad, who were authorities on venereal diseases, for real or fancied syphilis. He admitted this to the writer, and there was no reason to doubt the fact ; be- sides there was a suspicious discoloration upon one shin, agreed by one of his physicians to be possibly syphilitic. Before June, 1898, his brother-in-law, who had had syphilis, was sent to an asylum, and there died of paretic dementia. This had a most de- pressing effect upon him, and he not only dwelt much «pon the subject, but bought medical books and read a great deal. Knowl- edge of his own history led him to believe that he too might be- come insane, and he grew intensely hypochondriacal, and probably ■was in this condition at the time of the accident. According to the evidence he was picked up and taken to the house of a neigh- boring doctor. This gentleman found no cuts or bruises. The patient talked rationally, and said " nothing was the matter." He went home, and, according to his family and the two physicians who attended him, became insane, although it was not found nec- essary to send him to an asylum. According to them, during the summer of 1898 he had lively delusions of persecution, believing he was responsible for the death of a well-known musician, as well as that of the Empress of Austria ; that he was concerned in the blowing up of the battleship Maine, and was constantly pursued by detectives. He actually delivered himself up at a police sta- tion, confessing that he had done all these things. He referred to a conspiracy that was being formed, of which he was the victim, and said that he had been hypnotized ; but his delusions were all connected or evolved from his early sense of degradation and con- tamination. When I saw him, a year before the first trial, which occurred in May, 1900, he was free from his false beliefs, and admitted that they were delusions. He then told me that he had all the time dreaded syphilis, and spoke of his anxiety regarding the case of his brother-in-law. He also communicated to me his history of headaches and insomnia, and at the time his mental condition was one rather of dulness than excitement. He never worried about TRA UMA TIC INSANITY. 1 5 5 the accident, but had frequently referred to his dread of insanity. During the summer of 1 898 he went to his business unattended, and to his doctor's office, and backward and forward to the coun- try alone during the summer, and up to January i6th, 1899. He talked about his children intelligently, and played games with his business associates during the time he was alleged to be inco- herent, and to them appeared to be only dull. To various persons he complained prior to the trial of the case that he had syphilis. He was not so possessed by the alleged delusions that were claimed to be unsystematized and engrossing, that he could not talk about his early life to his wife, and show some interest in his affairs. The case resulted in a verdict for the defendants, it being proved that they were not responsible ; and it was also claimed that his psychosis was not due to the alleged accident, but was a species of syphilophobia; that originated -before and was curable. In 1902 it was admitted that he had recovered, but a second trial re- sulted in a disagreement. His mental state certainly bore no re- semblance to any classical insanity ; certainly it was not a genuine paranoia, but it is not difficult to diagnose a hypochondriacal mel- ancholia based upon the knowledge of the existence of a loathsome disease, with constant introspection, a sense of degradation, and delusions of self-abasement and culpability, which subsequently expanded into those of suspicion. Acute dementia or hebephrenia^ which is usually an insanity of early life, occurs in subjects who present the tendency to the degenerative psychoses, and shock is com- monly an exciting cause. It is characterized by rapidly developing confusion and stupor, which resemble the leth- argy of stuporous melancholia, and is not the form in which delusions or hallucinations figure. There is, how- ever, not the progressive mental decline of melancholia, but a sudden development which, under other circum- stances, is due to some such cause as the ingestion of an unusual amount of alcohol, overexhaustion of the brain ' Or a form of the dementia praecox of Pick. 156 RAILWAY AND OTHER ACCIDENTS. from overstudy, but in the cases under consideration may follow the shock incident to a railway or other ac- cident. The condition of the cerebral circulation is un- doubtedly one of profound anemia, and in this respect it resembles ordinary melancholia. The dulness of the pa- tient is apt to be very great, and his attitude and whole appearance is impressive and not to be mistaken. The surface and extremities especially are cold and livid. He makes little or no voluntary movement, is indifferent to external irritation, and may be so dull as not to notice the crawling of flies over the surface of the body. It is usually necessary to feed such a patient artificially, as he makes no volitional effort to swallow. He is always list- less, leading a vegetative life and appearing mentally much worse than he really is, for there may be recovery in a comparatively short space of time. His mental instabil- ity, however, renders him liable to other attacks, which may later have nothing to do with the accident. Some- times a katatonic state, with muscular waxy rigidity, may be presented. Apathetic conditions having an hysterical tinge are after trauma found in elderly people, and with these there may be an associated childish obstinacy and weak aggres- siveness manifested in assaults, destruction of clothes, and defilement of person and bedclothing, the patient seem- ingly being actuated by the idea of giving the attendants as much trouble as possible. The effect of an actual trauma upon an elderly patient whose blood-vessels are diseased may be such as to favor the development of a senile dementia, and the mental evidences of a general arteriosclerosis, which before the accident were not such as to attract the attention of the friends of the patient, TRAUMATIC INSANITY. 157 may become noticeable when others incident to fright or shock are added. Case XXXII. — Mrs. M , an aged woman, was thrown to the ground on July i6th, 1899, by a street car, which, it is alleged, started when she was boarding it. She claims to have received a scalp wound, but nothing else; but it is alleged by her family that she gradually became insane, and was committed to a sanitarium in August, 1899, where she stayed for eight weeks. During this time it was said that she suffered from insomnia, fits of despondency, restlessness, inability to recognize those she knew, and disorientation ; that she made attempts at suicide, ac- cused those about her of robbing and poisoning her, had visual hal- lucinations, stating that she had seen her father and mother, who were long since dead, and believed her daughter was married to a priest. The patient was seen by the writer March loth, 1900, and her history was detailed by Dr. C. J. McGuire, who stated that in addition to the above she had delusions of suspicion, fear- ing that she was to be locked up by persons who wanted to get her money ; that she had a dread of poverty ; that her memory was poor ; and that she was not able to go out alone. My exami- nation lasted nearly an hour, and there was no mental weakness shown except such as one might expect in a person of her extreme age, for she was nearly eighty. Besides the weakness of memory for proper names and of re- cent events, there was no disorderly behavior or mental aberration, at least then. Her chief complaint was that her son had been charged a large sum by the officials of the asylum for care and treatment, and for this reason she wanted to leave. Her former excited condition in the absence of other facts must be attributed to the mental shock, and as the weather was very warm at the time, there is little doubt that the general ex- citement precipitated her trouble, which in a person of her age was natural enough. She showed evidence of senile degeneration, her arteries everywhere being rigid. 158 RAILWAY AND OTHER ACCIDENTS. PARETIC DEMENTIA (DEMENTIA PARALYTICA). Injury is by many admitted to be one of the causes of this familiary mental disease, although syphilis ranks first. According to Defendorf, a clear history of its spe- cific origin cannot be obtained in more than thirty-four per cent of the cases, though other writers fix the propor- tion at a much higher figure. At a time not so long ago, syphilis and alcohol were by the Germans especially held to be the sole etiological factors; but a reaction has taken place, for strain, excitement, and protracted worry figure in the genesis of paresis, and doubtless trauma acts, as it so often does in locomotor ataxia, by develop- ing a parasyphilis, so the necessity of obtaining a reliable history of early infection is paramount. It is important to remember that the prodromal stage of the disease is one in which there is often a long-existing stage of break- down with expressions that are not clearly evident to most people. These consist for the most part in changes of disposition and habits, and a general condition of more or less mental weakness, which has already been referred to when speaking of neurasthenia. To these are added such physical symptoms as tremors of the lips, tongue, and hand, awkwardness of speech and a certain shiver- ing articulation, inequality of the pupils, and perhaps the Argyll-Robertson symptom. The knee-jerks in a certain number of cases are lost, and there is some deteriora- tion in handwriting. At such a time the receipt of an injury to the head may at once lead to the development of an acute condition of mental disturbance, an explosion of violence, or a rapidly developing dementia, and this is naturally ascribed to the accident alone. It may not be TRAUMATIC INSANITY. 159 difficult to ascertain, however, that at some previous time the patient has been melancholic, hypochondriacal, per- haps morbidly elated, or that some of the physical stig- mata have been present ; in other words, that the pro- dromal stage has existed for a considerable period. Head injury is far more likely to produce one of the forms of organic dementia than the more or less definite psychosis known as paretic dementia, and even the most pessimistic statisticians rarely go beyond eight per cent as their estimate of the proportion of purely traumatic cases, and this rather overstates the percentage. The incipient paretic is apt to get into trouble because of his mental peculiarities, or to fall as the result of his vertigo or unconsciousness, and this is still more likely if there be an epileptoid explosion, which is so often apt to be the case in the early stage of the disease. He may thus sustain a head injury, which is ascribed as the cause of the subsequent accentuated disorder. I have noticed in the prodromal stage, when the patient is superficially emotional, he is likely to become pliable under the influ- ence of suggestion, and through the machinations of dis- honest plotters may misrepresent his real condition or else allow others to do pretty much as they please. A case of Le Grand du Saulle, previously reported by the writer, is that of two brothers who consulted a Parisian psychiatrist of note, who made a diagnosis in one of paretic dementia. The other took the patient to an in- surance examiner, who promptly recommended a policy, apparently not noticing the existence of the disease. When the man died two years later, the money was paid without protest. It is quite probable in this case, as in many others, that the paresis developed from a light i6o RAILWAY AND OTHER ACCIDENTS. ^^^- . ■ ■ fl^t<< '^.. '. '. ^^ /, ■ ■ ■ , H ^ ;' ' ^jBt j .; ^^|^Hk|.'«-'' . 1 [V't^:, ^^^^H^^. / iL^ _Eil^j form of S3'philis, with slight primary lesion, and that no stigmata were found. Paretic dementia, beginning with an initial stage of depression or exaltation, develops quite rapidly, although its course may extend over a number of years. The idea formerly entertained that the disease ends in eigh- teen months or two years seems to be erroneous, for subjects are found in every asylum in whom it has lasted for ten or fifteen years. There is much uncertainty in its debut, the physical pre- ceding the mental symp- toms, or vice versa, but usually we find them coincident in the fully developed disease. There are commonly a decided change in the morals of the patient, especially so far as sexual ex- cesses are concerned, and a great deal of optimism, which is succeeded by expansive and preposterous delu- sions of importance. In the beginning he may be prod- igal in his expenditure of money as the result of these, and there seems to be no correspondence between their expression in people of different classes of life. The feeling of bien etre brings with it a sense of happiness and jollity. He orders innumerable things which are not paid for, and when arrested or confronted by those he has robbed or imposed upon makes an insane explanation, which is perfectly satisfactory to himself if not to others. He constantly plans, no scheme being too extravagant for Fig. 19.— Facies of Paretic Dementia. 77?^ irjIA TIC INSANITY. i6i him to adopt. At times he is violent, especially when in- terfered with, and as the result of his delusions may even become destructive ; but, unlike the paranoiac, he can be diverted or led, or a new idea may be suggested and readily adopted. Hallucination and incoherence, and delusions of persecution are sometimes present. After a variable period, during which there may be remissions, when the patient to many people is apparently well, there may be a relapse ; but there are rarely more than two or three such intervals, although certain writers describe an alternating or recurrent form. Ultimately the mental weakness grows more marked and dementia ensues. The physical symp- toms are always present when they have once appeared, although there is some variation, especially in the char- FIG. 30.— Final Helpless Sta^^e with Contractures m Paretic Dementia. acter of the dilatation of the pupil, and in addition to those of the prodromal stage there is a disturbance of locomotion characterized by unsteadiness and titubation. The facial muscles are tremulous and the speech is more embarrassed. The reflexes may later be exaggerated, especially in the cerebro-spinal form of the disease. II i62 RAILWAY AND OTHER ACCIDENTS. There is a great emotional instability as well as a tendency to cry, this even occurring without any apparent provoca- tion. Finally the dementia and physical weakness are so marked that the patient cannot stand, and he takes to his bed, where he remains for the brief remainder of his life. Progressive dissolution is marked by muscular asthenia, atrophy, and permanent contractures (Fig. 20), by incontinence of urine and feces, by the formation of bedsores, and by general helplessness and death. CHAPTER V- INJURIES OF THE VERTEBRAL COLUMN AND ITS CONTENTS, Nature has provided a most ingenious and well-pro- tected conduit for the complex and important bundle of nerve fibres which play so large a part in the human economy. Enclosed in a bony canal, which is made up of segments ingeniously supported and linked together by ligaments and capsules, and separated by buffers of cartilage, which take up the force of too violent concus- sion, it is in a position to do its work of carrying impres- sions and impulses from without and within and perform- ing its local duties. As if these safeguards, were not enough, we find the cord surrounded by membranes, cushioned by cerebro-spinal fluid, and in a measure sup- ported by the nerve trunks. In view of all this, concus- sion is not the common thing it is supposed to be, and if it does occur, it is, as a rule, evanescent and expressed by short-lived symptoms, such as fleeting disturbances of sensation and a certain degree of motor weakness. In- juries which lead to fracture or dislocation of the vertebrse under certain circumstances, however, set up inflamma- tion in the intervertebral cartilages, and may give rise to a number of serious structural diseases of the cord itself, which are immediate or slow. Thickening of the invest- ing membrane and compression myelitis, especially in the cervical region; injury of the important nerves of the 163 i64 RAILWAY AND OTHER ACCIDENTS. neck ; hemorrhages within or between the membranes, or in the substance of the spinal cord, with resulting compli- cations, are all grave, and are apt to follow the exhibition of sufficient violence. Of lesser importance, but of com- moner occurrence, are a number of painful and obstinate injuries, which are, however, exterior to the vertebral col- umn, and these may consist of contusion or stretching of the spinal nerve trunks, a possible separation of the attach- ments of the muscles of the back, so that muscle fibres may be ruptured as well as tendons, or bony eminences may be torn away. There are few cases of severe rail- road injury in which sprain is not found with or without neurasthenic symptoms, and Dana goes so far as to say that traumatic neurasthenia is nothing but ordinary neur- asthenia with added sprain, so important does he consider this result of the ordinary expenditure of violence to be. Sprain is mentioned in most of the treatises as a con- stant symptom of traumatic neurasthenia, which, however, it is not. It is hardly necessary to say that its extent depends upon the nature of the wrench, which may vary from a trivial affair with a localized area of back pain, to a forcible twisting of the entire vertebral column, with more or less torsion of the cord itself, when of necessity we shall have spinal symptoms of varying importance and duration, and possibly contusion of the nervous mat- ter. All back injuries, whether they be superficial or deep, are fraught with most serious consequences when the upper cord is involved, for not only is muscular pro- tection less fully provided there, but the vertebrae are themselves less strongly constructed, and- the liability of delicate parts to injury is sometimes very great. The phrenic and pneumogastric nerves may be injured even INJURIES OF THE VERTEBRAL COLUMN. 165 as the result of a strain, when the upper cervical vertebrae are unduly twisted. Case XXXIII. — Holmes reports the case of a man who when playing with his child got down on his hands and knees, and when springing forward tripped and rolled over with his head under him. The weight of the body came with an impulse on his neck, and gave him much pain from the twist it caused. He lay motionless for ten minutes, and then found, on attempting to rise, that he could not use his arms or legs ; and there was gen- eral dysesthesia. There were no tactile anesthesia and no pain except over the fourth cervical vertebra, where deep swellings could be found. In twelve hours motor power was restored. He subsequently recovered entirely, but for a long time was unable to rotate his head, and was obliged to turn his entire body. Case XXXIV. — The writer recalls a personal case of an army officer who, when riding in an ambulance, was thrown so that his head struck the top of the vehicle, when the front wheels suddenly dropped in a hole. The result was that his head was suddenly bent forward. Severe localized pain over the cervical region, dila- tation of the pupils, disorders of respiration and circulation, ver- tigo, were features of a long train of symptoms which extended over a period of years, and led to his retirement from the service. Case XXXV. — Another case which depended upon a fall into a sewer culvert was that of a woman who in consequence sus- tained a rupture of the latissimus dorsi and trapezius muscles of the left side, so that not only were there excruciating local pains, but she could not bend her head forward or turn the upper part of her trunk without agony. In this case there was a comparatively rapid recovery in less than a year. These illustrate different forms of trouble of a com- paratively light grade. There are others in which pro- gressive or immediately fatal symptoms may occur, even when there is -no fracture or impact of broken bone, but these latter are uncommon. Happily the lumbar region is the commonest site of sprain and muscular accidents, i66 RAILWAY AND OTHER ACCIDENTS. and the dorsal is exempt, except when, as Golebiewski has pointed out, the articulations between the transverse proc- esses and the ribs, or between the ribs and the bodies of the vertebrae, are involved, when a painful condition re- sults. This form of sprain, however, is very apt to be connected with some fracture of the ribs themselves. Case XXXVI. — W. H. D was injured in an accident on the Erie Railroad on March i6th, 1893. The man was in the middle of the rear sleeping-car when it was run into by the loco- motive of another train, and he knew nothing until he found him- self under the debris, and was aroused by a person crying near by. He was helped to his feet, but could not stand because of weakness and pain. He was carried to the Lackawaxen depot, where he remained for a time, and was then taken to the hospital at Port Jervis. He suffered from pain in the right side and back, from pain and numbness of the right forearm, due to a bruise over the olecranon process, and from local nerve injury with paralysis, and cuts upon the head. He was also slightly cut about the feet and back, and was extensively bruised. Three lower ribs on the right side and two on the left were found to be fractured, and he was placed in a plaster bandage. He found it difficult to swallow or speak for the first few days, and suffered from severe pain over the four or five lower costo-spinal articulations. The writer ex- amined him December 2d, 1894, and found the subject to be suffering at that time from a great deal of helplessness, due to pain and rigidity, which practically extended from the nucha to the coccyx, and with severe pain upon pressure over the lower dorsal vertebrae. He could not walk without help, and only then for a short time and with an increase of suffering. His back pain was so great that he was obliged to change his position frequently, and he suffered from, a certain amount of nervousness and appre- hension, while neurasthenic symptoms with twitching of both legs shortly developed. There was no muscular atrophy, and the muscles responded to both currents. His reflexes were normal and his vision was unaffected. His recovery was slow. INJURIES OF THE VERTEBRAL COLUMN. 167 TRAUMATIC LUMBAGO is attended by complaints of intense pain, chiefly in the small of the back, which interferes with bodily movement, and enforced quiescence and a fixed attitude are the result. There is the " fear of movement " which is recognized so often, and dwelt upon so much by Page. When the pa- tient uses his arms and legs, he contrives to do so without bending the body or using the muscles of the trunk, so great is the distress, his attitude and whole bearing expressing suffering which he would evidently gladly escape. There are a timidity and appearance of weakness which bring with it a certain degree of caution, and sometimes the gait will be peculiar, as the subject, perhaps, gets more ease in progressing sideways or taking short and hesitating steps. Page has called attention to the interference with free micturition by reason of the lack of natural support and help which the lumbar muscles pro- vide when this act is being performed. Constipation is common, and is probably the result of the general atony. Traumatic lumbago may closely imitate and suggest a more serious condition of meningitis perhaps, and may be associated with local muscular atrophy which is some- times deceptive, conditions of rigidity, and perhaps a neu- ritis of superficial nerves. CONTUSIONS OF THE CORD without any decided indications of vertebral injury, and of kyphosis or distortion are met with, and are ordinarily serious and progressive. Case XXXVII. — J. A , an army officer, consulted the writer in 1 882 for the relief of a condition following an accident in 1 68 RAILWAY AND OTHER ACCIDENTS. 1879, when he was thrown from a wagon, striking upon the left side and cutting and bruising the leg and thigh of that side and wrenching the right leg and back. According to his statement, he was not at first insensible, but fainted, and remained uncon- scious for a few minutes. His injuries were supposed to be com- paratively trivial, and he resumed his duties in his regiment in two or three days, doing light work. Within a short time he became nervous and was unable to sleep as he had been able to do before the accident, and was obliged to come East. Since July, 1 879, he has suffered from various symptoms, such as pain through the lower part of the spine, over the first and second lumbar verte- brae, which sometimes extends upward or about the body. He has in addition dull pain at the back of the head, but no vertical pain, and none in the arms. He has sciatica from time to time, as well as pain in the ankles, more especially the left. It is im- possible for him to get a comfortable position, and he sits on one side of the chair. He cannot rise from his seat without great difficulty, and there not only seems to be aggravation of the spinal pain, but some loss of power as well. There is difficulty in going up-stairs, and he usually does so laterally, the right leg being put in advance of the left. He limps slightly with the left leg, which is decidedly weaker than the right, and when tested the electrical reaction is diminished, but there is no atrophy. The left knee-jerk is absent, and the right is exaggerated. He co-ordinates well, and can stand with his eyes closed. He cannot turn over in bed with- out first sitting up, and has very great difficulty in arising from the recumbent posture. There is some incontinence of urine, as well as constipation. He has had vertigo and blurring of vision, but no ocular changes are to be discovered. His speech is somewhat affected, there being a clumsiness as well as an actual transposition of words. By far the most interesting feature of the case is the manifestation of trophic changes. The skin was white and soft before the accident ; within a year a peculiar bronzing and mot- tling appeared about the ankles, which were covered with morphea, there being more discoloration perhaps on the left side than on the right, and there is some swelling. This patient has received very little benefit from treatment of any kind, and it is very probable that he has a serious organic change of both brain and spinal cord. His recovery is very doubtful. INJURIES OF THE VERTEBRAL COLUMN. 169 FRACTURES AND DISLOCATIONS. These accidents, like others elsewhere, may exist to- gether or apart and follow the application of varying force. The merest consideration of a railroad accident is sufifi- cient to show that falls and blows of many kinds, violent torsion, and forcible and sudden bending of the body to an extreme degree may have to do with the production of vertebral injuries, great and small. Fractures of a ver- tebra may involve the body, laminae and processes (ar- ticular, transverse, and spinous), and may exist with or without laceration of the ligaments. Dislocations may be either (i) of the articular processes or (2) of the diastases. They may be /orward, backward, and transverse, the latter being a rare form. In regard to fractures, we may find that some are complete, and followed by an almost immediate train of fatal or serious expressions of mischief, and it is not un- usual to meet with them in connection with dislocation. Fracture with dislocation is more frequent in the cervical region than elsewhere, and uncomplicated fractures are usually found in the dorso-lumbar region, the twelfth dorsal and first lumbar being the vertebrae commonly involved. There are other fractures that are incomplete but never- theless grave, leading as they do not only to deformities, but to compression or contusion symptoms, or to lesions elsewhere of later appearance. With the former, if the patient be not killed outright as the result of a broken neck, the impacted segment of the fractured vertebra may promptly cause a transverse myelitis, either partial or complete, or a more slowly formed pachymeningitis with 170 RAILWAY AND OTHER ACCIDENTS. constricting pressure. This latter is more common, as has been said, in the cervical region, or it may be asso- ciated with subsequent inflammation of the intervertebral discs farther down, with kyphosis, and possibly with the formation of ischial abscesses. Incomplete vertebral frac- ture with contusions of the spinal cord maybe intractable and dangerous sequelae of accident, insidious in development and slow in progress. It is often difficult to diag- nose in the beginning because of the absence of any external deform- ity, and of the resem- blance to a variety of other affections, and for the reason that extra- dural hemorrhage, or possibly a meningomy- elitis, may be caused. The injury may at first involve the substance of the body of the were tebra, which, accord- ing to Golebiewski, becomes softened, and for at least a year (or so long as the patient remains in a recum- bent position) there will be no expressed symptoms of trouble ; but when he arises and attempts to walk the weight of the body above will lead to compression, the forniation of a spinal projection, narrowing of the inter- vertebral canals, pressure upon the spinal nerves, and Fig. -Deformity due to Traumatic Spondy- litis. CGolebiewski.) PLATE IX. Railway am> other Accidents. Fracture of the Sixth and Seventh Cervical Vertebrse with Crushing of the Spinal Cord. The patient was a woman, aged thirty-three, who lived seven days after the accident, death being due to respiratory failure. During life there were sensory and motor paralysis of the trunk and lower limbs, and partial paralysis of the upper limbs; the upper limit of the sensory paralysis was at the level of the third rib. There was retention of urine. In the region of the sixth cervical spine there was marked projection, which, under an anesthetic, could be obliterated. The illustration shows the fracture of the two vertebral bodies and the projection of the seventh backward, pro- ducing narrowing of the vertebral canal and crushing of the spinal c 'rd. (Helferich.) INJURIES OF THE VERTEBRAL COLUMN, iji possibly of the cord itself. As a result there are a great deal of local as well as radiating pain from the neuritis, increased reflexes, and possibly subsequent symptoms of cord invasion. The appearance of such a patient is very characteristic, and Fig. 21 shows the peculiar bent position and kyphosis in an old case reported by Gole- biewski. Sometimes the local injury is of such a nature as to give rise to certain symptoms suggestive of spinal- cord disease, there being no apparent indication of actual caries. Case XXXVIII. — Snch a misleading case as is described above was seen by the writer, as well as by Drs. Stimson and Cly- mer some years ago, in which the diagnosis of Pott's disease had been made by the late Dr. Sayre. The plaintiff was a man who attempted to control a pair of spirited horses, but was unable, his light wagon being drawn into a hole in one of the public thorough- fares. The accident occurred upon a rainy night, and he was ex- posed for many hours, remaining in his damp clothes. So far as was shown by the evidence his' only injury was a sprain, caused by his being pulled half-way across the dashboard. From the time of the accident he complained of severe spinal pain, which, however, was not localized until a few days subsequently. It was found, however, when examined within a year that he complained of pain at several points in the spinal column, which was more in- tense perhaps over the first and second lumbar vertebrae. There were absolutely no deformity and none of the symptoms of spon- dylitis ; but a few months after the accident he began to develop symptoms suggestive of inflammation of the postero-lateral col- umns of the cord, exaggerated knee-jerks and spasticity. After the trial of the case, which resulted in a heavy verdict for the plaintiff, his symptoms progressed, and within two or three years he died of exhaustion, there being preceding paraplegia with symp- toms of lumbar-cord disease, and at the autopsy there was found not only extensive inflammation of the bodies of the first and second lumbar vertebrae, compression and destruction of the cord, but an adjacent large abscess several inches across in the deep muscular tissue. 172 RAILWAY AND OTHER ACCIDENTS. In this case the diagnosis of Pott's disease was in the nature of an inspiration, for every indication favored the diagnosis of an initial spinal-cord . lesion, possibly a cen- tral hemorrhage occupying the posterior and lateral parts of the cord Symptomatology of Cord Lesions. Much depends upon the extent of the lesion, its level, and the invasion of other parts, either by ascending or descending degeneration in a manner well known to neuropathologists, when in addition to the immediately produced symptoms there are others which subsequently appear. As has been said, the cervical cord is much more vulnerable, and injuries thereof are apt, if not fatal at once, to be exceedingly grave. A transverse section of the cord above the fourth cervical segment is usually followed by death in a few days, if not immediately. In consequence of such a lesion we find respiratory paralysis through destruction of the fibres of the phrenic nerve. If the cord be but half destroyed, this disturb- ance will be unilateral, the diaphragm being inactive, as well as the intercostal muscles, on one side only. Total transverse destruction is, of course, followed by complete paralysis below the level of the lesion, the arms being the seat of flaccid paralysis with disappearance of the reflexes, though the Babiriski reflex may be found. There is also general anesthesia, which usually does not extend up to the level of the lesion, and the rectum and bladder are paralyzed. Certain peculiarities in cervical paralysis are presented which depend upon the direct or indirect injury of different parts of the upper cord. Thus, if the fourth segment be injured alone, the loss of power will be con- INJURIES OF THE VERTEBRAL COLUMN. 173 fined to the muscles supplied by the brachial plexus and the rest of the upper extremity, while, of course, motor and sensory function below the lesion is abolished. If the injured part be at the level of the sixth segment, the shoulder muscles will be paralyzed; if the seventh and eighth segments be involved, those supplied by the ulnar nerve will be paralyzed, the muscles on the radial side of the forearm escaping. A lesion at the level of the first dorsal and last cervical segments will be expressed by a loss of power of the small muscles of the hand ; those of the arm and other superior parts escaping. In all of these forms, of course, there will be more or less paralysis of motion and sensation below the lesion. A transverse lesion of the dorsal cord is followed by a loss of power of the trunk and lower extremities, bladder and rectum, perhaps by atrophy with the reaction of de- generation, by anesthesia of all kinds, and, as a rule, by in- creased knee-jerks, ankle clonus, and spasticity. Should the patient survive there may be a complete loss of the re- flexes, and possibly contractures. Compression or de- struction of the lumbar cord is followed by complete par- alysis without spasticity, by atrophy, by a disappearance of the reflexes, except that of the sphincter ani, and by deep anesthesia. A modification of the paralysis may occur when the cord at the level of the first lumbar vertebra is in- volved, when crural nerve paralysis takes place. In lesions of this region, as in others above it, we find paralysis of the bladder and rectum. Injury of the sacral cord is followed by much more limited loss of power, the muscles of the foot being those affected, and the anesthesia is not general, but confined to parts supplied by the terminal branches of the peroneal nerve. There is incontinence of urine and feces 174 RAILWAY AND OTHER ACCIDENTS. as a result of sphincter paralysis, and the anus is often anesthetic. The reflexes do not undergo any alteration. When the coccyx has been subjected to violence, there is not so much liability to injury as in regions farther up, and the chief expressions are local pain, sciatic paralysis without rigidity of the lower leg muscles, possibly the glutei, and perhaps the quadriceps femoris. There is a dis- appearance of the lower reflexes, sometimes vesical weak- ness and atony or actual paralysis of the rectum, while sciatic pains, as well as coccyodynia, may be found ; a re- sulting sciatic neuritis is a possibility. Muscular twitch- ings occur in a certain number of cases. Serious injuries of the coccyx and sacrum may follow falls upon the but- tocks, and it is rare for fracture to occur from a trauma unless the force be directly applied. There are excep- tions, however, and a curious one that has fallen under the writer's notice may be mentioned, where a glancing blow delivered by a jet of water under very great pressure produced a fracture of the lower part of the coccyx and serious nervous symptoms as well : Case XXXIX. — The patient, E. W. G , was standing near a hydraulic cylinder about eight inches in diameter and possi- bly about two feet in length, which was used to pack gunpowder in another cylinder in front, and which burst. Just previous to this the water pressure had been tested and was found to be a trifle over thirty-five hundred pounds per square inch. The patient's story is as follows: "That this pressure was not too much was shown by the fact that I had operated a piston two or three times without trouble. Then the hydraulic cylinder burst, which, I think, must have had four thousand pounds or more pressure per square inch on the water. The position I occupied was thus (Fig. 22), standing almost against the cylinder and facing the direc- tion of the arrow. The fracture is thus shown by the letter X. Thus, you see, the water struck me at an angle of about forty -five INJURIES OF THE VERTEBRAL COLUMN. 175 degrees. Nothing but water struck me, which started at the height of and shghtly in the rear of the hip-joint, following the contour of the buttock. This was forced over to the right side of me, and subsequent examination showed that the fibres and tissues had been completely destroyed, so much so that I could not stand the touch of the hand, and after the second or third day it felt exactly as if the skin contained a liquid instead of meaty tissues." Two weeks afterward, the local injury, which occurred May 3d, 1899, had been entirely recovered from, but he suffered from intense pain in the hip and spine. It was a few weeks after this that he was brought to the writer by his physician. He was in a distinctly nervous and apprehensive state, his mind being full of the accident and its results. His physical appearance was very good in every way, although I was informed that he had been Fig. 22.— a, Hydraulic Cylinder ; B, Powder Compressing Chamber. sleepless and constantly despondent. A very careful examination revealed the absence superficial of tissue changes. His subjective complaints were those of intense pain in the hip and spine, there being three hyperesthetic spots, one just below each shoulder blade, another in the lower dorsal region, and in addition there was intense coccyodynia. The actual cautery and injections of atropine for several months were without benefit, and in June,. 1900, the end of the coccyx, which was found to be fractured and twisted, was removed, and for a week or ten days there was an absolute disappearance of pain in the affected regions. While the operation was very successful, it was later followed by intense pain and ischuria, the patient not urinating for seventy-two hours, and then with great agony. He continues : " About two weeks after the operation I was boarding a trolley car, which started just as I was about to sit down, the result being that I was thrown backward against the metal arm of the seat, striking on the remaining end of the spine. From that time on I have never been free from pain. I remained away from all work until the latter part of 176 RAILWAY AND OTHER ACCIDENTS. September without any change in my condition The pain at times has been so intense as to make me sick." Renewed apph- cation of the actual cautery somewhat relieved the patient, but there was a relapse when it was stopped. In November, 1902, he writes: "My nervous system I believe to have been badly "wrecked as compared to my condition previous to the accident, when I did not realize the meaning of the word nervousness. This may be due to the great loss of physical strength I have undergone. ... I cannot place any reliance, however, on the strength of my left leg, which has been so weak at times as to cause me to drop to my knees. When ready to retire, it is my custom to sit on the edge of the bed and then to swing my legs over and under the cover. This action, or probably the slight bending in the body, causes an extremely acute pain in a spot about five or six inches above the end of the spine — the middle point spoken of before — which feels just as if a sharp knife had been thrust into me. This lasts for a moment, and gradually fades away. I have noticed this for the last six or seven months only, but it occurs regularly every time I retire. My most com- fortable position in bed is one in which my knees are drawn up close to the body." There was no suit in this case. Care should be taken when persons present them- selves for medico-legal examination to ascertain the exist- ence of an old fracture with coccyodynia, for it is some- times found in women with deformed pelves who have •experienced this accident during labor. A number of very characteristic manifestations attend injury or disease of the superior cord extending as far down as the seventh cervical vertebra, and are bilateral or unilateral according to the extent of destruction. Some of these depend upon injury of cranial nerve fibres, pro- ceeding from the upper part of the cord, while others are due to irritation or actual paralysis of the cervical sym- pathetic. They may consist of contraction or dilatation of the pupil, or insensibility of the same to light stimu- INJURIES OF THE VERTEBRAL COLUMN. 177 lation, ptosis, flushings, and increase or diminution in tem- perature, hyperidrosis, and glycosuria. In many cases in which the injury has been indirect slight symptoms of this kind, and for the time not associated Avith any con- siderable degree of paralysis either of sensation or motion, may exist for some time, or they may be expressions of a graver state. Buzzard reports cases of traumatic diabetes, and is of the opinion that this phenomenon is not due to concussion, but to severe injury, in which conclusion the writer fully agrees. It should be borne in mind, how- ever, that many of the persons who present themselves as litigants, claiming that they have traumatic diabetes, have in reality been victims of the disease for some years previ- ous to the alleged accident. If, however, there be no such history, but some local distress, actual paralysis, possibly speech disturbance, an increase in the pulse rate, anes- thesia of varying grade, and an immediate and great loss of flesh, the case may perhaps be considered traumatic. Certain trophic changes are highly characteristic of traumatic cord disease, although they may occur in other forms of myelitis. Among these are bedsores and other results of pressure, and certain forms of cutaneous lesion. The former may be found at points where the weight of the body is greatest, and if they be at all exten- sive may result in sepsis, which is one of the imme- diate causes of death. Injuries of the dorsal cord are apt to be associated with turgescence of the penis and occa- sional obstinate priapism. The bladder and rectal symp- toms vary very much in regard to the level of the lesion and its importance, and there may be retention, pain, and strangury, or atony, or incontinence, partial or complete, while the latter may vary from simple constipation to in- 12 178 RAILWAY AND OTHER ACCIDENTS. voluntary passage, which depends as often as anything else upon anesthesia of the lower gut and anus, or upon actual paralysis of the constricting muscles. The surface temperature of the paralyzed parts is usually lowered, and the skin is mottled and badly nourished. Local pain is unusual except where complicating meningitis exists, or where there is some disease of the bones or involvement of the posterior nerve roots. Peripheral pains in the muscles or nerves are found under some circumstances, and are increased by move- ment or the erect posture. Lesions of the cord pure and simple are not attended by pain ; but if they occur and persist for any length of time, it is quite possible that they are due to carcinoma or to the presence of some other tumors, or to aneurism. Severe pains extending down the back of the thighs and legs are due at times to dorso- lumbar injury or disease, and annoying intercostal neu- ralgia may have the same origin. Some authors contend that the anesthesia attendant upon myelitis of this region is not so profound as with lesions of other parts of the cord ; but this applies chiefly to indirect and incomplete lesions. The disturbances of sensation incident to the forma- tion of local foci of disease are as follows: When the lesion is situated at the level of the fourth cervical seg- ment, the area of anesthesia is confined to the shoulder and outside of the arm ; when at the fifth, to the outside of the arm and forearm ; when at the level of the sixth, to the radial half of the hand ; when at the seventh, to the inner side of the arm and forearm, and at the eighth, to the inner side of the hand. When the lesion corresponds to the first dorsal seg- INJURIES OF THE VERTEBRAL COLUMN. 179 ment, the ulnar supply to the hand is affected. When all of the dorsal region below the first vertebra is affected, loss of sensation is found in parts supplied by the spinal nerves. A lesion of the cord at the first lumbar segment is followed by an anesthesia of the groin ; at the second, by a loss of sensation of the outside of the thigh ; at the third, of the front and inside of the thigh ; at the fourth, of the inside of the leg, ankle, and foot ; at the fifth, of the back of the thigh and leg and the outer edge of the foot. A lesion at the level of the first sacral gives rise to anes- thesia of a part of the back of thigh and leg ; while aboli- tion of sensation is found in the perineum, anus, and geni- talia, when it corresponds to the level of the three lower sacral segments. As to special r^g/feir disturbance, we find that with lesions at the level of the fourth cervical segment there is an abolition of the pupillary reflex alone ; while if the fifth, sixth, and seventh segments be affected, this loss will be found in addition to impairment or disappearance or exaggeration of the scapular, supinator, triceps, wrist, and palmar reflexes. Lesions at the level of the first dor- sal are followed by changes in the palmar as well as the scapular reflexes; while from the fourth to the seventh dorsal we find the arc of the epigastric and below it the abdominal. The integrity of the cremasteric, patellar, and gluteal reflexes depends upon the condition of the lumbar cord, while the ankle clonus is to be evoked as the result of disease of the lower sacral cord. What is known as the Babinski symptom or reflex consists of the sudden dorsal flexion of the great toe, which is dependent upon disease of the pyramidal columns or motor tracts at any part of their course. The position and appearance of the individual who has i8o RAILWAY AND OTHER ACCIDENTS. sustained a vertebral fracture or dislocation is usually striking, although there are cases in which the deformity may be so slight as to be almost imperceptible. In the "healed" cases, which survive the immediate accident and improve to a certain extent, we find especially in the cervical region a malposition of the bones, so that the patient's attitude is one which is impressive and not to be forgotten. This consists of rigidity, the maintenance of a fixed position, and the inability to rotate the head. When the spinous processes are fractured there is a posterior thickening, and when the head is flexed or turned from one side to the other the deformity becomes plainly visible. Occasionally the head is thrust forward, and maintained in that way. If the mouth be opened, it may be possible to notice at the back of the fauces the bodies of the dislocated vertebra. In dorsal fracture it is a mat- ter of ease to detect the same immobility and the possible detachment of the spinal ends of the ribs as far down as the last segments. In old cases, in which absorption of the body and the cartilage has taken place, we find the familiar kyphosis, and the normal curves are changed. It has been observed that a fractured sternum always suggests vertebral fracture. Not only is there a local change in the relation of the vertebrae themselves in cer- tain forms of dislocation and fracture, but certain pecul- iarities in movement and gait are apparent. The patient is not only inclined to keep his body straight, but does not stoop as an ordinary person would, but helps himself in recovering from the bent posture by placing his hands upon his thigh, as children do in pseudo-hypertrophic par- alysis. Exaggerated lateral curves are often present, and side movement is exaggerated at the expense of flexion INJURIES OF THE VERTEBRAL COLUMN. i8i and extension. In dorsal fracture and dislocation there are usually pain at the costo-spinal articulation, and pulse instability through a disturbance of the sympathetic gan- glia. The subject of lumbar fracture or dislocation is apt to progress in a peculiar way — the so-called "steppage gait." This consists in the taking of short and mincing steps. Though, as has been said, there are often local de- formities, these according to Walton may be of doubt- ful import, for physiological irreg- ularities are often mistaken for the expressions of vertebral change. In this connection he presents nine reproduced molds of the spinal col- umn of healthy and normal stud- ents of gymnastics, -yirhich show all manner of departures from the conventional standard. There are many so-called " healed cases " in which there has been incomplete fracture or unre- duced dislocation which call for notice. These patients often un- dergo an initial acute stage of suffering and convalesce to a de- gree. There may be a slowly formed pachymeningitis, with slow compression or a series of symptoms extending over a long period. Uni- lateral lesions may destroy the motor fibres on one side and the sensory on the other, so that a Brown-Sequard paralysis is the result, there being a unilateral paralysis of motion, with perhaps hyperesthesia, while upon the Pig. 23. — Extent o£ Motor and Sensory Loss due to Destruc- tive Lesions of Cord. M, S, Motor and sensory tracts ; i, 2, 3, 4, area of lesions. 1 82 RAILWAY AND OTHER ACCIDENTS. opposite side there is anesthesia. Slowly advancing and irregular compression with myelitis, which is pre- ceded by thickening of the dura, the general formation of adhesions, and the constriction of the cord and nerve roots, is apt to occur with characteristic pains, paralyses, and trophic wasting, and a spastic condition. A case of this kind came under the writer's notice some years ago, which admirably portrays the development of a cervical pachymeningitis consequent to dislocation. Case XL. — J. B. M received a blow from a club in the hands of a highwayman. Beyond the production of a short period of unconsciousness, succeeded by headache, vertigo, and pain, loss of power and numbness in the arms and hands, which moderated and disappeared within a few weeks, no more serious symptoms were presented, and the would-be assassin received a comparatively light punishment. In the course of a year, however, the pain returned, and with it there was a loss of power connected with very great wasting of all the muscles of the arms. I first saw him in April, 1880, two years after the injury, and found, beyond the atrophy which was extreme, a great loss of substance of the posterior cervical muscles and left deltoid; there was a peculiar deformity, resulting apparently from the anterior dis- location of the third or fourth cervical vertebra, so that a de- pression existed, and the thyroid cartilage was very prominent, and the chin was thrown upward and forward. The upper ex- tremities where the wasting began presented the appearance of those in a person suffering from an advanced form of progressive muscular atrophy. There was a flexion of the fingers with great hollowness of the palms, the flexor tendons being quite prominent and the interosseous spaces deepened. He could not put the left hand upon the top of his head, and when he raised either there was aggravation of the severe pain of which he constantly complained. His co-ordinating power and sense of localization were affected, and he could " do nothing without the aid of his eyes." He could not pick up a pin nor touch his nose even when his eyes were open ; tactile sensation was not good ; the tendinous reflexes were everywhere exaggerated ; he was irritable and an- INJURIES OF THE VERTEBRAL COLUMN. 183 noyed by noises, and inclined to cry upon the slightest provoca- tion. The pupils were contracted when last examined, and did not respond readily. A significant feature of the case was the xiifficulty he experienced when swallowing. SPINAL TUMORS. The traumatic production of spinal tumors of various kinds and their relation and influence in the production of fragility leading to fractures, is an element that must be considered, and has considerable diagnostic impor- tance. Not only may certain malignant growths, such as carcinoma and sarcoma, be developed in connection with others elsewhere, or with violence exerted upon vertebrae, but a bony vertebral change takes place as a result of their immediate presence, which renders these parts more sus- ceptible to fracture, even when the injury is an inconsid- erable one. The progress of pathological alteration is very gradual and insidious, and may be symptomatized by early sensitiveness to pressure, and gradually develop- ing curvature and paralysis with increased reflexes, and final abolition of the same. Various tumors, among them glioma and sarcoma, often originate in the nervous tissue as the result of severe 'and sudden violence. We should be alive to the existence of contributing and transferred morbid processes the result of metastasis and injury, and under certain circumstances they should be regarded as is syphilis of the cord, which is aggravated or made to form the basis of new tissue destruction, as the result of trauma. Legally, these cases should be considered some- what as we would regard accidental infection, although the responsibility of the defendant is far less than in the former. 1 84 RAILWAY AND OTHER ACCIDENTS. HEMORRHAGE BETWEEN THE MENINGES, OR INTO THE SUBSTANCE OF THE CORD. I. Spinal Meningeal Hemorrhage (Hematorrhachis). This form of hemorrhage consists of an escape of blood between the dura and the arachnoid, or in the cavity of the arachnoid, or upon the surface of the cord itself. It may follow various forms of disease, but is usually due to a severe blow upon the back, the sudden lifting of a heavy weight, or to some form of extreme vertebral flexion, when it is immediate, or it may be a secondary consequence at a later period of caries of the vertebral bones, produced in the first place by injury. The development of symptoms, of course, depends much upon the form and degree of violence and the quantity of blood outpoured in a confined space. Naturally a hem- orrhage at a high level may by gravitation involve the' lower parts, which may be subjected to destructive press- ure therefrom and ensuing inflammatory processes. Sometimes the hemorrhage may be so small as to pro- duce no determining symptoms, but ordinarily the rupture of a meningeal vessel is attended by a sharp and severe pain in that part of the back which has been sub- jected to injury. The patient usually falls to the ground and his sufferings are agonizing. There is a loss of mus- cular power in the lower extremities which may be coincident with the pain, and almost complete from the beginning; or initial sensory disturbances, consisting of prickling and other disagreeable feelings, which may be succeeded by anesthesia or hyperesthesia, but more com- monly the latter. The loss of power and the other symp- INJURIES OF THE VERTEBRAL COLUMN. 185 toms to which allusion has just been made may be confined to one extremity, or all four if the lesion be cervical ; but as the dorsal and lumbar regions are usually those where the hemorrhage occurs the upper extremities escape. The converse is the rule in hemorrhage into the cord itself, which commonly begins in the cervical cord. It is not uncommon to find a very aggravated degree of spinal rigidity, which is due to the pain, the subject avoid- ing any sudden change of position and making as few movements as possible which require the use of the mus- cles of the trunk. There may even be painful rigid spasms, convulsive movements of the leg, and a tendency to extreme flexion both of the thighs and legs, if there be such central irritability. In many cases the knee-jerks and other reflexes are exaggerated, especially if the hemorrhage be in the dorsal region, while they are lost if the lesion affects the lower parts of the cord, when the bladder and rectum will also be involved. Girdle pains are not infrequent, and there may be added persistent and serious manifestations should there be compression of the spinal cord itself and a consecutive peripheral mye- litis. Hemorrhages of this kind are sometimes exceed- ingly grave, but are not necessarily incurable, although residual symptoms (consisting in weakness of the lower extremities and various dysesthesias) may continue for years, rendering the patient more or less a chronic invalid. Of course in making a prognosis it is difficult accu- rately to estimate the extent of the hemorrhage and the causes leading to the rupture of the vessel in the first place, so that it is wise to be conservative. In other cases a pachymeningitis spinalis with pressure and repeated hem- orrhages may follow. Surgeons are familiar with forms i86 RAILWAY AND OTHER ACCIDENTS. of spinal fracture where at some time subsequent to the injury itself there may, through the presence of necrosed bone or the detachment of a spicule, be serious vascular wounding and consequent unexpected hemorrhage. Case XLI. — A case of a light grade seen by the writer and Dr. H. L. Purdy, of New York, was that of an iron moulder who attempted to lift a weight of three hundred pounds, when he suddenly felt a violent pain in the middorsal region, and, drop- ping his burden, fell at the same time, and was unable to recover his feet without assistance, as his lower limbs refused to support him. This was in July, 1903. After a few days there were a slight return of power and a diminution of the pain, which was for a week or two agonizing. Then ensued a girdle pain, which was worse at night. When seen by the writer, about the middle of September, 1903, the left leg was found to be weaker than the right, while there were analgesia and a blunting of tactile and thermo-anesthesia, but more markedly the former. The left knee-jerk was slightly exaggerated. The electrical reactions were undisturbed and there was no atrophy. In other cases that the writer has seen the initial symptoms were those described above, and were followed by paralysis and spasticity of the lower extremities, by atrophy, and in exceptional instances by decubitus, ex- haustion, and death. 2. Hematomyelia. The escape of blood into the substance of the cord itself is more apt to follow injury of the cervical region than elsewhere, particularly in those cases in which the patient receives a vertical head blow. Examples have been reported by Bailey and various observers where it has fol- lowed the act of diving into shallow water, and in others falls upon the feet from a height have preceded the occur- rence of the hemorrhage. A distinction has been made INJURIES OF THE VERTEBRAL COLUMN. 187 between the so-called primary focal hematomyelia where the hemorrhage is due to a disease of the blood-vessels or some other local condition, and injury not associated with any vertebral fracture, for in the latter there may be laceration or injury. In the primary form the violence may simply lead to some accident which may be favored by existing syphilis, tumors, or a form of myelitis. The development of symptoms may be naturally very sudden, as it is in the extramedullary form, or more slowly devel- oped, when there will be a chronic and generally incurable train of expressions, due to the involvement of regions supplied by the central arteries of the cord. TRAUMATIC SYRINGOMYELIA. The consideration of this disease can hardly be un- dertaken without the foregoing, for the cavity which is formed in the cord is due to the hemorrhage. In this respect it differs from hydromyelia, which is a congenital condition. The condition in reality is a cavity in the cord, which is produced by the outpouring of blood and by a certain degeneration, and remembering the liability of the cerebrum to glioma as the result of injury, it is not surprising that the formation of gliosis tissue sometimes takes place in the central part of the spinal cord. The dominant and characteristic symptom of this disease is what is known as the disassociation of anesthesia — that is to say, that while tactile sensibility is preserved, there is a loss or diminution of the pain and temperature senses. This is connected with a form of atrophy which resembles the familiar progressive muscular kind. As a rule, the up- per extremities are at first slowly attacked, and the wasting is preceded by dysesthesia and obscure pain. The atrophy 1 88 RAILWAY AND OTHER ACCIDENTS. is symmetrical and general, and the degenerative reaction is present. The wasting and weakness at first are confined to the small muscles of the hands, but this is merely the be- ginning of a general muscular atrophy. It is not uncom^ mon to find certain trophic changes and such cutaneous eruptions as herpes, pemphigus, and disturbances of secre- tion, nervous edema, or a condition in a mild way resem- bling Raynaud's disease ; some of the trophic disorders re- sembling those of locomotor ataxia are occasionally found, the nails thickening or dropping off, or there may be exten- sive arthropathies and a liability to fracture. When the disease becomes pronounced some lateral curvature of the spine is usually found, which is most marked in the lower dorsal region. Ultimately we find the lower extremities involved, with a certain amount of hypotonia and in- creased reflex activity. Further extension of the central lesion is expressed by rectal and vesical incontinence, and the patient dies from exhaustion or bulbar symptoms. The diagnosis is extremely difficult, and it is often im- possible to discover the existence of the disease before death. Case XLII. — Abrahamson reports a case of traumatic hema- tomyelia which was rapid in developing, in which the patient fell, striking the back of his head on the floor ; a week and a half later there was numbness of the little finger of one hand, and twenty-four hours after the entire upper extremity became numb. Twenty-four hours after this both extremities became numb and weak, and on the fourth day of the trouble there was complete inability to move. The special senses were normal, there were ex- tensive wasting of the muscles and tremor of the facial muscles on one side, the tongue was drawn to the left, the knee and Achilles jerks were exaggerated, the muscles were flabby, espe- cially about the shoulders, there were no spasticity, no limitation to the field of vision, and no Romberg symptom. The volume of INJURIES OF THE VERTEBRAL COLUMN. 189 the left lower extremity was greater than the right. The patient had great difficulty in rising from his chair. Case XLIII. — A gentleman referred to me some years ago by the late Dr. Howard, of Montreal, and previously reported as a case of spinal concussion, but in the light of the advance in our knowledge was, I now believe, an example of syringomyelia. The Rev. Dr. L , a heavy man, weighing two hundred and twelve pounds, while walking upon a wooden sidewalk caught his toe in a hole and fell somewhat violently. This was in July, 1 882, and from that time to January, 1883, a train of very serious expressions indi- cative of resulting organic disease quickly appeared. He did not lose consciousness after the fall, but felt dizzy and sick for ten min- utes' or so, and beyond a slight bruise of the left hand, which he had thrown out to save himself, suffered but little inconvenience. About three weeks after the accident, however, he began to feel cramps in his left hand (the fingers becoming rigid), as well as great pain in the back, especially in the lumbar region, but subse- quently it extended upward. This was associated with paroxysms of intercostal neuralgia with attacks of coughing and besoin de respirer which at times amounted to distressing dyspnea. When I first saw him in January, there was some loss of power in both lower extremities, especially the left, and he walked with diffi- culty. There was no tactile anesthesia,' buf dysesthesia; the legs were generally atrophied, and his gait was characterized by spas- ticity, rather more marked on the right than on the left side. His superior extremities were involved, and the left hand and arm were especially weak, and it caused him great distress and pain to raise them. He could not button his clothing, nor use his hands in the execution of delicate acts. There was no lost sense of locali- zation, and the tendon reflex seemed to be unaffected. Galvanic and faradic action were disturbed, and but few of the muscles of the upper extremities responded to stimulation. His breathing was very shallow and rapid, and his voice dry and husky, and it was an effort to talk. No evidences of disease were found on examination of the heart and lungs, and the pelvic organs were affected to a slight degree. There were no cerebral symptoms and no morbid ophthalmoscopic appearances. Intellectually he had not suffered, but he tired easily, and could not apply himself to ' There were thermo-anaesthesia and some analgesia. igo RAILWAY AND OTHER ACCIDENTS. his work. This patient became more helpless, and died in August, 1 883, of the well-marked disease which had run an acute course. The prognosis of the primary form is much better than the other. Even when there is complete paraplegia with total relaxation and flabbiness and lost reflexes there may in a short time be an altered condition of spasticity with ability to walk. It is not rare in the recoverable cases for some residual atrophy and weakness to exist with a slight increase of reflex excitability. Many patients re- cover entirely in a few weeks.' PROGRESSIVE MUSCULAR ATROPHY. Progressive muscular atrophy or wasting palsy is an affection characterized by gradually extending wasting of the voluntary muscles, which usually begins in distal parts and extends upward, involving various groups, and finally those which preside over the important functions of or- ganic life. Consecutive to the wasting there are a paralysis of motion and, perhaps, a loss of reflex action, while coin- cident with the loss of substance there are vermicular con- tractions of isolated muscular bundles. Early quantitative loss to both currents and late degeneration reaction are found. There is no anesthesia, and rarely any other disturbance of sensation, except vague pains, which are undoubtedly peripheral. The disease was very fully de- scribed by Cruveilhier, Duchenne, Oppenheimer, Wachs- miith, and Roberts about forty years ago, although it was probably recognized by Van Swieten long before. Modern clinicians, among them Charcot, have divided it into several varieties, and have made a more or less suc- ' Of course,"^ true syringomyelia witli degeneration is incurable, although it may become stationary. INJURIES OF THE VERTEBRAL COLUMN. 191 cessf ul attempt to determine its pathology. The two chief subdivisions at present recognized include, first, a per- ipheral or myopathic form in which the muscles are first affected — the sO'Called dystrophies ; second, a spinal form, the myelopathic or progressive muscular atrophy, which is of central origin. In this latter there may be rigidity and exaggeration of the reflexes, dependent upon an in- vasion of the pyramidal columns of the spinal cord and the anterior horns, the symptoms keeping pace with the destruction of the motor and trophic cells. Most of the older writers held that traumatism, and especially injury of the cord, may sometimes be a sufficient cause ; but of one hundred and five cases collected by Roberts there were only six which were attributed to direct injury of the arm or hand, to excessive exertion in carrying heavy weights, and to falls. One doubtful case reported by this writer is that which began with atrophy of the ball of the right thumb, with a rather rapid progress of the disease, so that death occurred (preceded by an involvement of the respiratory muscles) in six months, the initial trauma being very slight. In all the original injury had been completely recovered from, and the nerve supplying the affected muscles was never involved. In the majority of cases we find the disease to appear between the twentieth and fiftieth years, and there are numerous causes that may be sufficient to account for it: among them exposure, most of the acute infectious diseases, metallic poisoning, especially lead, syphilis, mental strain, and more often than anything else the over-use of certain muscles in the per- formance of specia lacts. Mechanics, therefore, are pe- culiarly prone to the affection, and of twenty-eight cases reported by Dana the victims were smiths, ironwork- 192 RAILWAY AND OTHER ACCIDENTS. ers, bricklayers, tailors, barbers, locksmiths, etc. The writer has not only seen it among these, but has found it as a result of constantly repeated and almost automatic use of the fingers — in cigarmakers, printers, typewrit- ers, and clerks. He does not remember ever to have met with a pure case that was the result of railroad injury, although Bailey reports some which followed falls and injury of the hand and thumb, blows upon the neck and upon the chest ; but in most of these there seems to have been some such complication as exposure or syphilis and in the others there is at least a suspicion that the injury produced some other trouble as well as the dis- ease under consideration. One contested case in which the writer appeared was that of Hoey versus The Metro- politan Street Railway, where it was alleged that the plaintiff was well up to December, 1899, when he was injured. He received an injury of the head and right leg and a lacerated wound of the right hand. The phy- sician who was called upon the evening of the first day found him highly excited, hysterically crying and laugh- ing. For several days he was delirious and afterward apathetic for nearly three weeks ; he vomited often during this time, and there were insomnia, very great exhaustion, and some spinal pain. His pupils were dilated, and after- ward did not respond to light. At the end of three weeks there were coldness, numbness, and twitching of the right side. The examining phj'^sician found wasting of the right hypothenar eminence at this time, and later the claw- finger appearance, or main en griff e ; there was general tremor of muscles throughout the body, with some twitch- ing. He left his bed in March, 1900, and could not walk without assistance. He grew worse all this time, his INJURIES OF THE VERTEBRAL COLUMN. 193 muscles gradually wasting and his strength diminished. Dr. Bailey, who examined him, found the " electrical re- action slightly diminished." From the time of the acci- dent until August, 1900, he had lost forty pounds in weight, and in September there developed evident pul- monary tuberculosis, with night sweats, rise of evening temperature, and areas of flatness; but it does not appear that any bacteriological examination was made. He died September 30th, 1900, and suit was subsequently brought. It was shown that the deceased had been engaged for a long time in the mailing department of a large metropoli- tan paper, and that he was constantly employed in per- forming a particular kind of movement in which the right thumb participated. It does not appear that any one had ever looked for commencing atrophy before the accident, and the history of the case itself does not seem to be strictly in accord with our knowledge of the affection. There was no reaction of degeneration in the extremely atrophied muscles, but simply diminution of electrical irri- tability, and there was no recorded alteration of the re- flexes. The patient's condition after the accident was not such as to lead one to look for progressive muscular atrophy, and it is very doubtful if such a general condi- tion of wasting as that described could so quickly follow and extend as it did. In all probability the patient's rapid decline and death were due to infection, and were favored by his confinement and hard work. LOCOMOTOR ATAXIA. Locomotor ataxia is here used instead of tabes spinalis, which latter term must always be associated with an actual and slow degenerative lesion of the pos- 13 194 RAILWAY AND OTHER ACCIDENTS. terior columns with proliferation of neuroglia cells. When Duchenne adopted the former, he undoubtedly, to some degree, had in mind the clinical rather than the pathological character of the affection, and for many years it was made to include symptoms due to lesions both of the cerebellum and of other parts, as well as of the cord itself. In these days of advanced neurology the first are usually recognized without diflBculty and given their proper place, and are differentiated from the con- sistent symptomatic picture, which is the true tabes. In the present connection it is adopted for convenience, to include the various sensory and ataxic states, which may be explained by injury of the posterior nerve roots with- out necessary involvement of the cord itself ; by toxemic or consecutive lesions, or by peripheral or hysterical anesthesia, which gives rise to the inco-ordination and other of the symptoms which belong to this grave dis- order. The possibility of injury as the cause of ataxia has frequently arisen in connection with litigation, and many cases have gone into court presenting a trauma depend- ent upon a railway accident which has been alleged to be the sole etiological factor. These cases do not seem to have been considered true examples, for there is al- most complete unanimity of opinion that genuine tabes — that is, the form with arthropathies,. optic-nerve atrophy, Argyll- Robertson pupil, and gastric crises — can have no such origin, but in most instances is explained by syphilis. It has been maintained that when the symptoms develop in a conspicuous manner immediately after an accident, it is probable that they have been expressed in a minor de- gree for some time before, and have not been recognized INJURIES OF THE VERTEBRAL COLUMN. 195 by the patient or his physician ; or else have been mis- taken for the expression of some other disease. In other words, they are the Hghting up of a long dormant affec- tion. Walton, of Boston, whose industrious researches in this field of medicine are entitled to the highest credit both for their thoroughness and for their originality, some years ago investigated all the alleged traumatic cases, but was unable to find one entirely uncomplicated. Bailey, while reporting a case in which the appearance of a number of classical symptoms almost immediately fol- lowed a fall upon the buttocks, and in which there was no history of syphilis whatever, is as much in doubt as others about the relation of trauma to tabes, inclining to disbe- lieve in the possibility of such a connection. The writer, whose experience has been large, while perfectly con- vinced that a consistent and progressive case of the dis- ease as a result of injury is practically unknown, has seen so many patients in whom the trauma either lighted up a spinal syphilis or gave rise to a group of symptoms due to nerve-root injury, or consecutive to spinal laceration, that he does not feel inclined to dismiss the possibility of a locomotor ataxia, which may very closely resemble the form which is universally supposed to be so distinct an entity. It need hardly be said that rapid local tissue de- struction, or its aggravation in connection with syphilis, is often due to excessive use of alcohol, and doubtless violence when suddenly applied, is in some cases capable of rendering a long-standing and inactive syphilitic de- posit capable of producing local toxemia and resulting mischief in the cord.' Although Marie, I am informed, performs lumbar ' The so-called parasypliilis. 196 RAILWAY AND OTHER ACCIDENTS. puncture in all his cases of tabes as a routine diagnostic method, and finds a varying degree of lymphocytosis in commencing tabes, I am not aware that any one has in non-syphilitic cases made such an examination to deter- mine the early indications of this striking disease; Pos- sibly such changes indicating the establishment of inflam- matory action might be easily found in this as well as other kinds of non-specific myelitis, for the procedure is not a dangerous one and causes little embarrassment. Those familiar with the affection, and whose experience has been at all extensive, have recognized a respectable number of irregular cases which depend not only upon some cause outside the spinal cord itself, but in its vicin- ity, besides those commonly known. The pseudotabes of Gilles de la Tourette, Pitres, Petit, and others,' is char- acterized by the incomplete nature and development of symptoms, and by the possibility of cure, and Kowaleski reports a case in which symptoms attributed to tabes dis- appeared in twenty-seven days after hydrotherapy and rest. Finally there are hypochondriacal or hystero-hypo- chondriacal cases in which the symptom complex is strik- ing, but, of course, lacking in completeness, and when the psychic element is present. Reference need hardly be made to the familiar symp- toms of tabes, a disease which is notably chronic, last- ing sometimes even for forty years, and not in itself materially shortening life. Beginning with a preataxic stage, the expressions of which in the beginning are often mistaken for those of other affections, its early diagnosis is by no means easy. ' See also article by Mills : Trans. Am. Neur. Association, 27th annual meeting, i9oi,p. 26; and by Collins: The Medical News, January 3d, 1903. INJURIES OF THE VERTEBRAL COLUMN. 19; This is especially true so far as the disturbances of sensation are concerned, which depend upon the encroach- ment of the disease in a neighborhood where it involves the posterior nerve roots, the meninges, and at first parts adjacent to the cord ; although later there is a central ex- planation for others of greater gravity. Not only do we (usually with certain changes of weather, especially where the barometric pressure is low) find the occurrence of sharp, lancinating or fulgurating pains, as a rule at first in the lower extremities, with painful residual areas and points, but dysesthesia and tactile anesthesia, which may involve the plantar surfaces, preventing the individual from standing unsupported when his eyes are closed (Rom- berg's symptom), and sometimes contributing to the pro- duction of the ataxic gait (Fig. 24). Pupillary insensibility to direct light stimulation, with conservation of power for accommodation (Argfyll-Robertson symptom), diplopia; dysuria, sexual . weakness, constipation, joint weariness, loss of knee-jerk and other deep reflexes, arthropathies, etc., are followed by the characteristic ataxic gait, diffi- culty in turning or descending inclined surfaces or steps, sudden inhibition of muscular power through fear, gradu- ally developing , optic-nerve atrophy, while subsequent paralysis and atrophy of the affected muscles and pos- sible exaggeration of the knee-jerks occur when other parts of the cord than the posterior columns are invaded by the degenerative process. True tabes is manifested by a certain similarity of symptoms, the nature of the pains and their method of occurrence being very much alike in a given number of cases which are compared, and they are usually associated in active cases with gastric, laryngeal, rectal, or vesical crises, although in many cases 198 JiA/LlVAV AiVD OTHER ACCIDENTS. Fig. 24.— a, Gait in Traumatic Locomotor Ataxia; E, Static Ataxia in the same case. (Cinemato- graph by author. J there may be little or no pain. The same is true of the distribution of an- esthesia, which, if plantar, is more commonly found at the outer edge of the foot, or, if oc- curring in the up- per extremities, af- fects the ulnar side of the forearm and hand. The arthro- pathies, although comparatively rare, cannot by any well- informed physician be long mistaken for any other form of joint enlarge- ment; even when occurring after in- jury they have a character of their own, and are, as Charcot first point- ed out, quite insep- arable from spinal- cord degeneration, and when found have been preceded in every case by INJURIES OF THE VERTEBRAL COLUMN. 199 some of the peculiar symptoms of the spinal affection. In some cases of fracture, an accident to which tabetics are prone, it will not be difficult to get a history. The same may be said of perforating ulcers and of the earlier trophic disorders, which by the uninitiated are supposed to be due to ordinary conditions. The gait has a certain uni- formity, and the patient brings his heel down first, there being some spasticity, and it is only in the old cases that the disorderly titubation which is characteristic of demen- tia paralytica is found. These facts are thus fully referred to because in the irregular cases to which attention has been directed, one must be impressed by a certain pecul- iar disorder in progression. In most of the reported cases which are claimed to be traumatic there is, with but few exceptions, a history of sudden development and ir- regular progress, and usually a very rapid development of symptoms, the preataxic stage being short. The domi- nant sensory expressions of ordinary tabes do not appear to be important in this form, and the pains are rarely so intense as to need morphine. In cases which have come under the writer's notice, girdle and radiating pains have caused more suffering than those of the extremities, and even when the disease has advanced there have been no abdominal crises. The anesthesia has been irregular and rarely bilateral, except in one non-traumatic hysterical case, while in another the anus and lower rectum were anesthetic. While the knee-jerks were lost, the writer has never found the lost pupillary reflex, and in no case has there been any optic-nerve neuritis or atrophy. One of the striking and suggestive differences is found in the gait, which is far more disorderly in locomotor ataxia after trauma than in tabes of organic origin, in which 200 RAILWAY AND OTHER ACCIDENTS. » there is usually a syphilitic basis. While the heel impact and the trajection that belong to the ataxic gait are present, there seems to be at an early date a great deal of unsteadiness and disorder, thus resembling the Fried- reich type, and when the patient progresses the action of the quadriceps is exaggerated so that the knee is lifted higher than it is in the ordinary case of tabes, and there seems also to be a species of lateral wobbling or unsteadi- ness (Fig. 24). This lifting is not to be confounded with that associated with certain forms of peripheral neuritis. True arthropathies are not found in the cases to which ref- erence is here made, and when present, as Bailey and others have pointed out, there is undoubtedly an antecedent his- tory, and they are not attributable to injury alone. The traumatic examples that are apt to be met with are of three kinds : (i) Hysterical and neurasthenic forms — the pseudotabes of the French writers. (2) Residual cases in which, after laceration of the cord, there remains a lesion of the posterior columns. (3) Cases in which, through wrenching or twisting of the body, there is ten- sion or actual torsion of the posterior spinal nerves, trau- matic neuritis with predominating sensory symptoms. (4) Cases due to initial injury with a recurrent hyperemia and pressure. Hysterical locomotor ataxia is, of course, attended by none of the inevitable deep indications of central degen- eration, which belong to true tabes ; yet it may present the sensory and motorial indices of the real affection which are calculated to deceive some people. The anes- thesia, as a rule, is much more profound, and is rather sudden in its appearance, and the ataxia is coincident and sometimes marks a sharp debut. There are never pre- INJURIES OF THE VERTEBRAL COLUMN. 201 ataxic, lancinating pains, but ill-defined dysesthesia, and there is, as a rule, a neurasthenic basis with the general familiar symptoms. Case XLIV. — In a case seen by the writer analgesia existed,, and was complete and extensive. While the superficial reflexes were abolished in response to irritation of the anesthetic area, the knee-jerks were preserved and the pupils reacted normally to light. The ataxia was confined to the lower extremities, and if the patient closed her eyes she became agitated, emotional, and dropped to the ground, crying aloud as she did so. There is in tabes itself a period of swaying and toppling, however short, which precedes the fall, and the patient strives to balance himself by laterally extending his arm ; but there was nothing of the kind with this patient. There was a vesical spasm with considerable discomfort, but neither retention nor incontinence. The only visual disturbance was asthenopia, and the eye field was normal. She had before presented certain stigmata of hysteria, and was of a nervous family — her brother, with whom she lived, having had tabes. A trifling fall was the alleged cause, but undoubtedly there was some imitative tendency as well. After a few months' treatment a cure was effected, principally through the use of the induced current, the patient being isolated meanwhile. The en- tire duration of the symptoms was less than a year. Case XLV. — In contrast the case of J. R. G is interest- ing, because of the rapidity of its progress and its direct connec- tion with an undoubted spinal injury — possibly a laceration. It was impossible to determine the existence of syphilitic infection, and it is the writer's opinion that his present condition dated from an accident in the Harlem tunnel, which occurred January 8th, 1902, when there was a rear-end collision, and the patient was thrown forward, receiving a severe wrench and possibly a blow in the dorsal region, for there was resulting severe and obstinate pain which lasted some time. According to his story, he was able to leave the car, but was unnerved, and rapidly became neuras- thenic and demoralized. After this he did not dare to do any- thing requiring mental or physical effort, and was timid to a de- gree. He could not walk on a fallen log over a stream when in the country, and found it impossible to move about his room at 202 RAILWAY AND OTHER ACCIDENTS. night in the dark, or place his hands over his eyes when he washed his face without pitching forward. In April or May, 1902, he began to have " rheumatic pains " and a painful girdle at a level of about the edge of the lower ribs. He has had fulgurat- ing pains in his legs since May, 1903, and pretty much all of the year 1902 he had trouble with the bladder, passing his urine very slowly. His general break-up was so great that he went abroad in the spring of 1903, where a diagnosis of locomotor ataxia was made by Purves Stewart, of London. The doctor wrote me Sep- tember 26th : " His pupils are rather small, but react normally to light and on accommodation. The optic discs and cranial nerves are normal. He has no loss of sensation on the face, tfunk, or limbs to lightest touches or pricks; but along the ulnar bor- ders of hands and inner sides of soles, including the great toes, pinpricks, though felt acutely, are accompanied by a peculiar tingling sensation ; pressure on the ulnar nerves behind the in- ternal condyles is painless. The sense of position on passive movement is impaired at the toes, ankles, and hips, fairly good at the knees. There is distinct hypotonia of the calf and the hamstring muscles. The gait is ataxic, his handwriting is dete- riorating, and he feels himself clumsy when buttoning his clothes or when picking small objects out of his pockets. The knee- jerks, Achilles jerks, and supinator jerks are absent. There is some delay in micturition, and he is sexually impotent." Upon his return from Europe the patient consulted me, when I found all these symptoms, and evidently an increase of the ataxia, for he could ascend and descend the stairs only with the greatest difficulty, and he was in a very nervous and anxious condition, and so weak that he was obliged to spend most of his time in bed. There is the same hypotonia of the muscles of the hand as exists in the lower extremities, and he is unable to use them now at all except for gross efforts. In this case the same extreme disorderly walk is found that has been referred to when speaking of other traumatic examples, and the mental element is highly suggestive of that which belongs to the so-called traumatic neurasthenia. So far he has not responded to treatment, and it has been found necessary to direct complete rest and forced feeding. Recurrent Ataxia. — Two cases of a somewhat inter- esting nature, from the fact that certain symptoms were IXJURIES OF THE VERTEBRAL COLUMN. 203 recurrent in both, that there was a history of injury, and that these recurrences followed undue exertion, clearly show that there is a form of traumatic pseudotabes with obscure pathogeny, but not necessarily classic posterior column degeneration. Case XLVI. — J. M is now (in 1903) 50 years old, and has been a marine engineer for a long time and is at present chief engineer of a coast steamer. His general health up to 1884 was exceedingly good, as were his habits, and it is impossible to find a history of syphilitic infection. In that year he fell from an upper deck into the fire-room of his ship, about twenty feet below, landing upon both feet. Strange to say, beyond a slight concus- sion, some tingling and burning of his lower extremities, and a slight loss of power, there were no immediate consequences. In a few days,, however, he began to have pains suggestive of irrita- tion of the posterior nerve roots, rather general analgesia of the legs and feet, myelasthenia, insomnia, and attacks of lumbar pain. Micturition was frequent and difficult, and there was slight tenesmus after the act. His sexual power diminished ; he became neurasthenic and was obliged to give up his work. In 1886 these symptoms were supplemented by ataxia and difficulty in co- ordination, and his walk became " wobbly " and disorderly, there being at the same time great irresolution and timidity in finding his way about the streets. He presented himself at the Hospital for Ruptured and Crip- pled in this city in the summer of 1887, when he came under my care in the out-patient department. Both knee-jerks were evoked with difficulty, but the pupillary and other reflexes were but slightly affected if at all. Under absolute rest, spinal cauteriza- tion, and cod-liver oil he recovered in eight months, so that he was able to return to his work and made regular trips from New York to Havana until the spring of 1899, when he contracted a Tampico fever and came to his home in Orange, N. J. In Sep- tember of that year I saw him in consultation with Dr. Phelan, and found him bedridden. It was stated that he had been unable to walk for more than a month because of an extreme degree of ataxia that had rather suddenly appeared during convalescence, and when he made undue muscular exertion. When helped out 204 RAILWAY AND OTHER ACCIDENTS. of bed, he walked with great difficulty, raising his knees and legs very high and applying his heels to the ground in a jerking way quite different from the gait of true tabes. There was no pa- ralysis of motion, but there was tactile and pain anesthesia of the plantar surfaces, the outer toes of both feet being specially affected. He had severe gastric and visceral pains suggestive of crises, and at the time of the visit there was retention, and it was necessary to use the catheter. Both knee-jerks were still absent. After cauterization and ergotin he began to improve, and on Jan- uary 2d, 1900, he was able, after a few weeks of shore duty, to take charge of a new steamer, and since then has been, with the exception of slight gastric disturbance, a well and strong man. Case XLVII. — The second is that of G. L. K , a travel- ling salesman of 33 years, who has never had syphilis, and whose habits are good. He smoked moderately, and occasionally took beer or whiskey. About sixteen years ago, after severe mus- cular action in lifting a heavy tray from a sample trunk, he suf- fered a sudden lumbar pain which disappeared under simple rem- edies and was followed, as he said, by some swelling of knees and feet. This in turn disappeared, leaving him with a sense of weakness and a difficulty in locomotion which was due to ataxia. There do not appear to have been any leg pains or any bladder disturbance. In a short time he regained his ordinary vigor, re- suming his occupation as commercial traveller until 1 897. While in Columbus, O., in that year, he again performed an uncalled-for muscular act of a violent nature, which was followed by numbness in both limbs, which extended from the knees downward, the soles of his feet being perhaps the most insensitive. According to his story, there was a variation in the extent of the dysesthesia as well as a sort of intermission, there being a period of normal sen- sibility, which would last for four or five days, and was followed by an absolute loss of feeling. After a week or two of this his gait became affected, and it was with great difficulty that he could walk at all, because of lack of co-ordination. He recovered from this attack in a few months, and apparently continued in the best of health until eight weeks ago, June, 1900, when he began to have characteristic pains in both legs, which shot up through the feet ; there were pains as well on the right side of the head and right arm. There was, for a month or so, some INJURIES OF THE VERTEBRAL COLUMN. 205 numbness in both plantar surfaces, but this was not permanent. There was at times an imperative desire to urinate, but no other bladder symptoms. There was no constipation. No Argyll-Robertson symptoms ; both knee-jerks were feeble. His gait showed a well-marked ataxia, and when he walked he planted his feet far apart, tottered and staggered, but could stand with his eyes closed. Most of the motor symptoms were present, so far as the lower extremities were concerned, and it was appar- ently an exceedingly easy case for diagnosis. The history, how- ever, of the two subsequent attacks and the rapid d^but of the present one impressed me, as I learn it had Dr. Osier. From June, 1900, when I first saw him, he has continued to improve under treatment, which was kept up by his physician in Cleveland, O., with the result that by autumn his sensory symp- toms had absolutely disappeared and his gait was but slightly embarrassed. He was able to go up and down stairs without difficulty, walk about in dark places, and do a great deal of work. During the winter of 1901 he came to New York again, and I was unable to find any ataxia whatever, although the knee reflexes were still feeble. At one of these visits I found a painful crop of herpes situated in the inguinal region and upon the dorsum of the penis. There were also one or two. spots upon his neck and back ; these were followed by great local irritation and some neuralgia. There were absolutely no other trophic or cutaneous changes. Up to the present time (October, 1903), there has been no return of the trouble. The litigation cases are often fictitious, and might be at once dismissed from consideration were it not for the tendency w^hich so often exists to thrash out medical symptoms in court by laymen who naturally know nothing about their significance. Case XLVHI. — Such a case was that of Miss Z , who sued the Metropolitan Street Railway Company. The medical testimony for the plaintiff was given by three physicians whose diagnosis of " locomotor ataxia developing from myelitis " certainly is an illustra- tion of the weakness of certain kind of expertism. It was claimed that in an accident which occurred in February, 1896, she re- 2o6 RAILWAY AND OTHER ACCIDENTS.. ceived a blow on the back, that she was confined to her bed immediately, and there remained for fourteen weeks. One of her physicians testified that there was paralysis of both lower extrem- ities, as well as entire loss of sensation on the right side, increase of knee-jerks, and ankle cloniLs. The right leg was smaller than the left, " the reflexes of the eye do not respond the way they should to light or distanced Another who examined her testified that the disease was " myelitis running into a form of locomotor ataxia subsequently." He found that " the so-called patellar reflex was very much diminished^ There were "inversion of the foot, due to loss of power of the extensor muscles of the leg, loss of sensa- tion, more particularly on the outer side of the right leg, diminu- tion of the size of the right leg and ankle clonus!' The alleged loss of sensation found appears to have been an analgesia, An- other medical witness diagnosed the case as myelitis, and found partial paralysis of the right extremity, atrophy, contracture, ankle clonus, exaggeration of knee-jerks, loss of sensibility to touch, temperature, and pain. All these examinations were made at about the same time, and not only was there a conflict in regard to the presence of the reflexes, but the first physician appears to have had rather confused views as to the eye reflexes and their significance; there certainly was no evidence of tabes. The patient was seen by two doctors for the company, who found absolutely nothing at all, and regarded the case as one of malingering. It appears from the testimony that the young woman had gone to a seaside resort and was actually dancing at the time when she was alleged to be incapacitated and on crutches. CHAPTER VI. PERIPHERAL NERVE INJURIES. Peripheral trauma occurs in so many different ways that the resulting effects are necessarily varied, and each case must be studied by itself with reference to the ex- tent and completeness of destruction and the symptoms that may arise. Under some circumstances the initial damage and its after-effects are trivial, and even a slight injury may give rise to an obstinate condition of affairs. The writer has known of a man who in trying to board a car lost his foothold and was dragged a few feet, mean- while retaining his grasp of the hand-rail. As a result there was an obstinate and painful subacute neuritis, as well as some paresthesia of the hand, and a great deal of discomfort which lasted several weeks. A slight blow at the elbow-joint usually does little more than produce an immediate tingling in parts below, yet it, too, may lead to a painful affection of the ulnar nerve, which is slow in dis- appearing. Again, as a result of crushing, puncture, or partial or complete section of a nerve, there follow a vari- ety of disturbances of a painful nature, or a varying loss of power, the nerve trunk possibly degenerating when it is cut off from its central connection. As a result of these interruptions, a characteristic series of trophic alterations ensue, and are manifested by circulatory, muscular, and dermal changes, which will be later particularized. As some of the peripheral nerves have a motor as weH 207 2o8 RAILWAY AND OTHER ACCIDENTS. as a sensory function, it is to be expected that pain or anes- thesia will coexist with the lost motility ; but this associa- tion is governed by certain rules. If a mixed nerve be paralyzed, there will probably be an impairment of sen- sation, as well as motion; but when there is a resto- ration of the former, the anesthesia disappears long be- fore the return of muscular power. In fact, the motor loss is always more complete and enduring than the sensory. It need hardly be said that the lesion of a purely motor nerve leads to no sensory disorder. The loss of power may vary from a simple amyosthenia to a permanent paralysis. This partial or total loss depends upon the amount of pressure to which the nerve is subjected, or to actual division of the nerve trunk. It has been found that if the latter be subjected to the pressure from a col- umn of mercury the resulting loss of function will depend upon the weight applied, and if the peripheral part of the nerve be alone compressed, it will, of course, not be so severe as where the neuraxon is seriously damaged by greater pressure. Such pressure pareses are common enough among drunken people or those who during sleep lie in such a way that pressure is made upon a super- ficial nerve, and the writer has examined a man who had been pinned down in a wrecked car by a piece of timber, the result being a well-marked musculo-spiral paralysis in connection with other injuries of a graver kind ; and in another case a fall from a distance of a few feet led to a protracted anesthesia of parts supplied by the ulnar, there being no external wounds or abrasion. Case XLIX. — T. L , aged 62, in August, 1885, fell in a coal hole, striking his left elbow and coccyx ; he was dazed but not unconscious, and suffered with pain throughout the vertebral PERIPHERAL NERVE INJURIES. 209 column. There was anesthesia of the inner side of the left hand and arm, which was present a year afterward, as well as atrophy and loss of the nail of the little finger ; for four days after the accident he could not pass water. January 21st, 1886, he could not stoop or pick up a pin because of pain and vertigo ; had sub- jective noises; was subject to insomnia, and got tired easily. The general symptoms subsided in eighteen months. Traumatic peripheral paralysis is always easily diag- nosed. If at all profound, it is apt to be obstinate and often permanent, as the nutrition of the muscles is lost, and they diminish in size, there being resulting atrophy and shortening, vs^hich lead to permanent contracture. Again, there may be deformities, which are the result of the contraction of opposing healthy muscles, which in the upper extremity may give the hand a peculiar claw- like appearance {main en griffe), if the ulnar nerve be wounded; or a series of other characteristic deformities may be present. The muscles are usually at first flac- cid and limp, and when passive movements are made there will be no rigidity or resistance if the paralysis is at all complete. One of the most positive evidences of serious peripheral nerve injury is a degeneration that takes place in the nerve trunk itself, when, through sec- tion, it is disconnected from the central neuron. This is made known by a very decided and prompt change in its reaction to electrical stimulation, and that of the muscles it supplies. There are well-known laws. which govern the behavior of muscles and nerves to direct and indirect electrization, and there are normal qualitative and quantitative responses which do not occur when a peripheral nerve is severed from its base of supply; when we find that both the galvanic and faradic or induced currents do not awaken the same excitability as they 14 210 RAILWAY AND OTHER ACCIDENTS. did before. Usually within forty-eight hours after such section the nerve becomes less susceptible to the stimulus of the induced as well as the galvanic current, and this diminution gradually extends from the point of interrup- tion toward its distal portion (that is, the periphery), and in about fourteen days it becomes insusceptible to both currents, and perhaps forever loses its capacity to conduct. In cases in which the paralysis is not permanent there will be a gradual return of susceptibility to the stimula- tion of both currents and a restoration of function when the process of repair is complete. When the muscles themselves are tested, it will be found that they will con- tract when the induced current is applied, and there is not much impairment until the end of seven days. In another week, however, the excitability has gone en- tirely. While they respond to the galvanic current in somewhat the same way at first, the feebleness of response is followed by a greatly exalted susceptibility even to the feeblest currents, and a slow, forcible contraction lasts for some minutes during the time the electrodes are applied. In the normal state the strongest muscular contractions are those produced by cathodal closure — that is to say, when the circuit is formed by the application of the cathodal sponge to the surface, the anodal being already applied ; and the energy of the contraction bears a rela- tion to the strength of the currents, which are qualified, as a rule, as wea^, medium, and strong. After degeneration of the nerve this is reversed, anodal closure, even with medium currents, being greater than cathodal, and this constitutes the so-called " reaction of degeneration." When well developed, it may be expressed by the formula (AnSC>CaSC), and there is an increase of the PERIPHERAL NERVE INJURIES. 211 activity of the muscular response to the cathodal opening, so that it is greater than the anodal opening (CaOC> AnOC). Should the degeneration ultimately go on, the response to the galvanic current will become more and more feeble, and finally disappear altogether. Should there be recovery, however, the muscles at first will re- spond to an interrupted galvanic current and then to a slowly interrupted induced one, and finally to both cur- rents, as they do in health. When the regeneration of the nerve begins, it will be found that there will usually be a return of the response to both currents at about the same time, and sometimes as early as six weeks after the in- jury, although the time is usually later. With this there wiJ be a corresponding decrease of the galvanic irritabil- ity of the muscles. The diagrams from Erb show these changes, the asterisk indicating the return of motility (see Figs. 25, 26, and 27). Although this reaction is found in peripheral rheu- matic paralysis, which often affects the muscles sup- plied by the facial nerve, or in lead paralysis, when the extensors of the hand are involved, giving rise to the 'familiar deformity known as wristdrop, it is character- istic of extensive injury of a nerve trunk. The only other diseases in which it is found are those dependent upon degeneration of the great cells in the anterior horn of the spinal cord — poliomyelitis, and progressive muscular atrophy, and these are manifested by so many other char- acteristic symptoms that there is hardly room for a mis- take. Peripheral nerve injury is sometimes symptomatized by tremor of the hands and upper extremities especially. This is a species of quivering rather than a rhythmical 212 RAILWAY AND OTHER ACCIDENTS. tremor or " vermicular contraction," which appears in the atrophied muscles. Tonic spasms are also found with or without loss of the pain sense in conjunction with irri- tative nerve lesions. Degenei'ation of the Nerve ^ Atrophy and Multiplication of Nuclei in the Muscular Fibres Regeneration Cirrhosis Motility. %t Galv. 11 Paraa. c!( Galr.and £J Farad. Ex. !^' cltability ... / r" - \ ^ ; : 77^** ' ' ^ Ill /, ^ • •' • " " iirU^ V \ , « •• * ( ,iU^ V s , • ■ * .0 jlUU ^^^ - ^,^- ■■^ . ■ • jjA ujim ULlU: - Degeneration of Atrophy, etc, the Nerve of Muscles Fig. 25.— Recovery Rapid. Cirrhosis Regeneration 9 1 Galv.and C-JFarad. Ex- gt citabUity ^li^^^^ Degeneration of the Nerve Fig. 26.— Recovery Slow. Atrophy, Multiplication of Nuclei. Cirrhosis, Complete 91 6alv.aud g-j Farad. Ex- S ' citabmty Fig. 27, — No Recovery. Relation o£ Motility, Excitability, and Structtiral Changes in PeripheraJ Paralysis with Electrical Reaction. (Erb.) The trophic results of nerve injury, in addition to those enumerated, consist in very conspicuous vaso- motor changes, such as initial determination of blood to the surface, with a local elevation of temperature, PERIPHERAL NERVE INJURIES. 213 and a subsequent vascular stasis, the surface being livid and mottled, while there is both subjective and objective coldness in all cases. An atrophy of the skin, with a peculiar shininess (glossy skin), crops of herpes, or the appearance of bullae, which burst, leaving ulcers, is sometimes found, and the latter correspond with the course of the particular nerve ; and there may be an asso- ciated hyperesthesia. Sometimes the nails undergo a change, becoming brittle or crenated, or are exfoliated ; edema is rare. Various grades of sensory disturbances are found with nerve injury, consisting of anesthesia, which may or may not involve the same territory in which motility is deficient, or it may be present in company with hyperesthesia, or the various vague disorders which are included under the head of paresthesia, such as formi- cation, numbness, and ill-defined disturbances of feeling. Pain, either of a neuralgic character or tenderness of the nerve itself, should there be a neuritis, is a familiar and distressing symptom of trauma. Bowlby is of the opinion that there is little or no shock following an injury to the nerve trunk, although it would appear that such is not the case when there has been a gunshot wound. He attaches little importance to the pain that is caused by the division of a nerve trunk, regarding the loss of muscular power and tactile sensi- bility as the most important symptoms. In his numerous cases he found the thermic sense lost in proportion to that of touch, but even in examples in which anesthesia was not complete the patients were unable to discrimi- nate between heat and cold. Nerve injury is at times attended by a variety of irreg- ular disturbances, which may be at a different point 214 RAILWAY AND OTHER ACCIDENTS. from the seat of the lesion. Sometimes they belong to the group known as " reflex paralysis," or, again, there may be a migrating neuritis in association with more or less hysterical dysesthesia elsewhere. Among these cases Vieusse reports one of gradual paralysis of parts supplied by the median and musculo-spiral nerves, fol- lowing injury at the outer side of the arm, and Cenas a case of reflex trophic changes in both hands, consecutive to an injury to one ulnar nerve. Mitchell refers, among others, to a flesh wound of the thigh which led to a re- flex paralysis of all the four extremities. Bowlby groups these cases into two classes, one of which includes the paralyses developing coincident with the injury and the other those in which an interval of time has elapsed. The following patient with neuritis of the median nerve consulted the writer at the instance of Dr. Corwin, of Bergen Point, N. J., some years ago, and illustrates what has been said : Case L. — On the 2d of October, 1887, Mrs. S , a mid- dle-aged woman, attempted to undo a knot with a large pair of scissors with the result that the end of one of the blades ran into her left wrist, making a small punctured wound, at the point marked in Fig. 28. There were slight hemorrhage and some pain, and four days afterward the wound had healed completely; but as a result there was immediate numbness of the entire thumb, with the exception of the distal phalanx, which was com- pletely anesthetic. In a few days the ball of the thumb was numb, but above the wound for an inch or so there was exquisite hyperesthesia, so that the slightest touch caused great agony. For two or three weeks after the receipt of the injury the entire left arm and shoulder were hyperesthetic ; but there was no deep tenderness over the nerve trunks, and this soon subsided. It re- appeared in the left shoulder about December 23d. About Janu- ary 6th a twitching of the left arm and hand was first noticed, and has been more or less intense since then. This was hardly a PERIPHERAL NERVE INJURIES. 215 tremor, but more in the nature of a tic, in which successive groups of muscular bundles were involved. During the month of January crops of herpes appeared upon the back of the arm and about the wrist, and the skin of the entire hand and forearm was dusky and cold. Toward the latter part of January pain began in the right hand and arm, and subsequently involved the shoul- der, and there were areas of hyperesthesia on both sides of the A B I C F:g. 28.— Sensory Disturbances due to Wound of the left Radial Nerve. A, Analgesia ; B, Dysesthesia ; C, Hyperesthesia. The spots in right-hand figure are herpes. body. March ist, 1888, the patient was seen by the writer, who found, in addition to the anesthesia of the left thumb, a dysesthetic condition of the right lower extremity, where some insensitiveness to pain existed, and where there was tactile blunting, but no thermo- anesthesia. The surface over the cervical spines was exquisitely tender, and there were spots of hyperesthesia over the left shoul- der, at the angle of the scapula, over the arm and forearm and hand on the same side, and some analgesia of the posterior as- pect of the left hand. The tips of the index and middle fingers were anesthetic, and there was some blunting of sensibility, not amounting to complete anesthesia, over the corresponding fingers and thumb of the right hand. In the spring of 1888 there had 2i6 RAILWAY AND OTHER ACCIDENTS. been no change in the nutrition of the anesthetic parts, although a circular blister, which was applied after the method of Buzzard, was very slow in healing. There was no muscular weakness which could be determined by electrical tests, but some stiffness of the thumb and finger of the left hand which was very notice- able. At this time there was some tremulousness of the entire body which hardly amounted to an emotional tremor. In this case there was undoubtedly injury of the radial nerve, but the other manifestations were clearly hysterical, and the subsequent history of the case has confirmed this diagnosis. The patient's neurotic predisposition and the fact that she was undergoing the menopause were undoubtedly contributing factors. The frequency of special forms of peripheral paralysis naturally depends upon the exposed position of certain nerve trunks and their liability to direct violence through compression, or crushing, or rupture through fractured or dislocated bones. In the. cervical region such results are more often due to penetrating wounds, for the nerves of the neck are more deeply seated. The brachial plexus or its branches are susceptible to the effect of a blow to the shoulder, to pressure in the axilla, or at various points in the upper arm. The lower extremities are seemingly less often the seat of peripheral paralysis. Paralysis of the muscles sup- plied by the crural nerve is uncommon, unless there be an injury or fracture of the vertebral column or of the pelvis or femur. Sciatic paralysis is also rare as a conse- quence of injuiy, and its differentiation from that due to central disease is at times difficult. The peculiarities of peripheral paralysis have been de- scribed by Erb as follows : 1. It is a paralysis of conduction. 2. There is non-participation of branches of the same nerve branching off at a higher plane. PLATE X. Railway and other Accidenvs. rieroneasp^ro/ui vi- — suralis . — 1111 .nZarUaris i/tfe m-r — : ■-«^?gs?^ -f:^ Scheme of Nerve Distribution. (Jakob.) "The segments are printed in red. The motor nerves or portions o£ mixed nerves in solid blue lines. The sensory nerves or sensory portions of mixed nerves in dotted blue lines." For reference to parts ultimately supplied consult pp. 102-120; 172-174; 218-232. PERIPHERAL NERVE INJURIES. 217 3. The anesthesia is almost always present, and is pre- cisely limited to the region of distribution of the mixed nerve affected. 4. There is nerve retardation in the conduction of sensation (Weir Mitchell). 5. In addition to the voluntary movements — reflex, automatic, and associated movements are completely absent. 6. Spasms occasioned by central disease do not extend to the paralyzed muscle. 7. Marked vasomotor and trophic disturbances, espe- cially an early and well-marked atrophy of the muscles, indicate peripheral origin. 8. The reaction of degeneration exists in combination with a corresponding sensory disturbance. For the purposes of diagnosis the following tables are submitted. It must be borne in mind, however, that many forms of lost function may be due to other causes than trauma, and those most likely to follow injury will hereafter be particularized. SCHEME OF SYMPTOMS OF PERIPHERAL NERVE INJURY. 1. Motor. Paralysis or spasm. 2. Sensory. (a) Pain. (3) Loss of sense of touch. (c) Loss of muscular sense. {d) Loss of temperature. (e) Analgesia. Burning. (/) Abnormal sensations. -J p" ■ T^- Numbness. 21 8 RAILWAY AND OTHER ACCIDENTS. 3. Trophic. {a) Atrophy of muscles. (J}') Atrophy or hypertrophy of connective tissue. (c) Changes in the skin in color, texture, and consistence, as shown by the " glossy skin " ; ulcers, whitlows, and gangrenous conditions ; eruptions, which may be her- petic or bullous. (d) Changes in the nails in texture and contour, as shown by the ridging, and thickening, and curving, longitudinally and transversely. {e) Loss of hair (several writers report cases in which there was an excessive growth). (/) Changes in joints which may be ankylosed. (^) Bony changes; loss of weight (rarely found). 4. Vasomotor. Increased temperature of the part, hyperemia, and occasional edema, followed by subnormal temperature and cyanosis. The temperature is usually lowered over the anesthetic areas (Bowlby). Diminished sweating over affected areas. 5. Deformity (occasionally), such as {a) Wrist-drop, when musculo-spiral nerve is paralyzed. {b) Wing-like scapula ; postthoracic nerve paralysis. if) Claw hand in ulnar nerve paralysis. id) Foot-drop in anterior tibial nerve paralysis. (e) Calcaneus in posterior tibial nerve paralysis. 6. Electrical Reaction. (a) Reaction of degeneration when nerve has been com- pletely severed or crushed. (b) Quantitative changes when nerve has been injured by compression. Cervical Nerves (Eight pairs). Anterior and Posterior Divisions. Anterior divisions of first, second, third, and fourth in the for- mation of the cervical plexus. Anterior divisions of fifth, sixth, seventh, and eighth assist in the formation of the brachial plexus. Posterior divisions, muscular and cutaneous. PERIPHERAL NERVE INJURIES. 219 Muscular. Rectus capitis, anticus major and minor, and lateralis. Superior and inferior oblique. Complexus. Transversalis colli. Trachelo-mastoid . Cervical ascendens. Spinalis colli. Supraspinalis. Interspinalis. Multifidus spinae. Splenius. Semispinalis colli. Cutaneous supply integument, covering head and neck. These muscles assist in maintaining the head in upright posi- tion, and flex and extend, and also rotate it. They are rarely in- volved in traumatic paralysis, which, if it occurs, is combined. Spasm, unilateral or bilateral. Cervical Plexus. Occipitalis minor. Auricularis magnus. Superficialis colli. Phrenic. The first three nerves are chiefly sensory, supplying the integu- ment over side of the neck, head, face, and ear — injury or disease expressed by cervico-occipital neuralgia, etc. Phrenic — muscular and visceral. Muscle — Diaphragm. f Pleura. Viscera. \ Pericardium. [ Peritoneum. Motor Symptoms. Paralysis — unilateral or bilateral. Spasm — tonic or clonic (hiccouglj). Sensory. Pain over scalenus anticus with tender points. Neuralgia of pleura, pericardium, and peritoneum. Principal nerves. ■ 220 RAILWAY AND OTHER ACCIDENTS. Symptoms. Rapid respiration ; depression of epigastrium on inspir- ation ; dyspnea on exertion ; constipation. Hiccough and occasionally cyanosis ; electrical, reaction usually unchanged. Dorsal Nerves (Twelve Pairs). Anterior division, muscular, cutaneous, and visceral. Posterior division, muscular and cutaneous. Anterior, called intercostal nerves. First assists in formation of brachial plexus (sympathetic branch to eye passes through it — Klumpke). Second Third Fourth Fifth Sixth supply {a) Seventh Eighth Ninth Tenth Eleventh supply (a) ■ Internal and external intercostals. Infracostales. Triangularis sterni. Levatores costarum. {b) Pleura and lungs, (c) Integument covering anterior chest. 'Internal and external lower inter- costals. External oblique. Trans versalis. Rectus. Serratus posticus inferior. {]}) Abdominal parietes. {c) Integument over abdomen. Twelfth assists in formation of dorso-lumbar cord. These intercostal nerves are rarely subject to decided motor paralysis, but to sensory (intercostal neuralgia). Trophic Changes. Herpes zoster, etc. Posterior division, muscular and cutaneous. Muscular. Erector spinas. Spinalis dorsi. Semispinalis dorsi. Rotatores spinae. Supraspinalis. Interspinalis. Intertransversalis. Multifidus spinas. PERIPHERAL NERVE INJURIES. 221 Cutaneous. Internal, first, second, third, fourth, fifth, and sixth — in- tegument over chest. External, seventh, eighth, ninth, tenth, eleventh, and twelfth — integument over back. Motor Symptoms. Bilateral paralysis causes a kyphosis. Unilateral paralysis causes a scoliosis. Sensory symptoms are rare. Posterior thoracic (fifth and sixth cervical). Motor. Paralysis of serratus magnus shown by inability to raise the arm beyond horizontal; limited adduction, and lessened inspiratory expansion. Sensory Pain if accompanied by neuritis. Position: At rest, scapula elevated, and lower angle nearer vertebral column ; on motion, the arm cannot be raised beyond horizontal. Deformity. Winglike projection of scapula. Electrical reactions usually normal; perhaps loss of faradic irritability. Trophic. Atrophy, usually late in appearance. Anterior thoracic (eighth cervical and first dorsal). Muscles: Pectoralis major and minor. Motor. Inability to pull arm downward and forward and shrug shoulders (Dana). Inability to place arms in front and press palms together (Gowers). MUSCULO-CUTANEOUS. Muscular. Cutaneous. Articular. Biceps. Skin over radial Elbow- Brachialis anticus. side of fore- joint. Coraco-brachialis. arm, anterior and posterior. Motor Symptoms. Inability to flex elbow more marked when the hand is supinated (as the supinator longus cannot assist). 222 RAILWAY AND OTHER ACCIDENTS. Sensory. Anesthesia of radial side of forearm, back and front. Trophic. There may be stiffness in elbow-joint. Suprascapular (fifth and sixth cervical). Muscular. Articular. Supraspinatus Shoulder- Infraspinatus. joint. Motor. Inability to rotate humerus outward. Settsory. Anesthesia over scapula. Circumflex (fifth, sixth, seventh, and eighth cervical). Muscular. Cutaneous. Articular. Deltoid. Integument of Shoulder- Teres minor. shoulder. joint. Triceps. Motor Symptoms. Inability to raise arm. Limited abduction. Sensory. There may or not be anesthesia of the skin covering the shoulder. Trophic. Adhesions; ankylosis of shoulder-joint; atrophy of del- toid, causing flattening of the shoulder. Electrical reactions vary with amount of injury. MuscuLo-spiRAL (fifth, sixth, seventh. and eighth cervical). Muscular. Cutaneous. Triceps. Integument of radial Anconeus. side of back of Supinator longus and brevis. hand, back of Extensor carpi radialis longus thumb, index Brachialis anticus. finger, and half Extensor of fingers. of middle finger. Motor. Inability to extend and supinate forearm. Inability to extend wrist, fingers, and thumb. Inability to adduct or abduct fingers perfectly. Inability to extend distal phalanges. PERIPHERAL NERVE INJURIES. 223 Sensory. Numbness and tingling of radial side of forearm, hand, back, and outer side of arm. Deformity. Characteristic "wrist-drop." Electrical Reactions. Reaction of degeneration. Trophic. Atrophy and nodular enlargement in extensor tendon sheaths; also prominence of carpal bones. Median. Muscular. Cutaneous. Pronators. Radial side of palm, front of Flexor carpi radialis. thumb of first two fin- Flexor of finger. gers, half of third finger. Flexing and adducting thumb. Radialis lumbricales. Motor. Inability to flex radial side of wrist. Inability to flex second phalanges on first. Inability to flex distal phalanges of first and second fingers. Sensory. Anesthesia in palmar surface of thumb, index, and mid- dle fingers. Anesthesia in radial half of ring finger. Anesthesia in radial half of palm. Anesthesia on dorsal surface of index finger. Trophic. Very marked; glossy skin and curved ridged nails; affecting ring and little fingers as well as those sup- plied by median nerve (Bowlby). Hair absent ; also perspiration. Deformity. Forearm atrophied. Wrist bent to ulnar side. Flattening of ball of thumb. Thumb extended and adducted. Electrical reactions vary ; usually there is reaction of degen- eration. Ulnar (eighth cervical and first dorsal). 224 RAILWAY AND OTHER ACCIDENTS. Muscular. Cutaneous. Articular. Flexor carpi ulnaris. Anterior and pos- Wrist. Flexor profundus digitorum. terior surface Flexor brevis pollicis. of little finger. Ulnar lumbricales. Same of ulnar side Interossei. of ring finger. Abductor minimi digiti. Same of ulnar side Opponens minimi digiti. of hand extend- Flexor brevis minimi digiti. ing to wrist. Motor. Inability completely to flex ring and little fingers. The proximal phalanges are hyperextended upon meta- carpal bones, due to paralysis of interossei ; second and third phalanges are flexed on account of paraly- sis of interossei. Deformities. Heads of metacarpal bones are prominent in palm of hand, and the extensors are prominent on dorsal sur- face, due to hyperextension of proximal phalanges ; hand drawn to radial side. Adduction of thumb im- possible, also all movements of little finger. Hypo- thenar eminence disappears; palm is hollow, and there is a slight rotation of thumb. Sensory. There is usually loss of sensation of touch, pain, and tem- perature sense of anterior and posterior surfaces of little finger, ulnar side of the ring finger, and most of ulnar side of the hand. Trophic. Glossy skin, changes in nails, hair, and coldness over anesthetic areas. Deformity. " Claw hand." Electrical Reaction. There may or may not be the reaction of degeneration. Erb's Paralysis (combined paralysis). Deltoid. Biceps. Brachialis anticus. Infraspinatus (.?). Teres minor (.?). Supinators ( ?). Railway axd (ithek ALciuiiXTS. PLATE XII. Upper extremity: i. Branches of cervical plexus; 2. circunitlcx ; 3, upper Ijranch of the internal cutaneous; 4, 4', internal cutaneous; 5, mus- culo-cutaneous; 6, 6', 6". radial; 7. median; 7", palmar cutaneous brani^h of median ; S, ulnar ; S \ palmar cutaneous branch of ulnar PERIPHERAL NERVE INJURIES. 225 Motor. Arm hangs rotated inward and extended ; inability to flex arm (hands and fingers normal). Sensory. Slight. Electrical. Reaction of degeneration usually. Klumpke's Paralysis (first dorsal). Paralysis of the hand and ocular symptoms. Contrac- tion of pupil, narrowing of palpebral fissure, and re- traction of eyeball on the affected side. Lumbar Nerves (five pairs). Anterior and Posterior Divisions. Anterior, muscular and cutaneous. First. Second. Third. Form lumbar plexus. Fourth. Fifth. Forms part of lumbo-sacral cord. Posterior, muscular and cutaneous. Muscular. Cutaneous. Multifidus spinse. Integument over gluteal Interspinales. region. Erector spinas. Intertransversalis. Motor. When these muscles are paralyzed, there is an exaggera- tion of the lumbar curve, the shoulders are thrown back, and the abdomen is protruded. Sensory disturbance is rare. Ilio-hypogastric, muscular and cutaneous. Muscular. Cutaneous. Transversalis. Skin over gluteal region. Internal oblique. Skin over hypogastric. Motor paralysis incomplete, as these muscles are also supplied by lower intercostal nerves. Sensory more marked. Lumbo-abdominal neuralgia; pain in the loins, back, buttocks, and hypogastrium. IS 226 RAILWAY AND OTHER ACCIDENTS. Ilio-inguinal, muscular and cutaneous. Muscular. Cutaneous. Internal oblique. Skin over pubes and geni- tals; also upper and inner surface of thigh. Motor paralysis slight. Sensory. Pain over pubes and external genitals. There may be neuralgia of one testicle — "irritable testicle" of Cooper. Pain or anesthesia over inner and upper part of the thigh. Neuralgia radiating down the thigh. Genito-crural, muscular and cutaneous. Muscular. Cutaneous . Cremaster. Skin over thigh as far as half to the knee. Motor. Drawing up testicle. Sensory. Pain over anterior surface of the thigh. Obturator, muscular, cutaneous, and articular. Muscular. Ctttaneous. Articular. Obturator exter- Inner side Hip and nus. of thigh knee. Adductors. and leg. Gracilis. Pectineus. Motor. Inability to adduct thigh. Inability to press knees together Inability to cross leg. Flexion and inward rotation are difficult ; so is outward rotation. Sensory. Pain or anesthesia along inner side of the thigh as far as the knee. Anterior crural, muscular, cutaneous, and articular. Muscular. Cutaneojis. Articular. Iliacus and psoas. Inner side of Hip joint. Sartorius. thigh, leg, Rectus. and foot. PERIPHERAL NERVE INJURIES. 227 Vastus, externus and internus. Crureus. Subcrureus. Motor. Inability to rise from recumbent posture. Inability to flex hip or extend leg. Standing or sitting difficult. Running, jumping, and walking impossible. Sensory. Anesthesia of inner side of thigh, leg, and foot. A sen- sation of furriness, numbness, and chilliness. Loss of knee-jerk. Trophic. Atrophy of the thigh. Electrical reactiotts vary. Sacral Nerves (five pairs). Anterior and Posterior Divisions. Anterior division. First. Second. Third. Fourth. (Partial) with sacro-lumbar cord — sacral plexus. Fourth. (Remainder.) Muscular. Visceral. Levator ani. Bladder. Internal sphincter. Internal generative organs. Coccygeus. Fifth. Muscular and cutaneous. Coccygeus. Integument over back and sides of coccyx. Posterior division. Muscular. Cutaneous . Multifidus spinse. Integument over pos- Coccygeus. terior gluteal re- gion and coccyx. Sensory symptoms most common. Sacral Plexus. — Upper muscular branches to hip-joint. Articu- lar branch. Pyriformis. 228 RAILWAY AND OTHER ACCIDENTS. Obturator internus. Gemelli. Quadratus femoris. Motor. Impaired outward rotation of thigh. Impaired abduction. But as other muscles assist in these motions, outward rota- tion and abduction are imperfectly performed. PuDic NERVES, muscular and cutaneous. Muscular. Cutaneous. Transversalis perinsei. Skin over scrotum, inner Accelerator urinarius. side of penis, glans Erectores penis. penis, prepuce. Compressores urethras. Motor. Vesical spasm, priapism. Incontinence of urine. Sensory. Pain ; neuralgia of penis. Gluteal nerves (superior and inferior). Muscular. Cutaneous. Glutei. Skin over buttocks. Tensor vaginae femoris. Motor. Inability to rotate leg outward and inward. Flexion interfered with. Uncertainty in standing, balancing, and ascending stairs; loss of abduction and circumduction. Sensory. Anesthesia of gluteal region. Trophic. Atrophy of glutei, bedsores, ulcers. Deformity. Flattening of buttocks. Electrical reactions vary. Smaxl sciatic nerve, muscular and cutaneous. Muscular. Cutaneous. Gluteus maximus. Integument over perineum and back part of thigh and leg. PERIPHERAL NERVE INJURIES. 229 Motor. Paralysis of gluteus maximus, shown by difficulty in ris- ing from a sitting position and in going upstairs or uphill. Sensory. Anesthesia of the skin of the middle third of the back of thigh and upper half of calf. Trophic. Atrophy of buttocks, bedsores, ulcers, etc. Great sciatic nerve, muscular, cutaneous, and articular. Muscular distribution. Biceps. Semitendinosus . Semimembranosus. Adductor magnus. Flexors of leg and foot ) , ^ . , , , T-^ c , ir^J-by termmal branches, txtensors of leg and foot ) ■' Cutaneous distribution. Integument of whole leg (including terminal branches). Articular distribution. Hip- joint. Knee-joint. Ankle-joint (including terminal branches). Motor Symptoms. Extent of paralysis depends upon location of lesion. When near the sciatic notch, the flexors of the leg and all the muscles below the knee are paralyzed, and there is complete inability to extend hip, flex leg, or flex and extend foot. If lesion is below upper third of thigh, flexors of leg escape paralysis. Sensory Symptoms. These also depend upon location of lesion. When in perineal region, anesthesia in anterior and external side of leg, dorsum of foot, and greater part of toes. In tibial region, anesthesia over posterior surface of leg, sole of foot, and plantar surface of toes. If in the cavity of the sacrum, anes- thesia of scrotum and penis, urethra, bladder, and rectum. 230 RAILWAY AND OTHER ACCIDENTS. Vasomotor. Cyanosis and coldness over affected areas. Trophic. Atrophy of paralyzed muscles. Eruptions, herpetic or bullous, over affected areas. Ulcers or gangrene and bedsores. Paralysis of bladder and rectum when lesion is high in sacrum. Electrical Reactions. Usually the reaction of degeneration. Anterior tibial (one of the terminal branches of the sciatic). Muscular. Cutaneous. Tibialis anticus. Outer half of front of leg. Extensor hallucis. Dorsum of foot. Extensor communis digitorum. Peronei. Motor. Inability to flex ankle, abduct or adduct. Inability to extend first phalanx of toes. Flexion of first phalanges from action of unopposed in- terossei. Sensory. Anesthesia over outer half of front of leg and dorsum of foot. Trophic. Slight atrophy. Vasomotor. Cyanosis and coldness. Deformity. Talipes, equino-varus or valgus. Electrical reactions vary. Internal popliteal (terminal branch of sciatic). Muscular. Cutaneous. Articular. Popliteus. Outer half of back of Knee-joint. Soleus. leg, foot, and fifth Gastrocnemius. toe. Plantaris. Motor. Inability to extend ankle ; paralysis of calf. Inward rotation lost. Sensory. Anesthesia over lower part of back of leg and of sole varies. Railway and (Hher Aeximixxs. PLATE XIII. Loaje? txtitiiuty. i, Branch of genito-crural ; 2, posterior branches of lumbar nerves; 3, posterior branch of sacral nerves; 4. cutaneous branch of coccygeal; 5, lesser sciatic nerve; 6, femoro-cutaneous ; 7, crural branch of genito-crural; .S, genital branch of lumbar plexus; 9. obturator: 10. cru- ral; II, internal saphenous; 12, peroneal cutaneous; 13, external saphe- nous; 14, calcaneal and plantar Ijranches of posterior tibial; 15, musculo- cutaneous of external popliteal ; 16, anterior tibial; 17, external plantar ; 18, internal plantar. PERIPHERAL NERVE INJURIES. 231 Posterior tibial (terminal branch of internal popliteal). Muscular. Tibialis posticus, iiexor longus digitorum, and flexor longus hallucis. Cutaneous. Heel and inner side of sole of foot. Motor. Inability to raise inner border of foot ; adduction and flexion of distal phalanges and flexion of great toe im- possible. Sensor)'. Anesthesia of heel and inner side of foot. Internal plantar (terminal branch of posterior tibial). Paralysis of short flexors of toes, plantar muscles of great toe (except adductor), and two inner lumbricales. Anesthesia inner part of sole, plantar surface of three inner toes and half of fourth toe. External plantar. Paralysis of flexor accessorius of muscles of little toe, all the interossei, two outer lumbricales, and adductor of great toe. Anesthesia of skin of outer half of sole, little toe, and half oi fourth toe. Trophic changes in skin and nails. Coccygeal nerve (i), anterior and posterior. Supplies coccygeus and integument over same. Sensory symptoms most common. Much of the frequency of special forms of peripheral paralysis naturally depends upon the exposed position of certain nerve trunks and their liability to direct violence or crushing, stretching or rupture through fractured or dislocated bone. In the upper extremity, it is found that blows upon the shoulder or over the scapula, or dis- location of the humerus are followed by injuries to the brachial plexus and to such important nerves as the mus- culo-spiral, circumflex, musculo-cutaneous, and those branches of the cervical that supply the levator and rhom- boid muscles of the scapula, giving rise more often to what is known as a combined or Erb's paralysis, or again to paralysis of special nerves. Injuries lower down are 232 RAILWAY AND OTHER ACCIDENTS. apt to affect the ulnar and median nerves, or their periph- eral terminations. The rhomboid and levator anguli scapulce muscles, which are supplied by the third and fifth cervical nerves, when paralyzed prevent the subject from elevating his scapula without rotation. When the infraspinatus and teres minor, which are supplied by the suprascapular and circumflex nerves, are paralyzed, there is an inability to rotate the arm outward. Through paralysis of the sub- scapularis, the teres major, and latissimus dorsi, supplied by the subscapular nerve, there is loss of ability to rotate the arm inward, and, by the action of the opponens mus- cle, the arm is kept in a fixed position. Paralysis of the deltoid, which is supplied by the circum- flex nerve, prevents the patient from raising his arm later- ally or forward. A deformity results from subsequent atrophy, so that what appears to be a subluxation of the head of the humerus is seen. This form is rather com- mon after some injuries of the shoulder-joint, or it may follow a severe blow upon the muscle itself. Paralysis of the serratus magnus may be due to trauma, although other causes, among them a neuritis of the thoracic nerve following pneumonia (Leszynsky) may explain its origin (Fig. 29) . Direct injury to the shoul- der, which implicates the long thoracic or fifth and sixth cervical nerve, is the most likely cause of this variety,. Leszynsky's case presented a double paralysis, which of course would not occur from ordinary injury, giving rise to the well-known wing-like deformity. In this form the lower angle of the scapula is drawn toward the vertebral column, and there is some elevation of the whole bone. The patient cannot raise his arms laterally beyond a hori- Railway and other Accidents. PLATE XI. Section of Ulnar and Median Nerves. (After Bowlby.) 1, Palmar surface of a hand some months after section of the ulnar nerve, showing wasting of the muscles, the typical position of the digits, and area of anesthesia. 2, Dorsal .surface of a hand some months after section of ulnar nerve, showing wasting of interossei, typical position of digits, and area of anesthesia. 3, Palmar surface of hand, some months after section of median nerve, showing wasting of thenar muscles and area of anesthesia. 4, Dorsal surface of hand after section of median nerve, showing area of anesthesia. The darkness of shading in all the above indicates the amount of anesthesia. PERIPHERAL AERJE LXJURIES. 233 zontal line, unless the bone is passively and forcibly rotated and retained in place, when he can then raise them verti- cally. There are always associated sensory symptoms, neuralgia or dysesthesia. In describing Erb's paralysis the terms appei' and lower arm types are used by neurologists to define a form in which there is in- _ volvement chiefly of the muscles of the shoulder, or another in which those of the fore- arm and hand are as well paralyzed. The former is apt to be an obstetrical accident, while the latter is a familiar consequence of trauma that may be received at any time in life. There is al- ways considerable atro- phy and the reaction of degeneration occurs. In some cases the diagnosis is difficult, fig especially when there is a suspicion of poliomyelitis; but in making an examina- tion it will be found that in the latter, which is a disease of the spinal cord, the sensibility will be conserved. With a young child, however, the matter may be different, owing to the difficulty of making a subjective test. Care should be taken to recognize valgus or some lower leg or ,g__\Ving-like Deformity due to Paralysis o£ Serratus Magnus. (Leszynsky.) 234 RAILWAY AND OTHER ACCIDENTS. foot symptoms, which, if found, will remove doubt as to the central nature of the paralysis. The supiitator longus, which is supplied by the mus- culo-cutaneous nerve, when paralysed, will be manifested by the lost ability to flex the forearm on the arm, and this is seen more fully when the attempt at flexion is made during the supination of the forearm. It is a rare affec- tion by itself, but is usually found as a symptom of the combined brachial-plexus paralysis and as a rule there is some anesthesia of the outer border of the forearm. Musculo-spiral paralysis is one of the commonest of traumatic forms because of the exposed position of this important nerve. The nature of the loss of function has been elsewhere detailed, but attention may be called to the fact that its extent depends upon the point of com- pression or injury. If it is in the axilla, or at a high level, the triceps is involved as well as the muscles below ; if the lesion be at the middle part of the humerus, this muscle will escape, and if at a lower point the supinator longus will be exempt. The resulting deformity is the familiar " wrist-drop," which is conspicuous and can hardly be mis- taken. There is, as a rule, if the position be long main- tained, the formation of a hard projection corresponding to the synovial sacs through which the extensor tendons pass, or a hypertrophy of the carpal bones themselves (Fig. 30). We are sometimes called upon to differentiate between traumatic paralysis and that form due to lead poisoning, and cases also present themselves which are examples of simple pressure paralysis due to the use of a crutch or following some form of compression of the nerve by a hard body, or such as occurs when a person sleeps soundly with his arm beneath him, especially if he be in a PERIPHERAL NERVE INJURIES. 235 drunken stupor. In the plumbic form tine development of the paralysis is slow, peripheral at first, usually double, and accompanied by the colic and other symptoms of lead toxemia, including often the lead line about the gums. Case LI. — Dorman \'s Metropolitan Street Railroad. Tlirough an accident the plaintiff was injured on November 22d, 1900, it being alleged that he received a blow from a trolley pole attached Fig. 30.— Drop-wri.st, fi.nn Palsy of the Musculo-Spiral Nerve. (Bailey.) to one of the defendant's cars, the wire breaking and allow- ing it in some manner to fall. He was unconscious and suffered from shock and very great pain in the left shoulder which was struck, and was the seat of ecchymosis and swelling. He was seen by a doctor, who found paralysis of the muscles of the fore- arm and hand, " the arm bemg flat down by the side " ; but there was some subsequent improvement, for he could move his fingers. 236 RAILWAY AND OTHER ACCIDENTS. A diagnosis was made of injury of the brachial plexus with neuritis. There were early supersensitiveness and weakness, par- ticularly of the flexors, and a diminution of electromuscular irrita- bility, the reaction, of degeneration being subsequently found. It does not appear that there was any very great atrophy of the arm even as late as February, 1901. This man received a verdict of ^2,500. Paralysis of the median nerve is uncommon because of its deep and protected position, and unless it be wounded or punctured, or some fracture occurs, it usually escapes and is far more likely to undergo a loss of func- tion as the result of musculo-spiral injury higher up. Be- sides the paralysis of certain flexor muscles not supplied by the ulnar nerve, it sends branches to the abductors and opponent muscles of the thumb which are commonly involved. If a serious lesion occurs, the pronator teres becomes impotent and it is impossible to pronate the hand, and when the hand is flexed there are deviation to the ulnar side and extension, and adduction of the thumb which cannot be overcome. It is impossible to flex the last phalanges on the others, especially in the index fin- ger. Anesthesia of the radial side of the palmar surface, the ball of the thumb and the dorsal integument, of the tips of the index, ring, and half of the third fingers ought to be looked for, as well as a great deal of atrophy of the thenar muscles. By all odds the most frequently found traumatic per- ipheral disorder is that due to injury of the ulnar nerve, which supplies the important flexors of the hand. As has been said, it is extremely susceptible to violence through direct injury of the elbow-joint, where the nerve is superficial or as a consequence of fracture or disloca- tion, and is often associated with neuritis and anesthe- PERIPHERAL NERVE INJURIES. 237 sia, more marked on the outer border of the hand (see plate). Sciatic Paralysis. — This, according to Bowlby, com- monly follows division of the nerve below the origin of the muscular branches of the hamstring muscles, " and as the extensor muscles are supplied from a different source, the limb retains its mobility on the trunk. In the leg, how- ever, the case is different, the whole of the muscles below the knee and of the foot are paralyzed." The peculiar swinging of the leg and dragging of the toes and the gen- eral awkwardness of the body have been compared by Letievant to the gait of a person with an artificial limb. The loss of sensation is not very great, and there is usu- ally but a slight atrophy. CHAPTER VII. EXAMINATION AND THE POSSIBILITY OF ERROR. The examination of a plaintiff should not be con- ducted hastily, or where there are unsuitable or distract- ing surroundings. It is for this reason that the medical man should object to a hurried meeting during the recess of the court, or at some place where he and the patient are surrounded by a number of others whose presence is unnecessary. There should be no difficulty in arranging an interview at which a medical representative of the plaintiff, the plaintiff himself, and the examiner are alone together. A doctor's office is the best place for this, and preferably one supplied with the ordinary facilities and apparatus for diagnosis. Delicate electrical examinations are apt to be unsatisfactory if rough, portable apparatus only is available, and an investigation of the patient's sub- jective symptoms is not possible in a lawyer's office or in the corner of a court room. The same objection should be made to a dimly lighted and crowded room, perhaps in a tenement-house, in fact any place is objectionable where a crowd of sympathetic and officious bystanders are ready, not only to correct the patient in his state- ments, but to put words in his mouth. In this connec- tion, especially when the inquiry is directed to the deter- mination of subjective complaints, it is of the gravest importance that the questions should in no sense be lead- ing or suggestive ; but at the same time the utmost fairness 238 EXAMINATION— POSSIBILITY OF ERROR. 239 should be shown the patient, and he should be given ample opportunity to detail and explain his symptoms in his own way. The interposition of officious persons is to be prevented, for if the subject really suffers he is ordi- narily able to tell his own troubles. Discussions and argu- ments with the physician or others in the room do little or no good, and often lead to undignified controversy and possibly subsequent misrepresentation. The examiner is supposed to be qualified to make an independent and personal investigation, and should be allowed to do it un- molested. He, however, should listen to medical infor- mation and, if it be germane to the case, give it full weight. It is usually unnecessary even in doubtful cases to sub- ject the patient to harsh or painful tests, or, if he is thought to be imposing, to berate him or accuse him of fraud, for there are other ways to do this, with which most people possessed of common sense and an insight into human nature are familiar. A preliminary inspection of the sub- ject, even though a hurried one, must impress the experi- enced observer with the reality or unreality of the pa- tient's condition. Well-known disturbances of motility may be observed in the gait or in the execution of required muscular movements, and there is a consistency in the expressions of a real sufferer which cannot be mistaken. The chief thing to be remembered is that the uncon- scious acts are those chiefly to be taken into considera- tion, and that the objective expressions are of far greater importance than the complaints. In examining the alleged muscular weakness, if there is nothing to confirm the subject's claim that he has lost power, the dynamometer — either the instrument pro- vided for testing the hand grip, or that for the lower 240 RAILWAY AND OTHER ACCIDENTS. extremities — may be utilized (Fig. 31). If the former be used, the truly akinetic subject will make several attempts, the first forcing the needle to a greater point forward than those which follow, thus indicating the continuous exhaustion by repeated efforts, while the im- postor may either make no attempt at all, or will make pressure so irregularly as to suggest deception. If he be blindfolded, the deception can be easily recognized. As has been shown, well-known changes take place, not only in the muscle cut off from its central point of innerva- FiG. 31.— Mathieu's Dynamometer. tion, but with other kinds of cerebro-spinal disease there are variations in the response to electric stimulation. Under some circumstances when these cases become the subject of litigation, the popular idea of an electrical test implies that the injured person should stand a severe and painful application without flinching. While this may be true when hysterical or other anesthesia exists, there are many serious conditions in which it has nothing to do with the patient's real state. The use of electricity after all is of the greatest moment in peripheral or other paralyses where the reaction of degeneration is found, but even here there has been an inexcusable misconception in re- gard to what should constitute such a reaction ; in a re- cent case a medical gentleman, who qualified as an expert EXAMINATION— POSSIBILITY OF ERROR. 241 in electrotherapeutics, stated that the sensibiHty of the muscles to the stimulation of the induced current was at once increasea. Unless an electrical examination be properly and care- fully made, it is indeed useless. Not only should the electrodes and the " make-and-break " handle be suit- able, but the physician should rely upon a milliampere- meter, and not compute the strength of the current by the number of cells used, as was the old custom. While it is possible to approximate the voltage in this manner, there is no way of accurately estimating the quantity of the current. With this instrument it is not only within our power to make comparative calculations, but its read- ing will be final and accurate. To make proper tests a knowledge of the motor points which have been mapped out by Erb should be borne in mind, and the electrodes should not be applied indiscriminately as they so often are. A slipshod use of electricity for the purpose of diag- nosis can be of absolutely no value, and should not be given weight in a court of law. Not only is it necessary, in some cases, to have good conduction, but allowance should always be made for the dryness and thickness of the skin, which may as well interfere with a test of the condition of the reflexes. The two kinds of reflexes that interest us are the super- _ficial 2Jidi the deep. The superficial is evoked by irritation of the skin, when there will be a resulting muscular con- traction, usually of light grade. There are several places where this may be evoked, the plantar surface being the most familiar. Changes in the superficial reflexes are of interest when they are associated with some anesthetic condition of the skin, or in states of unconsciousness when 16 242 RAILWAY AND OTHER ACCIDENTS. they are usually absent. The tendinous reflexes depend upon the normal condition of a functionating spinal arc formed by the central neurone, by afferent and efferent nerves, and by tendon or muscle. The knee-jerk is probably that which is most often looked for, and its absence or exaggeration has a bear- ing upon many central or superficial conditions of dis- ease.' It is best tested by making the patient sit upon a high chair or table, his legs hanging limply, and tap- ping the patellar tendon with a rubber-headed hammer, a steel sound, or an ordinary ruler, which are all preferable to the hand. The result will be a contraction of the quad- riceps and other muscles and a resulting kick of more or less vigor. If the common way of testing this reflex is tried, that is, by making the patient cross his legs, it will often be found that in fat people there will be no re- sponse. When it is not possible to seat the patient in the manner suggested, he may be made to hang a leg at a time over the rigid forearm of the examiner. Sometimes a tap over the head of the fibula will produce a response. If the patient is not blindfolded, the method of rem- Jorcevient (which consists in causing him to attempt some other voluntary action at the same time) is recommended. He should be directed to look upward, while he locks the fingers of one hand with those of the other and pulls with- out relaxing his hold ; sometimes when the knee-jerk is not evoked by the ordinary tap, it will follow this proced- ure. Enough has been said about the significance of diminished or increased reflexes, but it may be further ' The deep reflexes are the pupillary, elbow or triceps, knee-jerk, and ankle clonus. The superficial reflexes are the abdominal, cremasteric, gluteal, and plantar. Others of minor importance are the wrist and jaw re- flexes, which are deep. EXAMINATION— POSSIBILITY OF ERROR. 243 stated that in about one in five hundred normal persons the knee-jerk is absent. In investigating sensory changes, especially anesthesia, there are certain things which sometimes seriously inter- fere with the accomplishment of satisfactory results. A patient should always be examined, if possible, in a room of comfortable temperature, and the condition of the skin itself should be observed, for certain individuals are natu- rally insensitive, and of course perception is not so acute in some parts of the surface as in others. I have found that the contact of certain underwear has often produced an appreciable amount of more or less insensitiveness, especially over the anterior part of the thigh and leg, and in other people the plantar or palmar surfaces are thick- ened, and materially interfere with the delicacy of tactile tests. Laboring men and women, especially those whose hands are kept in liquids which indurate the tissues, are often insusceptible to impressions which could readily be perceived by others. The esthesiometer (page 62) is an instrument which is not always exact and, as subjects are often inclined to guess, saying they feel three or four points instead of one or two, it is not only wise to make a great many tests, but to avail ourselves of certain means of detecting in a more definite manner the integrity of this kind of sensation. To accomplish this we may draw with a pointed instrument geometrical figures upon the surface, or follow the plan of Rumpf, which consists of making letters, their perceived magnitude determining the degree of sensibility. The sizes by which they can be recognized by the normal individual vary from one-fifth of an inch in height upon the finger tips to one and one- 244 RAILWAY AND OTHER ACCIDENTS. fifth inches in the calf and sole. Other tests to gauge the quickness of transmitted peripheral stimulation should be utilized, for in certain central diseases there is an appre- ciable retardation. The normal reaction time is consider- ably less than half a second, but in disease an interval of several seconds may elapse before it is felt. An amplica- tion of this test that necessitates the use of complicated apparatus may be employed not only to determine accu- rately the quickness and extent of certain partly or wholly involuntary functions, but to approximate the general in- tellectual activity. In making thermic tests the temperature of the applied substance should be sufficiently extreme, for a normal per- son cannot distinguish heat and cold as such when the test objects are at a temperature between 80.6 and 86° F. (Dana). It also makes a difference as to the size of the object which is brought in contact with the skin, a small surface being more quickly and keenly appreciated than a large one. If test tubes be employed at least four should be at hand, two respectively containing warm and hot water, and the others cold and iced water if possible. The test thus amplified, especially if the subject be blind- folded, prevents deception. In testing tactile anesthesia great care must be ex- ercised lest there be vibration or agitation conveyed to healthy parts in the vicinity, and Letievant speaks of the patient's ability to " discern friction on an anesthetic surface by means of vibrations carried by the tissues to corresponding healthy nerves." Bowlby, in referring to this, says that the likelihood of mistake is naturally great, especially in anesthesia of the fingers, when a false perception of touch occurs, especially when one EXAMINATION— POSSIBILITY OF ERROR. 245 finger is supplied by both the median and the ulnar nerves. In investigating the alleged pain of individuals who submit to examination we are not to lose sight of the ex- istence of what are known as referred ^2^xvs,, and that these are sometimes found in connection with disease of certain organs and bear no necessary correspondence with the exact site of the morbid process itself. They are alluded to here because of the possibility of confusion with trauma. They arise not only from organic conditions, but from func- tional as well, and are most eccentric and irregular, owing their creation to irritation of visceral nerves and of the gen- eral sympathetic system. " Irritation sent into the spinal cord through these nerves sets up sensory impulses in the various segments of the cord, each segment receiving im- pulses from a certain organ. These sensory impulses are sent upward to the brain and become conscious percep- tions. They are referred by consciousness, not to their actual point of origin, but to the part of the body from which sensations usually come when received at the par- ticular segment irritated. Thus, as in general experi- ences, sensations and pains coming from the various seg- ments of the spinal cord have been due to irritation in the surface of the body corresponding to these segments ; these various visceral sensations are referred to the sur- face of the body" (Starr). Among these referred pains may be mentioned the frontal and suboccipital headache^ due to eye strain ; the temporal or postaural pain, due tO' the existence of carious teeth, in which there is no local discomfort. The illustration on page 247 shows some of these various irregular areas of reflected pain in connec- tion with various visceral and functional diseases. In addi- 246 RAILWAY AND OTHER ACCIDENTS. tion, we find that with gastric disorders there are localized pains in the middorsal region, with hepatic disturbance there is the famiUar pain below the right shoulder, and some lumbar pain in association with uterine disorder. The author has availed himself of Dana's excellent dia- grams, which indicate the area, cerebro-spinal nerves in- volved, with their distribution; the associated ganglia of the sympathetic, as well as the parts supplied by the lat- ter. These are considered, so far as the parts included in Fig. 32 are concerned. It is best to test tremor by the myographium, but the ordinary sphygmograph has been utilized as a diagnos- tic aid, it being fastened to a table while the patient holds the lever between his thumb and forefinger. This is at best but a rough test, and it is impossible to get chrono- logical tracings at the same time which are sufficiently ac- curate. Besides this the mental effort required to keep the style from leaving the limits of the surface of the paper must cause more or less mental influence which to some degree inhibits the tremor. A crude test consists in making the subject spread his fingers, meanwhile bring- ing the thumbs together. Intention tremor, which is that evoked or increased by attempting some more or less deli- cate act, may be tested by asking him to carry a full glass of water to the mouth, and as it is often associated with speech disturbance, as in multiple sclerosis, the person may afterward be made to repeat certain words involving the use of special muscles of the organs of articulation, or to read, when "scanning" may be recognized, This is usu- ally connected with a peculiar pause after the enunciation of each syllable. Besides these tests, others should be em- ployed, when we may find s^aizc ataxia — that is to say, EXAMiyATIOX-POSSIBIIJTY OF ERROR 247 that loss of co-ordinating' pow- er and sense of direction wiien the patient tries to stand with his eyes closed ; or locomotor ataxia, which consists in the expression of disorderly gait or other defects of co-ordina- tion when he attempts to walk -Referred Pains. Dana.) (Modified from Suggestive of (i) anemia, endometritis, bladder ; (2) errors of refraction, gastric dyspepsia ; (3) decayed teeth, ej'-e-strain ; (4t liver; (5) otitis media, eye-strain, pha- ryngitis ; (6j neurasthenia with spinal ische- mia ; ('7) cardiac neurosis and organic dis- ease, sometimes ; ('3) uterine ; (9) pseudo- angiua pectoris or gastric neuralgia; do) liladder or, more rarely, penis ; fir ) spasm of ureter, ovary ; (12) broad ligament, ovaries; (14, 16) gout, neurasthenia ; (is) hip-joint dis- ease. Besides these there are a dorsal point connected with gastric disease, a lumbar area in which is located the backache of uter- ine disease, and two limited spots corre- sponding with the liver and spleen. 2 and 5 are often conjointlv affected and may be the seat of pai'oxysmal pain when exceedingly hot or cold substances are ingested. The areas, nerve supply, and sympathetic ganglia associated with distribution have been thus tabulated by Dana : •^tttJ'ie Cerebro- spinal Nerves. Distribution. Associated Ganglia of Sympa;thetic. Distribution. L Trigeminus, facial. Face and anterior scalp. Fourth cerebral. Head. n. Lipper fourth cer- vical. Lower fourth cer- Occiput, neck. First cervical. Head, ear. III. Upper extremitv. Second and third Heart. vical and first cervical, hrst dor- dorsal. sal. IV. Upper sixth dorsal. Thorax. First to sixth dor- sal. Sixth to twelfth Lungs. V. Lower sixth dorsal. Abdnmen, upper lum- Viscera of ab- bar. dorsal. domen and testes. VI. Twelfth dorsal and Lumbar region, upper First to fifth lum- Pelvicorgans. fourth lumbar. gluteal, anterior and inner thigh and knee. bar. VII. Fifth lumbar and Lower gluteal, poste- First to fifth sacral. Pelvic organs fifth sacral. rior thigh and leg. and legs. 248 RAILWAY AND OTHER ACCIDENTS. or perform suggested actions. In certain degenerative diseases such as tabes, these difficulties of movement are found, as well as a loss of the muscular sense, which interferes to a great degree with the subject's muscular appreciation of the passive relationship of his limbs. Suggestions have been made elsewhere that certain substances be used to determine the acuteness of smell and taste, and care should be taken, for, strange as it may seem, the exact appreciation of these functions is often misunderstood and improperly localized. Loss of smell is harder to test than that of taste, through the error of confusion and the difficulty of stimulating one olfactory nerve and not the other at the same time. If the olefactometer is not available, a number of small slender phials may be, which should be tightly corked and kept apart when not in use, each containing some familiar odoriferous substance, such as oil of rose, tur- pentine, asafetida, oil of cloves; and these, in solutions of different strength, should be tried one after the other. Diffusible or pungent volatile substances confuse the results and are not recommended. It is unnecessary to repeat what has been said about the tests of vision and hearing, except to urge the importance of always freely dilating the pupils, not only for the recognition of old iritis but to secure a proper ophthalmoscopic examination of the fundus. Before doing this the patient's permission must be obtained and he must be informed in the presence of others that he may suffer temporary discomfort, other- wise the examiner may be subsequently berated for tortur- ing the plaintiff, even if an actual aggravation of the condi- tion is not claimed ; this has occurred. In several cases with which the writer is familiar, the Roentgen rays have been EXAMINATION— POSSIBILITY OF ERROR. 249 utilized to depict the injured condition of the skull and ver- tebral column in certain litigated cases, in which fracture of the head and spine is said to have occurred, and some- times with fair success. The value of the jtr-rays is greater, however, in showing the existence of a foreign body em- bedded in the brain than in demonstrating fracture, and it is only when considerable displacement or very great de- pression of bone exists that it is of avail. The case is dif- ferent in spinal injuries, fractures and dislocations, espe- cially in the neck, for here excellent skiagraphs are possible and made without trouble. The matter of obtaining a picture which shows an antero-posterior deformity is more difficult and implies the exercise of great care. It is doubt- ful whether, in incomplete fractures or in those without much displacement of the various processes, any striking change can be detected. The exact location of a bullet or any other foreign body in the skull necessitates the making of two separate negatives, one at right angles to the other, and for this purpose we may adopt the method of Walsh, which is depicted in Fig. 33. " Two views are taken by shifting the focus tube, but the body to be penetrated and the sensitive plate remain in' exactly the same relative positions. The lamp is put at the same distance from the plate in both views, and also in some known relation to a given point, say the centre or the edge of the plate. By comparing the resulting shadows, a conclusion can be formed as to the intersection of the planes (No. I. a.. No. II., b). It need hardly be said that two plates must be used, one for each position." At best skiagraphs should be received with great cau- tion, but it does not do absolutely to ignore their value, for they may show a gross bony lesion or deformity or a 250 RAILWAY AND OTHER ACCIDENTS. foreign body, though the rest of the picture conveys but Uttle. In a case of this kind a very positive young man on the witness stand claimed that these appearances did not exist in a very clear case, when they were patent to ■■■9 Fig. 33.— Verifying Method of making a Skiagraph of the Head. (Walsh.) f. d., Foreign body ; SK, skull. every one, but the only anomalies he admitted were " exaggerated depressions corresponding to the situation of the Pacchionian bodies!" CHAPTER VIII. PROGNOSIS IN RELATION TO THE VERDICT. In the determination of the extent of injury and its bearing upon the future Hfe of the individual, there are several medical considerations to be taken into account beside those which are purely legal and pertain to the matter of contributory negligence. These consist in the recognition of the incapacitating influence of secondary and induced disease, as well as the prognosis of affections which under other circumstances might be non-trau- matic; the question whether the subject has sought or received appropriate or sufiRcient medical or surgical at- tention arises, or whether a possible tardy recovery or permanent disability may be due to malpractice or to the patient's own neglect. Additional subjects of inquiry are the pre-existence of other contributing illnesses, either proximate or remote, or again, possibly an hereditary pre- disposition may give the traumatic affection an entirely different complexion. Again, in some cases when the bacilli of tuberculosis or the micro-organisms of other affec- tions are introduced into the system through wounds of the body made perhaps through the defendant's admitted neglect, a new phase of responsibility is to be considered which of late has given rise to a great deal of discussion. Sometimes the initial injury may be exceedingly trivial, yet the recipient may succumb to the grave, implanted disease; or still again an injury with no immediate infec- 251 252 RAILWAY AND OTHER ACCIDENTS. tion may occur in a subject who later dies from tubercu- losis, the bacilli being taken into the body long after the accident in the ordinary way. In this connection, attention may be called to the possibility of a com- plicating tetanus or erysipelas with the development of which the defendant has little to do, yet so far as the responsibility is concerned the court has very strong ideas. If infectious micro-organisms produce disease through introduction into the circulating blood even through a trivial wound, it has been held in the Wisconsin courts that the injury and the disease are both elements of dam- age in actions for negligence. McDill has insisted upon the importance, therefore, upon the part of the railway surgeon that he should keep careful and accurate and minute records of all cases of slight injury " with careful anamnesis extending over the entire period from infec- tion of the trauma to the disappearance of the last vestiges of its results. When an action for damages is contem- plated, medical experts should remember that these infec- tious diseases do not usually follow injuries, and that, therefore, the disease must, in order to constitute an ele- ment of damage, be clearly traced to the injury, either immediately, or by an unbroken chain or succession of events, reaching from the injury to the disease and pro- ducing it. . . . It should be further borne in mind that the effects of slight injuries upon most tissues are gener- ally rapidly effaced by physiological processes, and if an infectious complication should arise therefrom it should follow soon thereafter, and would be expected to pursue an acute course." It would be almost impossible to fix any arbitrary rule PROGNOSIS IN RELATION TO VERDICT. 253 by which compensation could be fixed for injuries and their consequences which incapacitate partially or fully. In this country a medical man is not permitted to express any opinion except of the vaguest kind, while the records of the German insurance system, to which allusion has already been made, approximate the percentages of com- pensation for various forms of disability. The widely differing direct effects and the progress of spinal and head injuries with complications, must impress even the skilled observer with a futility of an infallible prognosis. The local law compels us to fix " with reasonable certainty " the patient's future condition, and this is very liberal ; but it cannot be gainsaid that many medical experts are prone to take too light a view t)f certain trauma and too severe a one of others, and it is here where experience and observation become of value.' What has been said of the prognosis of special con- ditions need not be repeated, except that many diseases of the cerebral cortex and basal and central parts, especially where there is infection, are often apt to be very grave, and if not fatal, their course is slow; that fractures of the upper part of the spinal column and of the base of the skull are more fraught with danger than others, and that certain degenerative psychoses consecu- ' Golebiewski refers to 449 cases of head injury, some of which were under observation twelve years ; of these there were contusion or contused wounds, 259; contusion or contused wounds, complicated by concussion, 137 ; fractures of skull, 134; lesions of face, 76. Of the first named, 50 per cent made complete recovery without any pecuniary allowances under the insurance system. Of 114 fractures of the skull the vault was the site in 39 cases, and the base in 25 ; 19 cases made a perfect recovery, and 50 were totally incapacitated for support and rewarded accordingly; the rest re- ceived varying amounts. Among the number, 13 had delirium tremens, 6 developed epilepsy, and 8 insanity ; while many presented the functional neuroses. There were 4 deaths, 2 having been suicides. 254 RAILWAY AND OTHER ACCIDENTS. tive to injury, such as organic dementia, are almost intrac- table. This generalization does not absolutely exclude certain lesions of other parts of secondary or indirect de- velopment, and of such diseases as epilepsy, systemic de- generations of the cord, or rare fomis of hysteria. In the functional or psychical post-traumatic neuroses the matter of temperamental influences must materially modify the prognosis, and what has been said regarding the intro- spective and aboulic life of the patient after the accident must be borne in mind, when we are called upon to say whether he will recover or not. It sometimes appears that the trauma is simply an accidental factor developing symptoms in an unstable subject, who may recover and have a fresh exacerbation through fresh influences that have no connection with the original injury. Case LII. — J. R. G , 35, railroad employee, seen August 3d, 1886. While riding in a freight car six years ago it was de- railed and he was thrown down and became temporarily uncon- scious and was delirious for some weeks. There were dislocation of the right humerus which was reduced, anesthesia of arm, fore- arm and hand ; neurasthenic symptoms followed with insomnia and general ill-health for six months, when he recovered. A year later he was treated for gonorrhea, and a strong solution of carbolic acid was used as an injection, producing local inflammation and stricture; the nervous disorder returned, there was occasional vertigo, as well as frontal fulness and throbbing, ringing in the ears, and cramps at night in the lower extremities ; he worried a great deal and was melancholic. After a long period of invalid- ism he again recovered. In some cases in which the symptoms are decidedly pro- found and apparently resemble those of organic disease, there is often a complete disappearance of all symptoms and a return to the ordinary normal condition in even a PROGNOSIS IN RELATION TO VERDICT. 255 few years. Undoubtedly there are examples in which the hysterical manifestations occur in connection with those of organic origin, such as disease of the right internal capsule; but there is a hemiplegia found as well, which is due purely to a destructive lesion and should not be mis- interpreted. If the disturbance be due to the fright or demoralization following the accident, proportionate but not excessive or punitive damages may be given. The great danger, as has been said, is the delay in such cases, which is conducive to the establishment of a state of in- validism or hysteria, particularly if the plaintiff be a wo- man. That the constant concentration of the attention upon one part of the body is apt to be followed by a va- riety of astonishing changes which are sometimes appa- rently structural and objective is one of the things recog- nized in medicine. In certain forms of hysteria observed frequently in French hospitals, the intense fixation of the mind upon the body may result in the production of stigmata, and Janet publishes the photograph of the foot of an hysterical woman whose fixed idea was that of crucifixion. On the anterior part is a small spot corre- sponding to the auto-suggested mark of the nail which pierced the feet of Christ. Such happenings are un- fortunately too often convincing to laymen. Christian Scientists, and jurymen of a sympathetic leaning; but no such action of the mind, it is needless to say, can in- duce anything like a consistent morbid process which in any way can be connected with a specific injury. In the majority of such cases cures may be effected by isolation, or a sufficiently powerful appeal to the subject's self-con- trol or hopeful expectancy. Every physician of experi- ence has seen these examples, and the writer has met with 2S6 RAIL WA Y AND OTHER ACCIDENTS. many who have presented functionally paralyzed muscles with disuse atrophy and other symptoms strongly in- dicative of serious disease of the central nervous sys- tem, but who were in time fully cured by psychic treat ment. In investigating and forming an opinion as to the exist- ence and mode of an injury, and the probable duration of its effects, much help is afforded by the nature of the testis mony of the patients themselves. An inspection of the sworn testimony in these cases impresses one, notably in street-railway accidents, with the improbable manner in which the alleged violence has been sustained. It is rare that a victim is struck by the car itself, or that the wheels or under part come in contact with them ; there is even a poor history of initial violence, wounds being unusual and not so often found as in ordinary accidents. To the ex- perienced physician who reviews an ordinary case, the absence of the common expressions of mental distress at the time of the accident seem at least strange ; and there is a decided difference between the alleged incapacitating effects and appearance of symptoms under these circum- stances, and others in which a person sustains a much more grave upsetting, the question of a lawsuit not' aris- ing at all. Nearly all of the "slowly developing" cases are closely alike in railway litigation, and differ materially from those in which the exerted violence came from an ordinary fall upon an icy pavement or from one's own carriage, although it is not for a moment held that nervous disorders may not sometimes follow these latter. As a minimizing factor the cultivated expectant atten- tion and failure to seek proper care imply a certain re- Railway axd othkr Accidents. PLATE XIV. A, Case of Hysterical Paraplegia of fourteen years' duration. B, The same patient after six weeks' treatment. (Purves-Stewart.) PROGNOSIS IN RELATION TO VERDICT 25; sponsibility upon the part of the patient, his friends and advisers. As Frankel says : " Generally, traumatic forms of hysteria, particularly in men, give a quoad valetudinem unfavorable prognosis. External accidents, tardy appli- cation of the proper therapeutics, or their frustration through lengthy legal proceedings, allow the malady to take root too • deeply, and future eradication becomes at times impossible." This is only the statement of a familiar fact which should be borne in mind and utihzed to hurry to trial, or settle such cases as soon as possible. The courts confine the medical witness to the expres- sion of an opinion which shall imply " a reasonable cer- tainty," and in the present state of our knowledge this sometimes is a matter of exceeding difficulty. A fair, broad survey of the particular case is absolutely neces- sary, and the judgment must be freely exercised, so that it is imperative that technical entanglements and theo- retical conventions should be given a wide berth. To do this the medical witness should not only have a sound idea of the pathogeny of organic disease, but a sufficiently broad experience to take into account all the curious variations of functional disorder which are so closely allied to mental departures. He should also be a student of human nature. All forms of accident aboulia recover in time, provided the psychopathic inherited state of the individual is not too deeply seated, and in such cases it seems hardly fair that the defendant who may be respon- sible for a trifling shock or injury should be punished or mulcted when more than two-thirds of the contributing condition is due to some congenital neurotic vice of organization or to previous bad habits, not always easily 17 258 RAILWAY AND OTHER ACCIDENTS. ascertainable.' In many of these cases some other cause might have developed the particular condition had there been no accident. In a few the state is intractable, particularly if the surrounding influence be especially bad and conducive to the habit of invalidism. Case LIII. — Ellen D , 17 years old, Irish, was examined by the writer, October 28th, 1899. It was alleged that when sitting on the front stoop of a house on Park Avenue, on the morning of June 2d, 1 8g8, she was run into and thrown over by an automobile that mounted the sidewalk. She was picked up unconscious, but soon recovered and was seen by a physician two days afterward, who stated that she had not slept the night previously, that she was bruised all over shoulder, and right hip, the left knee was swollen, and he " thought he could feel minute bodies under the edge of patella, but was not sure" ; in fact "he had not made a diagnosis." She had been treated by this physician until the time of my visit, a little over a year, by strapping and bandages, when I was imme- diately impressed by her expression and attitude. While in no way did she appear to be the worse for her accident or an ill woman, there were nevertheless the peculiar placid facial expres- sion and an air of helplessness and hopelessness so often found in protracted cases of the kind. She was seated in a chair with both legs rather rigidly extended, but it could not be said that there was paralysis, although she claimed that she could not raise her legs. In fact, when they were elevated and released she main- tained the position herself. With great difficulty she was assisted to the bed, and when her interest was aroused she helped the doctor get off her bandages. There was no muscular atrophy, but a cer- ■ The author is indebted to Paul D. Cravath, Esq., for the history of a case of a man who claimed to have been severely injured by an electric wire that had been cut by some employee of an electric light company, and which fell, indenting his low-crowned hat, but not wounding the scalp or injuring him in any way. He almost immediately developed a series of nervous symptoms, and eventually a functional hemiplegia. It need hardly be said that the wire was dead, and that his condition was largely due to his fright and neurotic predisposition. In reality, the company was only guilty of a technical responsibility for the damage of his hat. The case was wisely set- tled, for there is little doubt that had he gone into court his nervous state would have been attributed to the carelessness of the corporation. PROGNOSIS IN RELATION TO VERDICT. 259 tain tendency of the posterior thigh and leg muscles on both sides to contract spastically. The left knee-joint, which had been the subject of complaint, could be handled rather roughly when her attention was diverted, but at other times the slightest touch caused her agony. Her reflexes were normal, and suitable tests showed her sensibility to be everywhere unimpaired. A feature of the case was alleged constant vomiting when she sat up, but this did not occur at my visit, and her excellent physical condition would suggest that such was not the case. Other statements of the pa- tient and physician were that she had back pain, a feeling of inse- curity, restlessness and dizziness, constipation, and that her menses had stopped. The doctor had used the Paquelin cautery and strapped the spine, " not because she had any spinal trouble, but because she said she wanted treatment." This case is of interest because of the subject's complete condition of helplessness, which I believe was honest and due to the existence of a fixed idea. Had she been denied what was apparently unnecessary surgical treatment, and there had been no suit for damages in prospect, it is quite probable that the slowly developed inhibition might have been averted. As it was, the will had become so dormant and the idea of incapacity so all-absorbing that the patient is apt to go through life a miserable burden to her family. Owing to a legal technicality as much as anything else, there was a verdict for the defendant, so this disappointment undoubtedly was a further contributing element in the formation of a bad prognosis. The prognosis is better in simple neurasthenia than in hysteria, and worse in the hypochondriacal form than in either. Many patients, as has been said, get well with the settlement of the case or when, if there be no litiga- tion, they are isolated and disciplined, the following being an example : Case LIV. — A woman aged 29, of neurotic predisposition and addicted in some measure to drink, fell in the street upon her but- tocks, striking her coccyx, was taken home by her sister and re- mained for some time in a highly emotional state, being quite tremulous and nervous. In a day or so she complained of general pains in the lower part of the back, thighs, and legs, and of exqui- 26o RAIL WA Y AND OTHER ACCIDENTS. site hyperesthesia of both legs and the back as far up as the shoulders. There were for a day or two some hysterical anuria, and suppression of the menses, which were due. The physician who was called in gave morphine in large quantities and was un- wisely solicitous and attentive, making numerous visits and prof- fering an unnecessary amount of sympathy. In a few weeks she could "not move arms or legs," yet she was able to shake hands with some of the friends who visited her, and upon one occasion got out of bed without aid. At other times and as a rule her alleged prostration was so great that the bedpan always had to be used, but she never needed catheterization. Being an attractive woman, she had a number of friends who were permitted to be with her constantly, and her personal appearance seemed to concern her as much as her condition, for she always insisted upon being dressed becomingly at the time of their visits. To her visitors her recital of symptoms was constant and impressive. A consul- tation of physicians was held and the diagnosis of meningitis was the result. At this time there was some analgesia, but no tactile and temperature loss, tests being made when she was blindfolded. There was some apparent contraction of the visual field, but this was doubtful. No actual paralysis existed, and the electrical re- actions of the muscles were good, although there was slight dim- inution in response to the induced current. For several months before I saw her she had lain upon her back, with her feet drawn up and her knees bent, and it was only with difficulty that her lower extremities could be fully extended. Believing the case to be one of hysteria, I at once isolated her and she was systemati- cally treated by mental therapeutics and properly disciplined, with the result that in a few months she was up and about and appar- ently perfectly well. Other cases are harder to manage and slower to im- prove, and if there be combined injuries, the prognosis may be exceedingly bad. In a very small number the condition following mixed neurasthenia and hysteria is an absolutely permanent one, but in the experience of many years the writer can recall but one case of this in- curable kind in which there were directly produced cerebral PLATE XV. Railway and other Accidents. Case of Functional Paralysis, showing gradual recovery and subsidence of anesthesia. (Purves-Stewart.) PROGNOSIS IN RELATION TO VERDICT. 261 or spinal lesions. This hopeless condition was the ter-, mination of an initial shock and a developing aboulic neurosis. Case LV. — ^This man was employed in shifting grain in one of the cars of the Erie Railroad, and when so engaged was thrown to the floor, as the result of a collision of the car he was in with a " wild " car ahead. He was much frightened, very cold, and had a weak, fluttering pulse. Upon his return to his home he took to his bed and made no effort to move or help himself. Within a short time he developed a fine tremor, which increased when he tried to take a glass or cup offered him, or used his knife or fork; this ceased when he was undisturbed. His legs were " cold " and insensitive, and his wife brought and applied an elec- tric battery which he thought helped him. I saw him about eighteen months after the accident, and found him sitting in a wheel-chair. Both legs and feet were extended and quite stiff. He could raise his arms and legs with great difficulty, there ap- pearing to be a general amyosthenia and a spastic rigidity, but no actual paralysis or contracture. There was a general atrophy due to inaction, and the electric irritability of the muscles everywhere appeared to be reduced. There were apparently waves of tremor attending the simplest movement and a fine fibrillary tremor of the muscles of the back, and a tic of the sterno-cleido-mastoidei occurred when he changed his position. His facial expression was blank and he appeared demented. The man answered questions slowly but correctly. The deep reflexes were generally increased. There were no sensory disorders, save a slowness of conduction. His extremities were cold and mottled and the skin was dry. There was much to indicate a central degeneration. There were no visual limitation and no atrophy of the optic nerve, but he had begun to have some incontinence of urine. The patient's case was settled, yet he remained in this helpless state and several years afterward had changed but little. Undoubtedly the man's mode of life and surroundings had a great deal to do with his con- dition ; he lived in an isolated part of the country alone with his wife, who was a stupid woman, was without resources, and no attempt was made to arouse him or bring into play any mental stimulus whatever. 262 RAILWAY AND OTHER ACCIDENTS. In speaking of these examples Preston says: "The question should always arise, Is hysteria responsible for all the symptoms?" and refers to Mitchell's suggestion that organic expressions " may sometimes be painted upon a hysterical background." Doubtless in certain intractable cases there may be a hysteroid state in association with certain expressions of central disease. When deep and serious mischief to the organs of the central nervous sys- tem has been done, and there has been great psychic shock, such a combination is highly probable, and in illus- tration a recent case may be presented in which the hys- teroid tinge predominated. Case LVI. — Mrs. F , a middle-aged woman, sustained in- juries October 8th, 1892, in a collision at Menlo Park, N. J., she being in a car which was practically entirely destroyed as the result of a rear-end collision. She was taken from the wreck to a New York hospital, where she was seen and treated by Dr. Andrew Mc- Cosh, of New York. At the time, besides shock of the most severe kind, she sustained an extensive fracture of the pelvis accompanied with exquisite pain. I saw her on January 22d, following her dis- charge from the hospital, when she was in a decidedly agitated and tremulous condition, being easily excited. This irritability I learned was fully in contrast to her former mental state, for before the accident she was self-possessed, quiet, and well-balanced, and helped her husband in his business, often meeting emergencies that required nerve and decision. At the time of my visit she was so susceptible to external influences that when an unexpected application of the electrodes was made to one of her legs, the cur- rent being very mild, she was gyeatly prostrated, her pulse becom- ing almost imperceptible. Her expression was peculiar, her eye- balls not seeming to move normally, and an examination by Dr. C. S. Bull disclosed the fact that she had lost the power of binocu- lar convergence. One side of the face, the left, seemed flatter than the right, and the corner of the mouth was more marked on that side. The right palpebral opening was slightly larger than the left, and the pupil of this eye was dilated. Her usual mental con- PROGNOSIS IN RELATION TO VERDICT. 263 dition was one indicating demoralization, marked by restlessness, occasional excitement, and loquaciousness ; and I understood at times there was a great degree of irritability, which led her to treat those about her with unnecessary harshness ; this also is in direct contrast to her previous disposition. She evidently suffered a great deal of pain when she moved, was honest in her com- plaints, and did not exaggerate. She had no important loss of memory, but evidently lacked the power of concentration and attention. There was weakness of the entire left lower extremity without atrophy, but response to both galvanic and induced cur- rents was lowered. She could perform limited motions with dififi- culty, but could not abduct her thighs because of pelvic pains. Some weakness of flexors of both arms and hands existed, but it was worse on the left side. Although making an honest effort, she was able to move the dynamometer needle but a slight distance. Tremor attended almost every voluntary movement in the extremi- ties. During quiescence her right shoulder and arms were at times the seat of a clonic spasm, and this was absolutely beyond her control. The tremor was ordinarily increased when she was under observation or embarrassed. Both knee-jerks were enormously exaggerated. The plantar reflex was absent on the left side, which is anesthetic. Ankle clonus was absent on the left, but present on the right side, the test producing coarse agitation ; the super- ficial reflexes were everywhere increased to some extent. In addi: tion to the deep pain that the patient located in the pelvis, and which she said attended every considerable movement, there was a point corresponding to the ninth or tenth dorsal vertebra where deep pressure would cause pain. Her whole back and the entire right lower extremity were hyperesthetic. She had also severe sciatic pain. The left limb was analgesic and there were blunting of tactile sensibility, direction sensibility, and thermanesthesia. This impairment seemed to be most marked on the outer side of the leg and thigh, and was most complete below, extending upward to a line corresponding to the crest of the ilium. I could find no zones of disturbed sensation except a deep painful spot below the right angle of the scapula. The field of vision was limited in the right eye, the objects outside of a certain area being lost, and her complaint of this was that she sometimes felt as if she was look- ing through a tube. There was some impairment of the color sense, the field for green being contracted. A previous examina- 264 RAILWAY AND OTHER ACCIDENTS. tion some time before the accident had disclosed no trouble with vision. Hearing was unaffected, and smell and taste were normal. Heart sounds were weak, but not abnormal; pulse rhythmical, averaging 80. Patient cannot hold her urine, and it always drib- bles from her. Sometimes she retains it for a time, but is obliged to empty the bladder very suddenly. There is an evident ammo- niacal residue. Despite cleanliness, there is the familiar odor of a patient with incontinence. The most optimistic statistics (those of Page) show that about seventy per cent of cases of the traumatic neu- roses are cured completely and the others improved ; but it is impossible to fix a time for recovery in an affection which has so much to do with psychic influences and other determining factors; while of course the" broad statement that " these patients all get well as soon as their cases are settled " is manifestly unfair and untrue. That many of them do is true, but by no means all. The prognosis of hysteria, so far as actual fatality is concerned, is not bad. Although the disease is conceded to be one that does not naturally shorten life, there have been a few reported deaths due to inanition and starva- tion, preceded by vomiting, and it would appear from the fatal cases of Meyer, Wunderlich, Fournier, and others that there was usually some complicating condition or some other cause of death. Frankel reports three deaths, and concludes that such an ending may be the result of spasm or paralysis of any part of the respiratory mechan- ism; inanition due to hysterical anorexia, or uncontrol- lable vomiting ; paralysis of the circulatory or alimentary apparatus. Hysteria ordinarily, however, is almost as much a condition as a disease, lasting through life, always modi- fying the conduct and appearing in certain subjects in PROGNOSIS IN RELATION TO VERDICT. 265 many of the ways detailed in another chapter. I have seen it in young children, and in a woman, of sixty-eight, whose refusal to take food and obstinacy in many ways led to gradual starvation and exhaustion. In a class of neurasthenic and anemic subjects who develop a secondary sclerosis through inaction, perhaps kept up for years, a fatal termination has occurred from mere inanition. The prognosis of head injury has naturally become much more favorable since the development of antiseptic surgery. Even before the precautions were taken that to-day are everywhere in vogue, statistics showed a re- markable tolerance upon the part of the brain to violence. Of 316 cases of penetrating wound of the skull in which foreign bodies were lodged in its substance, and which were tabulated by Wharton about twenty-five years ago, the conclusions were the following: Recovered, 160 cases. Died, 156 " Foreign body removed in 106 " Of these 34 died. The foreign body was allowed to remain in . . . 210 " Of these 122 died and 88 recovered. The foreign body penetrated the frontal bone in . . 132 " Of these 58 died and 74 recovered. The foreign body penetrated the parietal bone in . . 58 " Of these 27 died and 31 recovered. The occipital bone penetrated in 23 " Of these 16 died and 7 recovered. The foreign body entered the temporal bone in . • Z^ " Of these 12 died and 19 recovered. The statistics of other observers are perhaps more fa- vorable, both in regard to the mischief inflicted by pene- trating wounds and the lodgment of foreign bodies ; and as to the outcome of fractures Parks says : " It is absolutely unfair to contrast the results of the surgery of to-day with 266 RAILWAY AND OTHER ACCIDENTS. those of the pre-antiseptic era. Rules then enforced are now entirely abrogated, and the methods of to-day would have made our surgical ancestors protest loudly. One respect in which we violate precedent is in our disregard to-day of the periosteum or pericranium. This is sacri- ficed without hesitation when found to be infected or torn, or lacerated beyond the capability of repair." If, therefore, the measures of surgical relief have been insuffi- cient, or if strict antiseptic precautions have not been taken (which to-day seems incredible), this neglect must diminish the liability of the defendant ; or if the patient will not submit in good time to properly determined sur- gical procedures which will modify the pressure perhaps of depressed and fractured bone, or will continue through habits of dissipation to aggravate an existing cerebral or meningeal affection of a traumatic nature, these things should be considered as they are by insurance com- panies, and in some measure should diminish the size of the verdict. We are called upon at times to judge of the gravity of the fracture as well as the question of the kind, extent, and duration of loss of function, as well as the remote consequences so far as they concern the duration of life. It is with the so-called healed fractures, which may or may not be connected with meningeal or cerebral compli- cations, with which we have to do in actions for damages brought by the survivor or his guardian. In regard to the gravity of fracture, it may be said that those of the vertex alone are far less important or dangerous than those of the floor of the skull, and recovery without com- plications is quite possible. Considerable depression of the vault may exist for years without any serious injury PROGNOSIS IN RELATION TO VERDICT. 267 of the parts beneath, and it is sometimes incredible how some individuals go through life as comfortably as they do with deep indentations with which one would naturally connect more or less underlying pressure. There are ex- ceptions, however, when a chronic meningitis of slow and unpreventable progress occurs in connection with dis- placed bone, which is preceded by cortical destruction and widespread disease of deeper parts, and ends in death. Sharply made fractures, either at the vault or base, heal quickly, and rarely leave any considerable trace, repair being almost perfect. They may sometimes do no very great harm except when the primary separation has been considerable, when the brain or its covering may be impinged and lacerated. As this form of fract- ure heals so quickly, it is often utterly impossible, after three or four months, to claim that uncomplicated stellate or linear fracture has existed. Such fractures, on the other hand, often occur without any brain injury at all, except when they involve the orbit, when its contents or the frontal lobe may be subjected to dangerous violence through the agency of a detached fragment of bone. Hel- der has found that of 96 fractures of the base there was fracture of the vault of the orbit in 73 cases, the superior wall of the optic canal being involved 53 times, and sub- vaginal extravasation existed in 42 cases with resulting complete unilateral amaurosis in 27. Baudry refers to the danger of a violent rupture of the optic nerve and its sheath, even when the fracture itself is inconsiderable, and speaks of the bad prognosis of absolute blindness with or without the ophthalmoscopic appearance of hemorrhage which is found on the return to consciousness, while the preservation of a part at least of peripheral visual func- 268 RAILWAY AND OTHER ACCIDENTS. tion is a hopeful indication. A direct fracture, however, of the superior wall of the orbit is grave indeed, and the mortality, according to Berlin, is about eighty per cent. Phelps,, who takes a rather hopeful view, says: "It is therefore true that in themselves cranial fractures are important only in exceptional cases. Their prognosis is really the prognosis of their complications." The im- mediate osteal injury is, therefore, in itself not danger- ous, it is only the connection with concomitant lesions. Roughly speaking, the cases of Phelps (1900) show that two-thirds of all that involved the base, and about one-third of those confined to the vault, were fatal. Mumford (1893) presents an analysis of 300 cases of fracture of the skull, 165 of the vault and 135 of the base; of these 56.06 per cent died. There were 279 compound and 21 simple fract- ures ; 80 per cent of the cases of basal fracture were fatal, and of the vault 37.05 per cent. It does not appear then from available statistics that fracture in itself is so often the determining cause of death. There are sufficient examples among the large number of cases brought forward by various writers to show that there is a great variation in their causation and in the consequences of injury, and these are at times unrecog- nized. Blows not sufficient to break the cranial bones may give rise to necrosis, and the outer or inner table may be the seat of obscure changes which are at times masked, all external appearance of scalp injury having disappeared. In rare cases like that of Howship, the cra- nial bones may be injured without any external wound, but with consequent atrophy and absorption of bone. The case of this author was that of a child who had a fall and sustained an injury of the right parietal bone, but PROGNOSIS IN RELATION TO VERDICT. 269 there was no wounding of the scalp whatever. Some weeks subsequently a pulsation of the brain could be perceived and paralysis supervened. Sometimes there are confusing symptoms, and when another serious head injury has perhaps been received at a previous time, it is occasionally difficult to say to which the symptoms found are due. The case of U. H which did not find its way into court, is an example of this, and though his symp- toms were indicative of at least two central lesions, he at the last time probably sustained a fracture of the base and possibly of the left temporal bone. Case LVII. — U. H , 67, president of a corporation, was seen by the writer in 1886. In 1873, while closing a boiler door which had been insecurely fastened it fell, cutting a scalp wound over the right parietal region. He was unconscious " for a minute or two," but laid up for two weeks. He convalesced, but afterward there were right-sided facial neuralgia, occipital pain on both sides, a great deal of nervousness, insomnia, and he was advised to give up his work for a time ; but in eighteen months recovered entirely, so that he was able to travel upon business. January 31st, 1885, while in a Pullman car, a slight collision occurred and he was thrown to the floor, striking his head on the side. There was a transitory loss of consciousness, and when he raised his hand to his head he found an open flesh wound on the left side, near the vertex in the lateral parietal region. On recov- ering he was confused, but could talk, and after the accident was taken to a hotel. There was pain in the left ear, which has lasted ever since. In a few days vision disappeared in the left eye and with this all sense of smell on that side. There was numbness in both hands, more marked in the left, the fingers being anesthetic. The right leg was weak and without feeling, so that a pin could be thrust into the surface without being felt, or causing annoy- ance. He could not walk without help for six or eight weeks, nor could he swallow or speak without great pain being caused in the back part of the throat and at the angle of the jaw. Six months later he consulted a Chicago aurist who, because the pain in the 270 RAILWAY AND OTHER ACCIDENTS. left side was so severe, opened the drumhead with a resulting escape of pus and blood and consequent relief for some time. He was first seen by the writer one year after the last accident. He complained of tenderness and pain over the left mastoid processes, and above the ear; there was almost constant headache and he could not walk steadily. There was at times tenderness, with ' throbbing on the left side of the head. If he attempted to read there was orbital pain on the left side, and if he persisted his vision utterly failed. The knee-jerk on the right side was exag- gerated, and there was anesthesia of the left foot. Both pupils were sluggish, and indications of optic neuritis on the left side were present. Some individuals may receive seemingly incapacitat- ing injuries and yet be able to seek assistance or do many things that may be required of them at the time. A laborer was struck upon the head with a pickaxe, the point entering the skull and the brain to the depth of the left lateral ventricle, yet he walked one mile and a half to the hospital. Certain persons who may survive the shock of a penetrating wound with the introduction of a foreign body which does not injure an important part of the cere- bral apparatus may lead comparatively comfortable lives with encapsulated bullets embedded in the brain, and the celebrated Massachusetts subject whose frontal lobe was pretty much all destroyed by a premature blast, which sent a tamping iron through the anterior part of his head, and who lived for years in comparative health, is too famil- iar to be detailed. Case LVIH. — In this connection attention may be called to a very interesting case reported by Keate, the patient being injured in the same manner. When the doctor reached him two hours after the explosion his pulse was 30 per minute and very weak. The eyes were blown out, the skin and muscles and forehead were partly blown off, while the anterior portion of the skull cap was PROGNOSIS IN RELATION TO VERDICT. 271 turned back over the parietal bones. The orbital plate of the frontal bone was blown into the brain, and the brain substance exuded through the opening into the cheek. There was also a hole in the centre of the frontal bone about the size of a silver ten-cent piece, through which the brain substance exuded. All membranes of the brain were badly lacerated, as were its frontal lobes. "After trephining, I removed twenty small stones and several pieces of bone, together with considerable dirt. Most of the foreign bodies were located at a point corresponding to the anterior fontanel, deeply buried in the brain. A large piece of bone corresponding to the roof of the orbit was extracted through the opening in the forehead. The amount of cerebral matter which came away weighed one ounce. The patient has never for one moment been unconscious. His mind has been perfectly clear, and he can readily recognize his friends when they speak to him. He answers all questions intelligently, and describes accu- rately the details of the accident. He has never complained of pain, and says the anterior portion of the head feels paralyzed. During the first two weeks his temperature ranged between 100° and 103° F., but during the- last two weeks it has been practically normal. "He has been able to get up every day since the accident, and locomotion is good. It has been just a month to-day, and as I write this article the patient is sitting in a rocker on the porch in the fresh air, chewing tobacco." The prognosis is in many cases difificult, when incom- plete spinal lesions exist, but in those in which there have been extensive injury and complete transverse destruc- tion of the cord, the task is easier. Fracture or disloca- tion of the upper part of the cord above the third cervical segment is usually almost immediately followed by death, although the patient may fest a few days ; but in a com- paratively small number of examples when the cord is not impinged upon or to a slight degree, life may be prolonged, the patient even lingering for a number of years. In some cases a sudden movement may result in the dramatic 272 RAILWAY AND OTHER ACCIDENTS. death of the patient, if the atlas and axis be involved, and the case occurs to the writer of an individual who had had an obscure neck injury and who, on turning his head sud- denly to speak to a member of his family who was enter- FlG. 34.— Keates' Case of Head Injury. ing the room, dropped dead as the result of the forcible encroachment of the odontoid process upon the medulla. Even when there is union of the fracture itself, there may be a tedious and ultimately fatal myelitis. It has been noted by surgeons that in more than PROGNOSIS IN RELATION TO VERDICT. 273 one-half the cases of fracture of the cervical vertebrae, the processes are broken rather than the bodies, while in more than two-thirds of the fractures which occur in the dorso-lumbar region the bodies suffer. In the cervi- cal region the danger increases with the proximity to the medulla. A severe fracture of the dorsal region may result fatally in three weeks or a month as a result of hypostatic pneumonia, and in the lumbar region in from three to four months as a consequence of exhaustion and sepsis following cystitis and pyelonephritis. Of course there are a large number of cases of dorsal and lumbar fracture or dislocation which make a fair recovery and which are cured by proper treatment. Upon the authority of Walton the average duration of life in fracture of the cervical vertebree is little less than a week, and of thirty-six cases collected at the Massachu- setts General Hospital the average time was fixed at five days, these being cases in which no operation had been performed. The prognosis is somewhat better in fracture of the dorsal and lumbar region without operation, the mortality varying from seventy-nine to eighty per cent, which is bad enough ; but when surgical relief is afforded, it is reduced to from forty to fifty-seven per cent. It would appear that American surgeons are less suc- cessful than those abroad, for at the hospital above re- ferred to, the fatality was sixty-six and two-thirds per cent, which is greater than that of either Chipault and Thor- burn. It does not appear that any material advance has been made in the very modern methods of treatment, but that operation has reduced the mortality to an encourag- ing degree, and in suitable cases should always be resorted 274 RAILWAY AND OTHER ACCIDENTS. to if possible. In such cases we may avail ourselves of the Roentgen rays as a diagnostic aid. There seems to be almost a unanimity of opinion that when the bones have been crushed an operation is unjustifiable, except when the injuries are confined to the Cauda equina or to the vertebral arches. Walton takes a firm stand in advocating an operation, believing in the fallibility of even the most careful diagnosis, and arguing that it will often disclose a condition of affairs that may be rectified. He does not favor surgical interference while grave shock exists, but as soon as possible. When the patient's vitality is not sapped by sepsis from the causes mentioned in a previous chapter, or from bedsores, there may be a let up in the compression and the active processes of cord inflammation, the victim liv- ing for many years in a more or less helpless condition. It occasionally occurs that previously existing disease may materially interfere with satisfactory diagnosis, or may remain as a complicating condition even after the direct effects of the trauma have passed away. These complicating conditions may have a decided medico-legal interest, mitigating in measure the culpability of the de- fendant. Edes reports a case of injury due to a fall in which pronounced muscular atrophy of both hands oc- curred in connection with symptoms indicative of postero- lateral degeneration. The man, however, presented a lead line upon his gums and other evidences of plumbic toxemia. A converse illustration is the following: Case LIX. — In a personal case which went into court the plaintiff was a man who, while sitting in a street car, received severe spinal injury by reason of a collision with a heavy wagon. The pole of the wagon was forced through the back of the seat. PROGNOSIS IN RELATION TO VERDICT. 275 striking him squarely in the middle of the back. He subse- quently developed a meningomyelitis with great pain, irregular paraplegia, and atrophy of the muscles of the lower extremities. When he sued for damages, evidence was brought forward to show that his occupation had been that of a painter. He had not worked at his trade for a long time before the trial, however, yet one of the witnesses thought he discovered a lead line. I could find no such change, but did find that his teeth were carious, and that he did not clean them, and the result was a spongy condition of the gums. His motor symptoms and atrophy were confined to the lower extremities, a very uncommon situation in lead disease, and there was no anesthesia. His reflexes were exaggerated, and his upper extremities were not involved. I subsequently learned that though he did not work at his trade after the trial, the symptoms advanced, A verdict was rendered for the plaintiff. The recognition of traumatic epilepsy and the possi- biHty of its cure by surgical interference must arise at times. This affection may result, as has been shown, from cortical lesions due to trauma or to fracture of the inner table of the skull vi^ith depressions or exostosis. The writ- er has known it to be produced by the penetration of the orbit by a splinter, and recalls a case in which a mounted officer rode into a low tree, one of the twigs of which pierced the vault of the orbit producing symptom of disease of the frontal lobe and a cortical epilepsy which lasted for many years without any general or serious trouble, but this is exceptional. In many cases the cortical lesion not only gives rise to the convulsive affection, but ends in the production of a hemiplegia upon the opposite side of the body. Again, the epileptic paroxysms may be due to some early local injury at a distal point. In epilepsy due to peripheral nerve injury, cases have been reported by Hufeland, Fere, Billroth, and Hadden in which the re- moval of a piece of glass from the foot or the exposure 2;6 RAILWAY ANB OTHER ACCIDENTS. and stretching of some of the nerves of the lower extremi- ties has led to a cure, when the fits have followed a fall or local injury. In giving the history of their affliction epileptics are apt to ascribe the disease to falls received in early life. It is to be taken into consideration that the fall is often con- secutive to the fit, which was due to some other cause, and that the first attack has been misunderstood. This view is likely to be taken by uneducated or unobserving people. Bailey does not believe that even one per cent of the cases of the disease are the direct result of injury. We should not forget that after shock or slight head in- jury, attacks may appear in persons who through heredi- tary predisposition, alcoholism, or some other general de- praved cerebral condition are susceptible to them. But few of the psychical equivalents of ordinary idiopathic epilepsy appear in the traumatic variety. While we may sometimes in the early stages help such patients by sur- gical procedures, nothing does much good when the brain becomes the seat of a progressive and grave degeneration, which is the rule if the blow has been violent, and espe- cially if there has been laceration due to fractured bone. The relation of surgical interference to prognosis seems to show that heroic measures are not always necessary, and that when the epileptic paroxysms follow the creation of a superficial wound or cicatrix, the early use of the actual cautery or some other revulsive may result in a dis- appearance, even at times when the disease is recognized as a cortical manifestation. The relief afforded by tre- phining or other surgical procedures is fairly encouraging, especially in those cases in which the blow has produced a hemorrhage, abscess, or some neoplasm consecutive to PROGNOSIS IN RELATION TO VERDICT. 277 meningeal injury. Of course where fractured and de- pressed bone exists, its removal is clearly indicated, and much good may be expected. Some older authorities, among them Echeverria, report a large number of cases in which two-thirds were either cured or improvement occurred. The modern results are even better, as the sta- tistics of Horsley, Keen, and others show. Of course it need hardly be said that the longer the operation is put off the poorer are the patient's chances. There seems to be at present some reaction from the optimistic opinion gen- erally entertained a few years ago in regard to the advan- tages of cranial surgery, but I think this applies mostly to operations for tumors and other non-traumatic lesions. The most careful investigation should be made with a view of determining the existence of old epilepsy and the stigmata peculiar to certain persons who are likely subjects. In some kinds of malformation of the cranium, in extreme degrees of asymmetry, such as dolicho- and brachycephaly particularly, and oxycephaly, scaphoceph- aly, as well as various departures from the normal stand- ard, we may recognize the soil in which the disease flourishes. Defects of the eyes, the shape of the ears, and in fact various stigmata of a congenital nature are all significant in predisposed subjects. In old epileptics evidences of tongue biting, and scars upon the scalp due to old falls that may have preceded the alleged accident, may be found, and should be kept in mind when considering the patient's claims. Cases which are said to have developed two or three years after the alleged accident must be looked upon with suspicion, for the rule is that the paroxysms begin within a few months. It is true that exceptional cases have been reported in 278 RAILWAY AND OTHER ACCIDENTS. which the epilepsy appeared several years after the in- jury, and in one case after fourteen years, but this is rare. The local mischief as a rule is quickly produced, and with the exception of pachymeningitis, in which the cortical pressure and consequent irritation are of tardy growth, the debut of the epileptoid attacks is not de- layed. Injuries oj the peripheral nerves are as a rule curable, unless there be very extensive disorganization of the nerve trunk itself, or some migrating neuritis. In recognizing the gravity of such injuries it may be borne in mind that crushing wounds are necessarily more intractable and more productive of deep-seated mischief than where there is a clean cut. Should there be neuromata or active and long-existing neuritis, the outlook is serious, but not nec- essarily very bad, for the former are of course removable, and the patient's sufferings may be at least ameliorated if not removed. It does not do to venture a diagnosis too early, for, as Mitchell has pointed out, there may be much distress when a large number of filaments are bruised in addition, perhaps, to section of a large nerve, and under such circumstances we must wait until there is a disap- pearance of pain and other sensory disturbances which are the effects of shock or due to the pressure of exudates. The regeneration may sometimes be so complete that, as has been pointed out, there may be a fair possibility of remote repair, or at least some return of function, even where a large piece of a nerve has been removed. Of course electrical examination is the most conclusive and reliable mode of determining the ultimate prognosis in such cases, and if the reaction of degeneration has been found, and has been succeeded by an absolute loss of elec- PROGNOSIS IN RELATION TO VERDICT 279 trie irritability of every kind in the muscles, and much atrophy with shortening and contracture has occurred, the chance of ultimate recovery is very much reduced, if not absolutely unfavorable. Here, too, the resources of surgery should be adopted, if possible, before the case is pronounced hopeless, for suturing, nerve stretching, and the tubular union of divided ends may sometimes be fol- lowed by encouraging improvement. The prognosis of special forms of peripheral paralysis cannot be determined with any certainty, for there are so many modifying circumstances. Akineses, varying from simple paresis to complete paralysis, may exist conjointly and be more or less obstinate in their susceptibility to cure. Such paralyses last from a few weeks to a year or more without treatment, but under proper care the time is materially reduced ; of course, where there is associated fracture which has not been properly managed, or unre- duced dislocation, it is impossible to fix any time, and the duration of a paralysis dependent upon callus is exceed- ingly rebellious and as a rule continues until some surgi- cal measures are adopted and the nerves are relieved of the pressure. Compression paralyses, especially those in- volving the muscles of the shoulder and upper arm, are generally curable in from a few months to a year, through the systematic employment of electricity. CHAPTER IX. FRAUD. " If falsehood had like truth," says Montaigne,' "but one face only, we should be upon better terms, for we then should take the contrary to be what the liar says for perfect truth; but the reverse of truth has a hundred thousand shapes, and a field indefinite, without bound or limit. The Pythagoreans made good to be certain and finite ; evil infinite and uncertain ; there are a thousand ways to miss the white, only one to hit it." The limits of false representation are unknown, and may vary from simple exaggeration of real symptoms to downright criminality ; from a form of deceit which co- quets with truth, in which ordinarily virtuous and honest people forget their every-day morality — to the well-laid and deep plans of professional malingerers and syndicates of rascals who concoct far-reaching plots to defraud cor- porations." Strange to say, the first-mentioned cases are ' Essays (Trans.), 1875, vol. i., chap. 9, p. 84. ' Bailey has described the operation of the notorious Freeman family, who mulcted several railroads in various parts of the country and who ob- tained considerable sums in settlement ; but the career of Doran is an illus- tration of how much further picturesque swindling may go in these days of competitive fraud. " The first of his series of operations was in April, igoo. He was riding on a car with a friend named Ritner. He fell off and gave his name to the conductor as Ritner, while Ritner became a witness under Doran's name. Then Ritner went to bed as the injured man and Doran went out to fall from another car. The company paid over j56o, but suspected a fraud and caused the arrest of Ritner, who was sent to prison for one year. In August of the same year Doran, in company with a man named Myers, did the same 280 FRAUD. 281 the most difficult to deal with, for the patients find no trouble in engaging the services of sympathetic doctors and lawyers of the highest standing; and the ordinary effort of the railway company to protect itself is looked upon as a little less than cruelty. • When the time for trial comes the patient is brought into court upon a litter, surrounded by flowers and at- tended by an entourage of silly people. It has been the writer's privilege to meet with many of these cases, and it does not appear that the deception is always deliberate ; but the story of suffering is apt to vary with every fresh suggestion, it being difficult to draw the line between truth and falsehood. It is often easy to find that when not under observation, they are enjoying the ordinary pleasures of life. The literary lady, who has had a harm- thing, taking Myers' name and securing %\o from the company. In October following, Doran persuaded his wife to throw herself from a car at a corner where Doran and two friends were prepared to become witnesses. The woman was arrested, but the case was not pressed. A few days later, riding with a man known as Mutschler, he again jumped from a car and. got ^10. This time Mrs. Doran, smarting from her ill-treatment, ' peached ' on Mut- schler, who was convicted and sent away for a year. On November 29th, with a man named Duffy as a witness, Doran stepped in front of a car, using Duffy's name, and got $15. Three days later he did the same trick with his brother, Bernard S. Doran, as a witness. Bernard was arrested and got nine months; Doran himself got %\o. Again, on December 12th, with Charles Brit, Doran got|S5. Ritner left jail in December, 1901, and pressing him into service again, Doran used his name and tried to bunt a car off Ger- mantown Avenue. The case was settled for $5. Then a woman known as Mrs. Brodie stepped in front of a repair car and sued the company for ;?30,ooo. We suspected her and she fled to Union Hill, N. J., where she was arrested. She received a five-year sentence. In each of these cases — and there were dozens I have not mentioned — Doran, after performing the acrobatic part of the task, assumed the name of his ' pal,' while the ' pal ' went to bed as the injured person. This served two ends^ — Doran, as a wit- ness, escaped arrest each time, and as a professional contortionist he was able to get out the next day and fall from another car, to keep the wolf from the door. No amateur could possibly have undergone the pounding he stood for two years." — New York Sun, October 6th, 1902. 282 RAILWAY AND OTHER ACCIDENTS. less fall, and whose pelvic contents in consequence are hopelessly " dislocated," and whose spine is permanently " concussed," receives the examiner in all the theatrical regalia of invalidism, indulging in tears and other appeals to his sympathy, and after the visit dresses herself, and goes to teas and the opera, or spends long hours with the dressmaker. In other walks of life the neurasthenic and " paralyzed " shop girl leaves her bed to wash clothes or go to the picnic. The long paralyzed hand of the plain- tiff and its fellow are horny, and bear the traces of recent dirt, and work interrupted only by the doctor's visit. It is needless to refer to such transparent cases as these, which one sees frequently, except to show moral obliquity. An instance which I witnessed, and which has since been reported by Godkin, is that of an apparently helpless man, who with great difficulty took the witness chair, and after testifying to the absolutely paralyzed condition of his right arm, was quietly asked by the defendant's coun- sel how high he could raise his hand before the accident, and without a moment's hesitation he thrust it high above his head. The same thing occurred in a case against the Forty-second Street and Manhattanville and St. Nicholas Avenue Railroad Company. The plaintiff, who received a verdict of 1^5,000 for a collection of vague symptoms and alleged injuries and who in the court-room w^as the picture of helplessness, made a violent and appar- ently muscular demonstration of joy when the jury an- nounced her good fortune. There are other cases that are far more subtle because of a mixture of reality and pretence, and it behooves the investigator to exercise the greatest care so that no injustice be done. Some of these patients are honest enough at first, but FRAUD. 283 undergo a moral degeneration that often ultimately leads them to disregard the truth. There is then a limited re- sponsibility, for the lies as a rule are not deliberate, and often spring from an actual belief in the reality of the morbid condition. The ego or organic memory is at these times so deranged that there is resulting feebleness of judgment, betokening a state which is neither hysteria nor downright malingering. It has been recommended that the cases in which litigation is a feature should be isolated and watched in a hospital. Against this may be urged the probable bad influence of association with the invalids by whom the subject may be surrounded, and it is there- fore better to watch such patients without their knowl- edge, to interview disinterested friends and neighbors, and to receive the plaintiff's statements with caution, bearing in mind his possibly altered psychical state. The importance of rigidly investigating the antecedents of the alleged neurasthenic cannot be too strongly urged, for not only must the existence of the inherited predisposi- tion be appreciated, but a possibly vicious mode of life, which naturally he will do his best to conceal, may ac- count for all the symptoms, and sometimes an alcoholic neuritis will be ascribed to a trauma. Such an example was that of a man who claimed that a long list of symptoms of apparent organic disease was due to a head injury, and by the merest accident his name was found upon the books of a hospital, showing that he had been a frequent inmate of the alcoholic ward, and had subsequently been treated for the identical symptoms which were alleged to be traumatic. In the absence of such knowledge and as the defendant had been denied a personal examination, it would have been difficult to have 284 RAILWAY AND OTHER ACCIDENTS. gone into court with any good defence, or to have con- tradicted the plaintiff. It may not be necessary even to show that vicious provocative causes were exerted imme- diately before the receipt of the alleged injuries, for a continual and remote indulgence in drink, even if it were unrecognized by most of the particular community, is sometimes sufificient to cause an ultimate breakdown be- neath a shock which any ordinary healthy man could stand. Perfectly legitimate brain work, if exercised under certain circumstances, will do the same thing. In neuras- thenics past middle life who claim that their condition is due to or has followed an accident, it is quite possible that these things enter into the case, as well as past de- bilitating diseases. The excessive use of tobacco continued over a number of years is often at the root of neurasthenia, which is pro- found and intractable, and numerous cases of nicotinism undoubtedly exist that may be taken for more serious affections. All the motor weakness, ocular symptoms,, insomnia, and hypochondriasis of neurasthenics may be due to this agent. The railroad company should be as careful as that which insures lives, in the matter of medi- cal investigation, as well as the collection of information regarding the previous mode of life of the plaintiff, for there is every bit as much reason for caution. Since the introduction of electricity into street-car propulsion, a number of persons have brought suit against corporations for alleged injuries. The burning and shock- ing of some of them have formed the basis of bonafide actions and material claims; a large number of others, however, have been tried, and the exhibition of an im- mense amount of ignorance in regard to the nature of FRAUD. 28s electricity and its effects upon the human body has been shown. Sometimes the claimant ascribes the alleged state of ill-health to poisoning from the fumes of the storage battery in the car in which he had ridden for a short time, or his "shock" has been received from a current of such low voltage that it would hardly kill a fly. One dishon- est woman whom I saw had been hurled twenty feet, "by stepping on an insulated wire." She claimed to have re- ceived a burn, but a small spot of chronic eczema was all that was found. The following newspaper account of an occurrence of this kind is an example of these absurd and impossible claims : "It is not often that such a concise description of the torments of a severe electric shock is given. This narra- tive supplied to the Journal by Mrs. X. proves that the trolley car is versatile in the infliction of pain. Mrs. X. is still an invalid, although it is a week since contact with a defective car heater threw her into paroxysms of agony unlike anything she had ever imagined. The most strik- ing visible trace of her adventure is a patch of gray hair over her right temple. It produces a startling effect, this patch of gray among the bronze, and is the more remark- able as the face beneath it is young and comely. ' Yes,' said Mrs. X., seeing that the eyes of her visitor were attracted by this singularity, ' that is one of the results of my experience in the trolley car. Is it not strange and distressing.? And it only happened last night. I was quite startled this morning when I saw the change. It was there on my temple, that I felt and feel yet one of the most violent of the many symptoms produced by the electricity. There is nothing I can compare it to except a heavy hammer, hammer, hammer here on my temple.' 286 RAILWAY AND OTHER ACCIDENTS. " She was resting at her home at muffled in shawls. It is a beautiful home, commanding a view of the mountains and surrounded by lawns and flower beds. Her face was pale and showed traces of pain. ' I had been making some calls,' she continued, having been asked to tell her story from the beginning. 'A car of the traction company's line stopped for me at a street corner, and I entered it with the intention of returning home. As it happened, there was a vacant seat over one of the heaters which are placed under the benches. There is a metal register projecting several inches from the heater. I can't tell you exactly why it happened. But when I sat down this register came in contact with my leg. That was when the shock came. Describe it ! oh dear ! I can feel it now. It has been returning to me ever since. Why, it was a complication of sensations. I remember distinctly doubling up. My chin and my knees were pulled together by a swift and irresistible force. It seemed to me that my bones had melted. That's the only way I can convey it -my bones had melted, and my interior was quivering,' etc., etc." It is probable in this case that the unfortunate lady had accidentally come in contact with a hot rheostat, but it was certainly doubtful if she underwent these extraordi- nary contortions at all unless the circuit was completed by her body, and then she would undoubtedly have not been here to give the interview to the reporters. The fear of electricity probably causes the susceptible individual to magnify ordinary accidents and to invest trivial injuries with a new and undeserved importance. Knapp, Bailey, Dana, and others have recognized the form of hystero- neurasthenia, due to electric accidents, which is so com- FRAUD. 287 mon of late, and numerous cases are recorded of persistent states of agitation after fright, while the sight of an electri- cal accident has been known to upset a neurotic subject (vide p. 258). Real injury is rare, strange to say, and more people are hurt by broken glass and splintered wood than by the receipt of discharges of electricity. Of course the element of fright enters here as it does in ordinary railway cases, and perhaps to a greater degree. The newspaper account of another case is highly characteristic of the state expressed by evanescent paralysis and vague ner- vous symptoms : " Mrs. X., who was taken to Bellevue Hospital Monday evening suffering from the effects of an electric shock received while riding on a car, was dis- charged yesterday. The effect of the shock was unusual, according to the hospital physicians. Mrs. X. was sup- posed to have received it by stepping on the iron slot at the car door, which had become charged in some way. The direct result was paralysis of the right side of her body and incidental hysteria, although no burns or dis- colorations were apparent. The paralysis passed away during the night, and the only development yesterday morning was a slight tingling sensation in the left leg. Yesterday afternoon Mrs. X. was taken home." An example of malingering which is conventional may be cited. It is of interest because attempts at fraud were made by the dishonest claimant or his friends. Case LX. — A man of 55, of prematurely aged appearance, fell into a coal hole in September, 1 898. He states that he fell over, striking the left side of his head, and as a result he imme- diately became unconscious and was removed to his house in a carriage. Up to the present time (August 13th, 1899) he has been helpless and bedridden, declaring that he cannot move his legs, much less walk, that he has been deaf, and that he hears two 288 RAILWAY AND OTHER ACCIDENTS. different noises constantly, one of high pitch and the other deep ; that this ringing followed with the deafness immediately after the accident, "but that his hearing is better downstairs than up." He says that his head is drawn to the right side, and that he can- not turn it ; that he cannot use his arms in any way, and his as- sumed position and apparently complete disability would suggest this. At times he passes his feces in bed, and says that it is im- possible for him to hold his water. I carefully examined the man, bringing out the following points in his history : That there was no escape of blood from his ears, eyes, or mouth, or any sign of fracture of the skull ; and that his unconsciousness could not have been serious, for when he forgot himself and became interested, he minutely detailed the happenings at the time, when he was able to take a lantern and search for his watch and package of "lunch" which he had lost when he fell. He also referred to the anxiety and behavior of his wife and daughter, who were with him. He now presents no scars, his pupils are even and react prop- erly, and there is no affection of vision. His tongue is protruded in a straight line, his heart and circulation seem to be normal, and there is little or no appearance of bodily change. With some little urging he was able to get out of bed and walk awkwardly, the toes being turned in, and though there was apparent stiffness there was nothing, however, suggestive of spastic paralysis. This changed decidedly before the termination of my visit, which lasted about an hour, and he used his feet and legs freely. With the right hand, which he said was " more paralyzed than the other," he was able to point out the places upon his head where he said he had been struck. The response to both electric currents was excellent. There was no anesthesia. When I saw him a few days afterward by appointment I found him in bed looking anx- ious and worried, and complaining bitterly of his helplessness. With some ostentation he referred to the condition of his bladder, and when I pulled down the clothes found that there was a large piece of cotton cloth, several yards square, completely saturated with urine, which he said had been placed there dry but an hour before. The quantity was so excessive that I felt sure that he was trying to impose upon me, and at the end of my visit I took a piece away, and later subjected the fluid to a rough analysis, which showed that it was not urine but simply water. Although he FRA UD. 289 claimed this condition was constant, I found nothing of the kind at my previous visit, and there was none of the odor which is as a rule found when there is continued incontinence. He admitted that he could hear a little with the right ear, but that he was ab- solutely deaf in the left. The ends of two rubber tubes, con- nected with the phonendoscope, were introduced into the meatus of each ear. When it was found that, after compression and clos- ure of the soft-rubber tube that went to the left was made with- out his knowledge, he declared that he heard a question asked him, it was obvious that there was no trouble with his pretended deaf ear. This man, of course, received nothing, and shortly afterward went about his business apparently well. Page, whose extensive experience as an examining physician for one of the greatest Enghsh railroads entitles his vievi^s to great respect, has published over two hundred cases of alleged railroad injury. Of these thirty-two were frauds or cases of wilful exaggeration, twenty-one substi- tution cases in which there was a history of gout, phthisis, chronic epilepsy, or alcoholism, "female diseases," or con- ditions of previous ill-health ; six women alleged that the nervous symptoms of the menopause were due to injury, three had been in previous accidents, seven were the sub- jects of fright or suggestion, and one case of glycosuria was attributed to an accident, but was shown to be of pre- vious origin, and in another an old syphiHs was made to do duty ; in one case in which insanity was claimed to be the result of an accident, it was proved to have antedated it. In forty-four there is a history of " no exaggeration," or the patient made a moderate claim ; of the above cases, therefore, it will be seen that at least in two-fifths there was a suspicion of fraud. 19 290 RAILWAY AND OTHER ACCIDENTS. SUBSTITUTED DISEASE. Dishonest litigants, either through their own cunning, or with the help of others, are apt to make old injuries or the symptoms of previously existing disease do duty in the presentation of suits against corporations, and while such attempts are as a rule made knowingly, it happens from time to time that the patient connects with the acci- dent certain conditions that have long existed and of which he has been unaware. Sometimes a trivial injury followed by simple subjec- tive symptoms causes him to seek a physician whose knowledge of his profession is rudimentary, and who is so careless as to overlook the already existing disease, and ignorantly to ascribe the symptoms to the new violence ; or, on the other hand, he may be so disreputable as to seize upon anything he can find to bolster up and strengthen his client's case. The term " substitution of origin " has been applied to this kind of cases, and the duty of the defendant's physi- cian is to ferret old symptoms out if possible, and be on the alert for evidences of inconsistency ; in fact, in the determination of the amount of injury, should such exist, the doctor should always pay the closest attention to the chronological development of the alleged symptoms, and to the previous history of the litigant. Under some cir- cumstances it may be found that he has brought other suits, and has received substantial damages for conditions which are again brought forward. Case LXI. — A recent case illustrating the failure to secure compensation for a real injury by a dishonest plaintiff who resorted to unnecessary perjury on the witness-stand to strengthen his plea. FRAUD. 291 is that of McFadden versus 'the MetropoUtan Street Railway Company, and as a result his counsel threw up his case. McFad- den was seriously injured by a car which ran into a truck he was driving, and in consequence there was an undoubted central spinal hemorrhage. When examined by Dr. Hirsch and myself, we found evidences of a laceration of the gray substance of the upper lumbar cord, loss of bladder and rectal reflexes, atrophy of the glutei with reaction of degeneration, and a disassociated saddle anesthesia, the tactile sense being unaffected. In this accident, which was in August, 1901, his coccyx was also fractured and sub- sequently removed, the scar of the operation being found. At a higher point was a longitudinal scar as well-as other evidences of an old injury, there being no suture marks, however, and he swore positively that he had never been in a hospital. Thanks to the skill of the detectives of the company, it was disclosed that ten years before the first accident he had fallen from a loft and was taken to the Post-Graduate Hospital and a laminectomy performed by Dr. Powell. Though the cord was not crushed at this time, there were an irritative lesion, paraplegia, and incontinence, from which he recovered ; and for a long time he had been doing hard work driving a truck, and his wife had borne him two children, both of whom were under six years of age Had it not been for his per- jury and attempted concealment of his early accident, he would undoubtedly have received a substantial verdict. The case of Kelly vs. the Metropolitan Street Rail- road may be also referred to in this connection : Case LXH. — W. K •, 44 years, laborer, who in 1885 had received a fracture of the skull, from which he had recovered, subsequently developed a striking and characteristic train of hys- terical symptoms, and for many years was shown at several clinics and lectured upon. On April 8th, 1901, he claimed to have been injured in an accident, and sued the corporation, the case coming up for trial December 4th, 1902. He had been seen by a number of competent physicians, whp testified that when he entered the nospital April 15th, 1901, they found the signs of the old fracture, which the plaintiff had the effrontery to say was recent. It was ascertained that the patient's father had died of Bright's disease and his mother of brain tumor, 292 RAILWAY AND OTHER ACCIDENTS. that there was no history of venereal disease, but that he had drunk for a long time to excess. The original fracture involved the upper portion of the right parietal bone, and in January, 1 886, three months after the first accident, he suffered from double vis- ion, difficulty in reading print, constant ischuria, tingling in the throat, unsteady gait, and a general tremor. There were left hemianesthesia, dysphonia, exaggerated re- flexes, and convulsive movements. The latter would occur un- expectedly when the trunk and legs would become the seat of spasm, the shoulder and neck being twisted to the left; and during this seizure he emitted a peculiar hissing noise. At one time his left arm was paralyzed and contractured. All of those who saw him, including Dr. Nammack, the visiting physician to Bellevue, emphasized the violence of the agitation, which they spoke of as a " tremendous " intention tremor. It certainly was the feature of the case. This man's condition had lasted seven- teen years, and yet he had suffered no apparent impairment of his general health. He was well nourished, the temperature and pulse were normal, and he was rational; although, according to Dr. Hammond, somewhat dull in comprehension. It would ap- pear that there had been some moral decadence, for his conduct was such that his family could not live with him, and his latest attempt at imposture in seeking to obtain damages for a condition due to a previous accident many years before confirms this. The experience of many years is full of absurd cases of substitution, not the least ridiculous of v^^hich was that of a man who sued for an alleged injury of the face, alleg- ing that an enormous nose, which was the seat of the rather rare affection known as rhinoscleroma, was an evidence of injury inflicted by the defendant a few months before, when in reality it was of syphilitic origin. Many examples occur to the writer in which contract- ures and deformities existed that were so patent that there is every reason to suppose that no one could be deceived : Case LXIII. — Within a year or two in Brooklyn, a case was tried in which a carefully prepared diagnosis of amyotrophic lateral FRA UD. 293 sclerosis was made by a neurologist of experience, who testified that the spastic contractures of both knee-joints were the result of a degeneration of the spinal cord, and a prognosis was given that seemed reasonable enough that the man would never recover. Before the end of the trial, however, it was shown that he had in Russia, before his emigration to this country, inflicted bilateral wounds upon himself with a shoemaker's knife to escape military service, and the resulting deformity (due to severance of the ham- string muscles) had preceded the accident for many years. A substitution case, exposed by Mr. Carriere, the quick- witted counsel of the Fidehty and Casualty Company, was that of a boy who claimed that a talipes equiims had been produced by an accident. When he was forced to remove the other shoe, it was found that the same defor- mity existed to a lesser degree, and in both extremities was due to an old poliomyelitis. Another case was that in which the characteristic deformity of the hand so often found arnong shoemakers was ascribed to spinal injury. Case LXIV. — A case of some interest in which the writer ap- peared was tried in one of the branches of the Supreme Court of this city several years ago. The allegation was made that the patient had sustained a serious spinal injury in the year 1895, hav- ing been knocked down by a horse attached to one of the defend- ant's cars and thrown beneath the platform. When the car was stopped he was removed and carried to a neighboring bar-room. He was found to be unable to walk or help himself ; was not able to dress or undress, and the upper extremities were the seat of tremor and without power. He subsequently was able to go to work as a nickel-plater, which had formerly been his trade. The testimony of his phy- sician was that he saw him in February, 1895, and found a cut and bruises about the knee on the front of the left leg; that he put the patient to bed, who was so helpless and shaken he could not stand on his right foot, which, however, was the one that was not injured. (Thedoctor made no electrical or other tests.) The sub- ject presented disturbances of co-ordination, being unable to stand 294 RAILWAY AND OTHER ACCIDENTS. with his feet together; the knee reflexes were both exaggerated, and the functions of the bowels and bladder unimpaired. A dis- tinct spinal kyphosis was ascribed to the accident, and alleged to be due to vertebral disease that had developed since. It transpired that the patient had had cerebro-spinal meningitis in 1 894, with a temperature of 104° to 105° F., retraction of the head, and coma. He was ill in bed three months and slowly recovered, and that after his recovery, many months before the accident, there was weakness of both upper extremities so that he was unable to bur- nish, as he was required in the exercise of his trade, and was forced to abandon his work. It also transpired that the spinal deformity was of early origin, developing after Pott's disease in childhood, and of course had nothing to do whatever with his present con- dition. Case LXV. — B. F , a healthy appearing man of about 60, sued a street railroad, alleging that before alighting from one of the defendant's cars it started and he was thrown against the curb. This was in December, 1899. When seen by the writer, two years later, there was an ankylosis of the right knee, and he walked with a cane. With this there was slight tremor of both hands, which was not pathological. He said that the day after the accident a lump appeared in the perineum," which looked like an abscess," but disappeared in two months There were imme- diate numbness of the left lower extremity, more on the outer surface, prompt incontinence of feces, and prolapse of the rec- tum. He was greatly shocked. In 1901 "his legs were so weak that he had to watch and place his feet " ; no paralysis or atrophy was found, and no true affection of sensibility, yet he complained of " pains every minute." He walked better at times than others, especially when absorbed in his story, or when his attention was diverted. There was no evidence of relaxation of the sphincter ani, nor local anesthesia of the gut. In this connection he said : " When my bowels are very loose I don't feel the paralysis." And at another time : " I cannot walk because no volitional action takes place, because my foot does not convey the sensation of touch of the ground to my brain. When I walk more than a block, pain starts from my heel and is transmitted to my brain." In fact his replies were largely indicative of coaching and suggestion. The only ob- jective appearance was the stiffness of the right knee-joint, which FRAUD. 295 impressed me at once as being due to an old injury, and it turned out that in 1856 he had had a fall of forty-two feet (?) in a build- ing, and struck on both feet, losing the use of his right lower extremity, and there evidently had been some ulceration of the cartilage and local inflammation. This man, when not under ob- servation, presented no indications of injury, except a slight limp, and his case was settled for a small amount. Plaintiffs are often prone to claim that the symptoms of long-existing general disease are due to accident, and diabetes is one of these. Case LXVI. — The details of the case of an elderly man, who was seen by the writer, and who obtained an enormous verdict recently, is about as glaring an example of fraud as can be found. The plaintiff, a man of advanced years, claimed to have been thrown down and injured by one of the defendant's cars, and that in consequence the original "shock symptoms" developed in addition to diabetes ; and it appears that when he was taken to the hospital, sugar and casts were found in his urine. Shortly before the trial it was ascertained that several years previously he had been in rather a serious railroad collision in another State, and had sustained grave injuries with traumatic neurasthenia; and at the time examinations of the urine had disclosed evidences of long- standing renal disease, which were unmistakable. His appearances upon the witness stand and in court, where he could be closely observed, were very suggestive that he had for a long time suf- fered from the disease, and there was little doubt in the minds of the experts that it had antedated the first accident, many of the symptoms of which were mustered up and made to do duty again by his disreputable lawyer. It seems almost impossible that a disease characterized by so pronounced a deformity as a goitre would be un- recognized by those who coach a litigant, yet the fol- lowing case is one in which a claim was made that the cardiac symptoms of Graves' disease were not connected with the thyroidal affection, but were ascribed to the in- 296 RAILWAY AND OTHER ACCIDENTS. jury itself, and the plaintiff's claim was reinforced by other fraudulent misrepresentations. Case LXVII. — R. F , a woman, aged 36, claimed to have been thrown from a street car, falUng upon her back, in the year 1893. She was 36 years old, married eighteen years, and had six children, the youngest of which was ten weeks old. The immedi- ate consequences of the accident were not serious, but when taken home she had a profuse hemorrhage from the uterus, and was curetted by her doctor. She complained of coccygeal pain, and an examination revealed an old fracture with filamentous union. She did not claim to have struck the end of her spine. She said she had pain over the liver and region of the gall bladder, and contusions about the hip, continued headaches, pressure upon top of the head, dizziness and palpitation, impairment of sight, and saw "mixed colors." If she bent over she could not get up without pain in the back, many parts of the body were numb, and she could not sit in the regular way. Her doctor said that the uterus was painful to the touch, and there was some endometritis. Connection with husband caused great distress. She could not walk but a few blocks without getting tired, or climb stairs with- out shortness of breath and fatigue. There had been an alleged loss of memory, which did not appear to be genuine. She " could not hold Water, but it dribbled from her and was red." An ex- amination by the writer shortly after showed that she was rather pale, anemic, and badly nourished. The face was puffy and the eyeballs were prominent, more particularly the right ; the pupils were dilated. Ophthalmoscopic examination revealed a congested condition of the retinal vessels. According to her physician she was "hypermetropic before the accident, but now myopic." The body was fairly nourished so far as muscular development was concerned, but the skin was generally pale. There was an old well-marked asymmetrical goitre; the pulsation transmitted strongly when pressure was made ; there was a venous thrill over the jugulars; the pulse was 120 and intermittent; the hands were cold and rough, and showed evidences of constant daily use and more or less hard labor, though she claimed she did nothing. Pressure tests showed then that the vague pains were subjective; rectal examination revealed an old fracture of the tip of coccyx ; there was no appearance or suggestion of inability to hold water. FRA UD. 297 no odor or wetting ; the electrical reactions were good, and vague dysesthesia was present. There was a light tremor, particularly of the hands (about nine per second) ; this was continuous and observed throughout the examination. The tremor was alleged to have appeared after the thyroid development, which was im- probable, as it is an early symptom of Graves' disease. In this case the goitre, which was easily noticed, had not attracted the attention of her physician or herself, and certainly antedated the accident. SIMULATION. It is almost unnecessary to say more about the fre- quency of this particular kind of fraud, except to enumer- ate various prominent symptoms that may be counterfeited with more or less success by dishonest litigants. Besides the list of vague subjective complaints which bear a family resemblance, but do not stand the test of even the most perfunctory examination, there are others which are more or less ingeniously presented by those whose success de- pends upon the aid given them by designing persons, or upon the sharpness of the impostor himself. It may be said, however, that a very intelligent person who tries to sham is often apt to make deplorable and inexcusable blunders, thus fulfilling the lesson of the familiar maxim in regard to a little knowledge. Most physicians are able to recognize the incongruous associations of symptoms, and the errors made in regard to the mode and time of development of real expressions of disease, but it is neces- sary as well to fix their intrinsic genuineness by proper test. Motor Symptoms. Paralysis^ Contractures, Spasms, Tremor, the Reflexes. — With real paralysis there are consistent concomitants of which the simulator is usually unaware. Besides the 298 RAILWAY AND OTHER ACCIDENTS. want of power we find in genuine paralysis vasomotor disturbance expressed in changes of color, and coldness of the surface and, perhaps, atrophy with contracture and reflex diminution or exaggeration, and alteration of the electrical reactions. If the simulator be watched, it will be found that there is an apparent variation in his loss of power, and if he is told to make some movement with the limb that he admits is not absolutely " without life," there will be an utter absence of any volitional effort whatever, and he may sometimes go so far as to refrain from moving the sound limbs. Certain forms are quite beyond his reach; among these are the paralysis of the ocular muscles and of the face. Not only would an attempt to simulate these meet with failure from their very characteristics, but it would be impossible to keep up a sustained effort for any great length of time. The association of a corresponding expression of weak- ness with the characteristic attitude for any prolonged period is also difficult. It must not be forgotten that a person who may feign many other symptoms with some degree of success may quite readily present the fine tre- mor which belongs to functional nervous excitement, as an evidence of his anxiety, and it may be genuine enough. These persons as a rule perform actions in which the paralyzed muscles participate, and when off their guard will forget about their pretended disability. An appar- ently helpless old woman, to show her scars, will get out of bed with agility, using her paralyzed arm and hand perhaps to help herself ; or the male suspect, after an ex- amination, will pull on his drawers or put on his coat with no apparent effort. It has been the writer's experience FRA UD. 299 that paraplegia, or a paralysis of one lower extremity, is most often feigned, and that hemiplegia, being more diffi- cult, is not imitated so often. When it is, there are often suspicious evidences of deception ; the limbs in all forms of paralysis rarely appear flaccid, but are held by the patient in the position in which they were placed by the physician and are sornetimes kept rigidly extended by the malingerer instead of falling to the ground. In hemiplegia there is the ordinary circumduction of the paralyzed leg and foot and the dropping of the toes, and the anesthesia with loss of motor power is a consistent evidence of the genuine condition which is rarely copied by the impostor. Knapp has- also suggested that the sole of the shoe is not worn at its inner and anterior part, as it in real hemiplegia that has lasted. Care should be taken to recognize the hysterical element where no actual deceit is intended ; the anesthesia in such cases has peculiarities of its own to which reference has been made in another chapter. It is not likely, even if the simulator knew them he would pretend to have them, preferring to copy a more serious paralysis. As nearly all cerebral hemiplegia is preceded by some antecedent symptoms, and if it be right-sided probably by aphasia, a case presenting itself in which there are no premonitory or initial expressions of disease of the brain is extremely improbable. To be consistent there should be facial paralysis and deviation of tongue, and the paraly- sis itself should be on the side opposite the head injury. The detection of feigned disease of course requires that the mind should be free from any bias or feeling of sym- pathy or pity, and the apparent circumstances of the sub- ject should have no influence whatever. 300 RAILWAY AND OTHER ACCIDENTS. Case LXVIII. — A case which illustrates this occurred to the writer early in his professional experience ; where mistaken sym- pathy for a man, who was apparently seriously wounded, led to un- due carelessness. The patient was brought to the hospital in a helpless condition. He had received a bullet wound in the back while engaged in a burglary, and upon his admission apparently could neither move his legs nor feel the point of a pin. The bullet had entered near the sixth dorsal vertebra upon one side, but could not be found. While under observation there were no vesical or rectal symptoms, and he had no erections. After a stay of several weeks there was no pathological atrophy, and the electric reac- tions were good. Numerous consultations were held at his bed- side, which he listened to, and he seemingly took a great interest in his case. He was finally carefully removed upon a stretcher to the jail, to be cared for by the physician of that building; and when he left us he apparently still could not move his legs. The night after his departure, however, he broke out of his cell, scaled a wall, dropped to the ground, and found his way to parts unknown. In this case there was every reasonable ground to believe the pa- tient's case was a serious one, though the absence of some symp- toms was suspicious and should have put us on our guard. An alleged incontinence is occasionally claimed by litigants and, as a rule, this may be easily detected. The insufficiency of the anus and the atonic state of the lov^fer bowel may be easily recognized by passing the finger into the gut, when the contractile power of the sphincter will be found to be impaired or lost, or that the parts will be anesthetic, a condition of affairs which cannot be shammed by the impostor. The latter may sometimes voluntarily pass well-formed feces in the presence of the examiner, meanwhile making a great parade of his alleged weakness. Incontinence of urine upon the part of the simulator is often also voluntary, as has been .shown on another page (Case LX.). The sub- ject of real incontinence will not only give forth the am- FRAUD. 301 moniacal odor which often depends upon the escape of residual urine, or that which decomposes in contact with the clothing, but there will usually be found some red- ness of the skin, or other evidences of irritative action. A popular test which is generally recommended in sus- pected cases is carefully to dry the meatus with absor- bent cotton after the patient has emptied his bladder, and then attentively to watch the locality; and should dribbling occur it is probably due to a genuine inconti- nence. The simulation of contracture seems to be more or less general among malingerers, but here too it lacks the characteristics of true disease, and the subject is apt to assume positions which could have no reasonable pathological explanation. It is usually connected with some assumed paralysis, and is always more extreme under observation, and if caught off his guard the patient is quite likely to resume his ordinary position. Organic contracture due to descending neuritis is associated with increased reflexes and shortening, which, of course, can- not be assumed, and in genuine cases such contractures do not disappear when the person is rendered uncon- scious, for they are usually dependent upon actual struct- ural alterations. It is also impossible to feign the con- tracture of peripheral paralysis, for in the latter the reaction of degeneration will be found. Temporary voluntary distortion of the extremities, usually with some form of hyperextension, may be of feigned origin. Case LXIX. — The case of Kennedy vs. The Metropolitan Street Railway is of such interest in showing feigned contracture and paralysis, as well as other alleged symptoms, that it may be quoted at some length. 302 RAIL WAV AND OTHER ACCIDENTS. The plaintiff had been thrown from a cross-town car by a col- lision with a car of the defendant's line at Fourteenth Street and Broadway, April 24th, 1896, and was picked up unconscious and taken to the New York Hospital, where he remained two days, and was then removed to his home in Jersey City. He first noticed a loss of power at the h-ospital : " falling back when he attempted to rise from his bed." He was not aware of the period of unconsciousness, but remembered being examined by the sur- geon and being removed to Ward K. He stated at other times that his paralysis commenced in the carriage, on his return to Jersey City, and afterward that it was not until he reached home that there was loss of power. His physician stated that he treated the plaintiff from April 26th last to the present time, and had seen him frequently. He had found marks of injury, that the patient had pain, and on the 26th became paralyzed on the left side, with no loss of conscious- ness. He also stated that the patient had subsequent nose-bleed- ing and convulsions, the latter being confined to the right side of the body, and not involving the left arm or leg. The man, ac- cording to the doctor, had subsequent fits, always preceded by nose-bleeding. The left leg had improved somewhat since the accident, but not the arm. When I went to his lawyer's office to examine him, he was notified, and entered the room, moving with apparent difficulty, and holding his left leg stiffiy. The gait in no respect resembled that of hemiplegia, there being no loose motion of the lower ex- tremity and no dropping of the toes. The left upper extremity was likewise apparently affected and rigidly fixed. I noticed once during the interview that the whole upper ex- tremity was rotated so that the thumb was backward and the palm was outward ; but, as a rule, the palm was pressed tightly against the thigh; there were no unequal contractures, no extension of the foot or flexion of the forearm or of the fingers, which belong to true paralysis, but that all the muscles of the leg, thigh, fore- arm, and arm were apparently equally contracted, and I judged such contraction was purely voluntary. He manifested a great deal of strength upon the right side ; but when told to make an effort with the left, there was apparently not the slightest attempt upon his part to do so, for when the arm and forearm were grasped there was no muscular action whatever, though the muscles them- FRA UD. 303, selves were of good volume and apparently of normal size, and there appeared to be no evidence that they were not continually exercised. I was impressed with the strong contraction of the adductors of the arm, such an exercise of force, in my experience, being unknown in any form of paralysis ; but upon one occasion during the interview this was remitted, showing that it was not permanent. The knee-jerks and wrist reflexes were not exag- gerated, as they would be in degeneration and contracture. Examination of the head disclosed no scars, no depression of skull, or external injuries. The face was flushed, and the ears were equally warm to the touch. There was no facial paralysis, the buccal line being straight ; the pupils of both eyes were s}'m- metrically dilated and acted well to light. Examination with ophthalmoscope revealed no changes indicative of disease, and the tongue was protruded in a straight line and did not tremble. No marks of old epileptic scars were found on the tongue or elsewhere ; the color of the skin of the alleged paralyzed arm was healthy, and the temperature of both hands was apparently equal and not lowered. His pulse was rapid and beat 140 a minute, cir- cumstances which I attributed to his excitement. He was demonstrative and courted painful tests, inviting me to apply the battery or run pointed instruments into his body. One other complaint was that he was without feeling upon the left side, and that the limit of insensibility, as fixed by him at my request, was determined by a line which ran from the shoulder down the left side and backward, corresponding below to a point indi- cated by the crest of the ilium. It was shown that during the time of his alleged helpless con- dition he went to a pool-room and played. That he marched with a target company, holding a gun with his "paralyzed " hand. During the trial I had the chance to observe his unconscious ac- tions ; and my diagnosis of malingering was confirmed by his limp- mg with one leg one day and the other the next, while on a third occasion he used all of his extremities in a perfectly natural way. The superficial and deep reflexes, being involuntary phenomena, are beyond the reach of the simulator, and although he cannot control them, he may, if posted, pre- tend to have exaggerated knee-jerks and kick sometimes 304 RAILWAY AND OTHER ACCIDENTS. before the blow is actually made upon the patella tendon. If he be blindfolded, however, he is not apprized of the impending blow, not knowing when it is to be made and therefore abandons his attempt. Bailey has called atten- tion to the fact that when the person sees that the test is to be made, an appreciable interval elapses between the receipt of the stroke and the movement he consciously m.akes which is due to the formation of the voluntary impulse. The subject may try to restrain the knee-jerk, but the voluntary contraction of the flexors is readily perceived when he makes the attempt. If the deep reflexes cannot be evoked and there is no evident effort made to suppress them, it can be taken for granted that (if it is not an ex- ceptional case in which they are naturally absent) the patient is not trying to impose upon the examiner. The superficial reflexes, so far as inactivity is concerned, are always beyond control. In cases of disease in which they should be absent, that is, where there is peripheral anes- thesia, there ought to be a consistent loss or, as Bailey says, " if they are not lost in places alleged to be anesthetic, it should excite suspicion of shamming." The ankle clonus cannot be simulated. Tremor cannot be feigned for any length of time with success, and always lacks the rhythm found in real disease. It is of course possible by the ap- plication of the finger tips or toes to an unyielding sur- face, or by the assumption of a strained position, to pro- duce a kind of tremor, but this stops when the strain is remitted. When manifested in traumatic cases it is a question whether it has not preceded the alleged acci- dent or is not a manifestation of advanced age, or possibly an habitual or family peculiarity ; perhaps, too, it may be FRA UD. 305 found in a person who drinks, and individuals of this sort are apt to press it into service in support of their claims. It is rare that paralysis agitans is feigned, and if so, it is difficult to see how the malingerer could at the same time feign the festination or successfully counterfeit the facial expression. Convulsions with or without loss of consciousness and like disturbances are not so commonly feigned as might be supposed. Sometimes the paroxysms of hysteria are so intimately associated with the states of mental perversion, and so easily induced as to lead to the suspicion of duplicity; but the general history of the case, if obtainable, favors the formation of a reliable estimate of the patient's responsibility. Fortunately in this country there are few of these sub- jects who apparently have convulsions to order, as in the French hospitals, and grave hysteria is rare. In both male and female subjects the attacks can be often aborted by making firm ovarian or testicular pressure, a method that may be adopted as well in ordinary malingering ; so the diagnosis should be easy. The true epileptic paroxysm, if at all severe, is expressed by a tonic and clonic stage of severe convulsion, tongue- biting, perhaps involuntary discharges from bladder or bowels, lividity of the surface, characteristic stertor, foam- ing at the mouth, insensitiveness of the pupils, and post- convulsive reflex loss. In some cases there are petechise. A significant feature of true epilepsy is that the paroxysms rarely occur in the presence of other people, and it is not usual for the physicians to see a patient in a convulsion unless at a large special epileptic hospital, or occasionally in a crowded street. The simulator, apparently, in the vernacular, is ever ready to " throw a fit " but takes good 20 306 RAILWAY AND OTHER ACCIDENTS. care not to injure himself. These impostors nowadays rarely put soap in the mouth to produce foam, and if they do, the deception can be readily detected. Old epi- leptics are apt to present certain marks of the long-stand- ing disease, such as the facial expression, the vasomotor changes, the existence of old tongue and scalp marks left after wounds produced in previous attacks, and some- times mental dulness as well as the stigmata of degenera- tion are present. In doubtful cases of paralysis or con- tracture, resort may be had to such anesthetics as nitrous oxide gas, or ether, which should be pushed only to the point of commencing mental confusion, when the simu- lator will, under such circumstances, be apt to use his arms and legs in a struggle to avoid their further ad- ministration, and perhaps walk, when for a long time he has carried on a successful deception. These agents are also useful in clearing up certain imitated forms of gait or pretended titubation, such as was adopted by the murderer Ennis, who was lately executed at Sing Sing, and in prison had simulated paresis. It is some- times difificult to judge accurately of the degree of alleged simple muscular weakness, and this is possible only through careful observation, or the use of the dynamome- ter which is to be used by the suspected person, who should be first blindfolded. Sensory Symptoms. Pain, Anesthesia. — The existence of real pain, which is the most common and oftenest feigned subjective com- plaint, is often determined with difificulty, for its reality and extent must depend in great measure upon the truth of the patient's statements. Our knowledge of the ordi- FRA UD. 307 nary manifestation and causation of this symptom, its association with other evidences of disease, and its effect upon the behavior of the individual is happily of use in estimating its reality and extent ; and it is at such a time when experience and common sense count. The pain of the malingerer is always more or less associated with some exaggeration of the emotions, and it may be easily diverted in some subjects by simple suggestion, to reap- pear in a new place. If seemingly constant and superfi- cial, it may not correspond to the distribution of well- known sensory nerve fibres, or with the location of some underlying organ. The facial expression is often not that which belongs to real suffering, and the physical condi- tion does not indicate strain or exhaustion. In this re- spect it resembles the fictitious insomnia which is so often claimed to exist and in no way impairs the subject's vi- tality or physical condition. In this connection reference may be made to the so- called Mannkopff test, which is more or less reliable in those cases in which severe localized pain is alleged. The success of this test depends upon the fact that if pressure is made upon a definite tender point it will cause an acceleration of the pulse of from fifteen to twenty beats. Care should be taken to make the test without the patient's knowledge, or else the incidental nervous trepi- dation will excite him and cause an ordinary emotional quickening. At best it cannot be regarded as an infalli- ble test in every case. Aneslkesia.—T\\Q malingerer, especially if he be coached, can feign a loss of tactile or pain sensibility, but is usually unable to sham thermic anesthesia. Through training, or because of an attribute of low organization. 3o8 RAILWAY AND OTHER ACCIDENTS. certain individuals may undergo a great deal of torture without any apparent suffering. During the trial of the Bolte case, the writer sent for a professional known as the " Human Pin Cushion," who would allow needles and other sharp things to be thrust through his skin, or who would stand the strongest application of the induced current without evident discomfort, and he afterward heard of numerous imitators of this person who could be engaged for a reasonable consideration. In this connection attention is again called to the auto- suggested anesthesia which may be induced in those who have religious or other ends in view. The simulation of anesthesia is difficult because if there be no actual condi- tion of insensitiveness the subject is unable accurately to respond to repeated tests and give consistent answers. If, for example, the surface of the trunk is chosen, the limitation of the alleged loss of sensation may be found and marked by a pencil of one color, a line being drawn at the point where feeling is said to disappear abruptly. At the next and succeeding trials different colored pen- cils are used, and at the end it will be found that the lines of limitation will be found to vary. The subject should, of course, be blindfolded through all this. Sudden sur- prises by means of unexpected pin pricks, electrical appli- cations, and the dashing of hot and cold water on the surface will sometimes cause an impulsive exclamation, or movement to get out of the way. A sudden increase in the strength of the current in the course of an electrical examination which has been conducted in a guarded manner, avowedly as a test for the muscular condition, will cause him when off his guard to betray himself, or when testing tactile sensation with a camel's-hair brush, FRA UD. 309 a concealed needle or pin may be pushed down suddenly, when he may cry aloud. Sometimes the mere exhibition of the actual cautery will discomfit ^le malingerer. In conclusion it should be borne in mind that the ig- norant impostor will not be able to know the correspon- dence between the limit of feeling that should exist with relation to definite areas of nerve supply, which are known to the observer, who also is familiar with the pecul- iar hysterical variations. In regard to the recognition of heat and cold, the hys- teric or simulator will often feel perfectly the hot and cold body, where the thermic sense would naturally be affected, while on the healthy side he will make all man- ner of intentionally foolish guesses. It has been sug- gested that the unexpected application of very hot or cold water will elicit complaint. Great care must be taken, however, not to mistake \}cv^ pain for the thermic sense. Insanity and Uitconsciousness. — The selection of men- tal disease for simulation by persons who plead irrespon- sibility for crime, or who are perhaps engaged in extortion for fancied injuries, is in some degree a matter of fashion, the records of the New York criminal courts for the past two or three years containing many cases of this kind, some of which were undoubtedly feigned ; but in previous years the cases were only sporadic. It does not appear that feigned insanity has been at all common in accident cases. Knapp refers to a boy who simulated dementia, and I have seen several persons who among other things claimed an utter loss of memory. The complaints of most of the plaintiffs are more general so far as general intellectual failure is concerned, and it is difficult to portray at length the inharmonious expressions 310 RAILWAY AND OTHER ACCIDENTS. of the simulator. If watched continually, his conduct will be expressed by wide variations ; he is usually intent on the outcome of hif performance, and will break down when subjected to too close an inquisition. The precon- ceived idea of what constitutes insanity upon the part of an ignorant man or woman is usually one that will lead them to indulge in a disorderly lot of manifestations, and they are apt to overdo the part. Even when such a per- son has been before thrown with insane patients, and he may have acquired a few tricks of manner and gesture, and may possibly counterfeit some of the motor symp- toms, it should be easy for the skilled examiner to appre- ciate his inconsistent answers, for they do not form a part of a clinical entity. Noisy and disorderly conduct and self-defilement is the popular idea of what constitutes insanity, and acute mania is simulated by people who meanwhile eat and sleep and do not lose flesh, and who stop in their out- bursts covertly to watch the effect produced upon the by-stander. There is often a sudden change to new topics preceded by a period of reflection. In fact, there are none of the well-known and harmonious indications of mental disorganization which are familiar to the students of psychiatry. Suggested symptoms, no matter how ab- surd, are adopted, portrayed, and repeated as if they were looked upon as good things. In this connection a word of warning must be conveyed in regard to the danger of misjudging the hypochondriacal insane, or those with sensory hallucinations or delusions who are quite apt to feel many of the things they are told to. Total loss of memory is often claimed, which is so profound as to be unreal. In some instances the dishonest subject will, in FRAUD. 311 apparently trying to remember, give some absolutely silly but positive answers. This is especially true as to nu- merical matters, questions of situation, and identity. If asked where he was upon the morning of the alleged accident, he may reply : " I was in New York until ten o'clock, and in Pekin in Asia at from p.m." Again, if asked "How old are you.?" he may reply "Thursday," and immediately after, in answer to the question : " What day of the week is it .-^ " will reply " Thirty-five." Even the most confused or incoherent lunatic would not answer in this way. At this point it may be said that certain of the insane, especially those who present the symptoms of one form of traumatic insanity, manifest what are known as hallucinations of memory, or paramnesia, which leads to the apparent fabrication of lies regarding alleged previous incidents of their lives, but this can hardly be mistaken for the above absurdity of reply. There is usually too much method in the madness of the malingerer. As under other circumstances it is far easier to feign de- pressed states or limited insanity, but even these may be detected with tolerable ease if time is taken. The simu- lation of another kind of insanity by the mentally un- sound is well recognized by psychiatrists. I can remem- ber but one case of this kind in which it was done for the purpose of imposing upon an examiner. Case LXX. — The subject was a young Polish doctor, aged 29, who through great self-sacrifice had educated himself and secured a degree, but found it difficult to get practice, and in con- sequence suffered from ill luck and poverty. For some months previous to October, 1 899, he had run down in health, become depressed and melancholic, and had threatened suicide. There had been no stuporous condition or delusions. At the suggestion of his physician he took long rides in a light wagon, 312 J^A/LWAV AND OTHER ACCIDENTS. provided by his family, and upon the occasion of the accident (which was on October 3d) he had gone to New York from his home in Broolclyn. In attempting to cross the railroad track on Sixth Avenue his wagon was run into by a car, and he was thrown out, striking his back against a column of the elevated railroad structure, and sustaining slight abi-asions and some shock. There seem to have been no serious immediate effects except these and a transitory unconsciousness. When he was taken home his depression increased, but he was not thought to be too ill to be allowed to go about ; and at the time of the writer's un- expected visit a one-horse vehicle was waiting for him outside of his residence. He was found lying upon a bed fully dressed, and presented an apparent cataleptic rigidity, with his eyes firmly closed, and lie resisted attempts to open them. There was con- siderable apparent, but not real flexibilitas cerea at the elbow- and knee-joints, with some voluntary effort at resistance when passive movements were made. When not watched he opened his eyes, and apparently noted the movements of others, but closed them tightly whenever approached. The deep and superficial reflexes were both slightly exaggerated, and there was general hyperesthesia, more over the back than elsewhere. The circulation was poor and the hands were cold. When the induced electricity was applied to the surface he did not complain, but when he was blindfolded and m.ild currents were applied, he kicked, struggled, and cried out. He voluntarily placed his hands and arms in an apparently cataleptic position when watched, and contracted his fingers. When a drop or two of chloride of ethyl was applied to the surface without his knowledge, he started violently and became agitated, as if about to have convulsions. When watched quietly, he made silly faces and presented the " Schnautz Krampf," or again opened his mouth and shut it automatically, or sighed deeply and groaned as if in pain. When told to put his tongue out he said, " I can't." It appeared that he talked to his mother and other persons, imme- diately before our visit, in a rational manner, but feigned mute- ness in the presence of the examiners alone. At one stage of the examination, which extended over a considerable time, he feigned hiccough. Pulse at the beginning 84, at the end 96. He slept well. There is every reason to believe that this man suffered FRAUD. 313 from an initial simple melancholia, and the subsequent variations in his conduct indicated that he simulated a rather inconsistent katatonic state, which was confined to the time of our examination. As he was a person of some education and shrewdness, he overdid the part, although he impressed many with the fact that his insanity pro- ceeded from a trauma, which it certainly did not. We may avail ourselves of agents which upset the self- possession of the impostor, and any one thing will often destroy his reserve and set his tongue free, when the mask is dropped. Even in genuine cases of insanity the writer has sometimes been in the habit of using nitrous oxide or other agents- as a diagnostic measure of diverting the nar- row play of ideas or absorbing delusions, as the result of a habitual trend of diseased thought-mechanism, and with some success. Case LXXI. — Punton, of Kansas City, reports in full the case of a man who seems to have imposed upon a number of physicians in the Southwest, and who had deliberately gone about to victimize a railroad by feigning a condition of mental aberra- tion, which was pronounced by his own physicians to be a mixture of "idiocy, dementia, and insanity," following a concussion, and primarily due to a blow received at the back of the head. There had been an immediate loss of consciousness, convulsions, and aphasia. " He was compelled to be nursed and treated as a baby for the rest of his life, was wholly oblivious of his surround- ings, had been deprived of all mental life, and he was living a vegetative life, for all of which he was entitled to serious damage " ; in which latter conclusion the jury seemed to concur, and Hos- kins, the plaintiff, received a verdict of ^35,000. It subsequently leaked out that a lawyer, who had kept silent during the trial, had some time previously been approached by the man and his mother, who had sounded him about the amount of damages that an enter- prising young man might receive should he happen to be in an accident that might cause him to be unconscious, " and become 314 RAILWAY AND OTHER ACCIDENTS. like an idiot, or lose entire control of his mind." It is unneces- sary to say that the counsellor told the mother " that he would not take such a case for all the gold that could be dug Qut of the ground, and that he warned her not to undertake it," but, un- daunted, she left, saying that " her mind was fully made up to try it, and that she would consult some other lawyer." Subsequently the man was put under ether by Dr. A. C. Waller, of Fort Worth, and after a mauvais quart d'heure of active and persuasive methods, wheh an operation was suggested, he quickly broke down and con- fessed his deception. Upon being called to see a patient having a claim, we may find him apparently unconscious or oblivious to what goes on about him, and sometimes it is even claimed that such states have lasted for months or even years (see Case XIII.). If hysterical or cataleptic, there are usually sufficient data upon which to make a diagnosis, and then there should be no difficulty in telling whether a person is really comatose or not. The Whittaker case, in which the writer appeared, is an apposite cause celebre, and has a bearing upon those ex- amples in which it may be claimed that an accident or assault may lead to a condition of unconsciousness. Case LXXII. — Whittaker was one of the few colored cadets who went to West Point, and one of the least intelligent. He had repeatedly failed in his studies, and upon the eve of an exami- nation, which undoubtedly would have resulted in his suspension, he made a desperate attempt to gain the sympathy of the country, as well as the opportunity to secure time for extra study. As the medical adviser of the Government I had ample opportunity to examine not only the record of the court, but made a personal visit to his room at West Point. The defendant was found early one morning in his dormitory, in an apparently unconscious state, bound to his bed with strips of cotton cloth. His eyes were closed and his pulse showed nothing unusual. There were slight cuts — one upon the left ear and the other across the great toe. FRAUD. 315 He remained apparently oblivious of his surroundings and of the people about him for some time, and finally opened his eyes, and in a dazed condition expressed great astonishment. From his story it appeared that he had been surprised several hours bejore by a body of masked men, who felled him to the floor, bound him, and cut his ears and toe, and then after threatening him left the room. The medical witnesses for the defence were of the opinion that the threats of the assailants, the fears of the victim, and the excitement had resulted in the production of a trance. Much carefully given evidence effectually disposed of this fanciful theory. It was proved that none of the wounds was of a serious character — in fact, they were all painless and trivial, and unattended by hemorrhage ; that on the toe hardly severed the skin. They were in a position where he could have made them himself, and the presence of a razor and a looking-glass on the floor near by strengthened this belief. No marks of violence re- sulting from a struggle were found; and the bandage was so loosely applied, and so flimsy, that he might have readily applied it himself; in fact, a young officer went through the process of tying and untying himself, as Whittaker had probably done. The room in which the alleged assault had taken place had numerous openings communicating with other apartments, in which many cadets were at the time, and any disturbance would have been heard at once. A prominent feature of the case was the produc- tion of a " letter of warning " to the prisoner, which, it was alleged, was written by Whittaker, and this drew forth a fight between the experts in writing. It appeared after the trial that the writer had carried on a regular correspondence with a woman friend ; and in the opinion of the experts the letter of warning was in her hand- writing, and had probably been prepared for the occasion. Visual and Ocular Defects.— \n the examination of all persons who present themselves claiming injury to the apparatus of vision, it is important to search for evidence of old disease, not only of iritis, but to detect forms of congenital weakness which are .occasionally put forward as traumatic sequelae, and at the same time to differen- tiate between the simple asthenopia and visual failure, or 3i6 RAILIJ^AY AA'B OTHER ACCIDENTS. weakness due to some more serious cause. So far as the writer's experience goes, the dishonest Htigant rarely feigns any serious form of ocular trouble, and his com- plaint is usually that he " cannot use his eyes for any length of time without fatigue," that when he tries to read Fig. 35. — Derby's Stereoscope. he " grows dizzy " or " that the letters appear blurred." Of course these are vague and difficult to determine at times, but usually, like other subjective comiDlaints, are disproved by some inconsistency in conduct. When the simulator who is blind in one eye presents himself simple tests are available that are usually sufficient. If, for instance, pressure is made at the external angle of the FRAUD. : 317 pretended amaurotic eye and he sees two objects, there can be little doubt that he is a fraud. Much of the success of all ocular tests depends upon the precautions taken by the examiner, and by his self- possession, especially when the subject has been coached, or has studied up the subject in the medical books in a public library. For the determination of feigned blind- ness, plain and colored prisms for Graefe's test must be provided, perhaps a stereoscope, and the ophthalmoscope by all means. If a prism of 10° to 15° be placed in front of the sound eye, the base being upward or down- ward, and the person is told to look at a candle flame or some small, well-defined object, and if he sees two images, there is clear proof of fraud, for the alleged blind eye must be used. The test may be carried further by rotating the prism, when the reflection will be found to correspond with its changes in position. Bear- ing in mind the fact that in the stereoscope the axes of vision converge in the normal individual, we know that if there is really blindness, this will be impossible. If two different outline figures, a square and a circle for in- stance, be drawn on the card, they will be superimposed under ordinary circumstances. Kugel's method consists in placing transparent glasses of different colors before each eye, and then a colored opaque glass is held before the good eye, and at the same time a transparent glass of the same color is held before the alleged sightless eye, when if he sees the object he is simulating. Total blindness of both eyes is rarely feigned, and if so with poor success, for the impostor can rarely keep up the appearance and counterfeit the actions of the really blind person. If the pupils be stimulated by artificial 3i8 RAILWAY AND OTHER ACCIDENTS. light they will contract, while the patient may maintain his inability to distinguish light and darkness. What is known as consensual action takes place when a beam of light is thrown into the sound eye, when the pupil of the alleged blind eye will promptly contract. Although simu- lators are apt occasionally to dilate the pupils with atropine or belladonna, such dilatation will be more more excessive than when a real amaurosis exists. A method of detecting feigned amaurosis has been used by French military surgeons, by means of the " box b;^ ,,. of Flees." The subject is made to look into this box, great care being taken \ / that both eyes should be kept open, and that at no time during the experi- ment should he shut one. When under these condi- tions he has looked in, and he is asked what he has seen in the bottom of the box, his reply is interpreted in accordance with the arrangement of the apparatus at the time. He may tell us that he sees " a white wafer at the bottom of the box on the left side." Now if we ex- amine the construction of the box, we find that the white wafer, B, which, owing to the reflection in a mirror, ap- pears to be situated to the left at B', in reality can be seen only by the right eye. The left eye, on the contrary, can see only a red wafer 7?, apparently situated to the right at i^'. In a word, the apparatus is constructed in such a way that one eye can see nothing but the object ''.«/ _ f. / />s ■••'/'' N < '* \ ^ "•^ >>4 FIG 36— The ' ' Box of Flees." FRAUD. 319 which is apparently on the opposite side (Raymond and Janet). The ophthalmoscope and perimeter should be used for the purpose of determining the condition of the fundus ; and in these instruments we possess aids which are of considerable value, for with the former we may detect the existence of neuritis and atrophy should they exist. Like the cutaneous test of anesthesia before referred to, the perimeter will reveal the inconsistency in the patient's statement, for the outline of a feigned concentric limi- tation as Oppenheim and Knapp have pointed out, is unique and absolutely unlike that obtained in a case of real disease. Again, in connection with simulated blind- ness, we must not forget that the phenomenon of word- blindness, which is dependent upon a central lesion, may occasionally suggest fraud of which the patient may be perfectly innocent, when he says that he cannot read written or printed words. Hysterical blindness, which in one way is real enough, may also be detected by the perimeter, and it usually ex- ists in connection with the other stigmata of the disease. Hearing. — The ordinary malingerer of course presents no evidence of local disease, and, as Knapp has shown, is unable to distinguish between vibratory sensations which are conveyed to his sense of feeling by loud noises, and those which are brought to his sense of hearing by the same noises, and he will often deny any sensation whatever. Unexpected noises, or questions calling for a reply, or questions asked when he is under the influence of drink or anesthesia will call forth responses. In another way the unreality of the alleged loss of hearing may be determined by an involuntary exclama- 320 RAILWAY AND OTHER ACCIDENTS. tion ; by asking a series of questions at first in a loud voice, and subsequently gradually lowering the same with- out attracting the subject's attention, and meanwhile get- ting answers. In a case of the writer's, when a woman pretended deafness, it was possible by a few questions to arouse all her ire, so that she found her voice and burst forth into invective. There are many ways of doing this besides making the person angry, which will doubtless commend themselves to the resourceful examiner. In some cases we may avail ourselves of an instrument called the phonendoscope, or a stethoscope supplied with long rubber tubes may be utilized. The success of the test depends upon closing the tube going to the sound ear without the patient's knowledge. If he still hears taps or scratching of the instrument, there is but one conclusion to be drawn — that he is trying to deceive. In a recent case in Brooklyn, where a plaintiff claimed deafness in one ear, his counsel asked him if he heard a watch which was approximated to either ear. On the "sound" side there was no difficulty, but in the " deaf " ear he naturally heard nothing until it was brought within a few inches of the side of his head. The opposing lawyer secretly re- moved the works from a case with which he tried the same test, and with the same results ! Mutism. — Malingerers very rarely try to imitate the disturbances of speech which belong to organic disease, and if they do usually come to grief. Sometimes, but not often, they are able to keep quiet long enough to deceive a person in a short examination ; especially when fortified by the falsehoods of those about them. Of course, conditions of aphonia, especially if hysteri- cal and accompanied by emotional disturbance, may often FRAUD. 321 lead one to do injustice to a person who presents few of the other stigmata of that disease ; and whose semi-volun- tary vagaries of conduct suggest deceit. If hysteria is suspected the application of static electricity, or the wire brush connected with the induction coil, may cause prompt disappear an(!e, when the patient will suddenly find her voice. Feigned or absolute mutism cannot be kept up by a healthy person for any great length of time, especially if she be watched, but sooner or later something is said in response to a suggestion or as the result of an adequate stimulus, or the .subject talks gibberish. Reference has before been made to the case of a woman who had been pronounced aphasic by a physician, and this plaintiff on the witness stand and elsewhere would not only indulge in diminutives and other affectations, but with evident purpose mispronounced words. Simulated agraphia is, I believe, unknown, but the following may be cited as an allied species of fraud : Case LXXIII. — Mrs. H. C. D claimed to have been in- jured on March 7th, 1897, and stated that when getting off a car it started and threw her upon her buttocks, when "she heard something crack" and became speechless. She was picked up and put in a front seat of the car to continue her journey, " but could not speak or move." She was seized with a chill, and "could not fix her hat, which had become disarranged." Just before she left the car she had another chill. When examined a few weeks later she talked plainly and intelligently, but declared there were times when she could not talk at all. In asking her to write, she put " d " for " g," and always repeated this except when her attention was diverted, or when she was confused in the ex- amination. She, however, wrote her name in which there were two " g's," and when this was pointed out to her, she expressed great chagrin and confusion. 21 BIBLIOGRAPHY. Traumatic Neurasthenia and Hysteria.. Landouzy : Traits de I'Hystdrie, Paris, 1846. Briquet: Traitd de I'Hystdrie, Paris, 1859. Skey: Hysteria, London, 1867. Handfield-Jones : Studies in Nervous Diseases, London, 1870. Paget: Clinical Lectures and Essays, 1875. Charcot: Progrfes Mddical, May 3d, 1878. Beard: Nature and Diagnosis of Neurasthenia, New York, 1879. Tardieu: £tude mddico-ldgale sur les blessures, Paris, 1879. Westphal: Wiener med. Blatter, vol. iii., pp. 315, 347, 375, 1880. Hodges: Boston Med. and Surg. Journal, April 21st and 28th, 1881. Mobius: Betz's Memoriabilien, 1882. Walton: Boston Med. and Surg. Journal, October nth, 1883. Journal of Nervous and Mental Disease, July, 1891. Hamilton : Nervous Diseases, their Description and Treatment, Phila- delphia, 1878. Medical Jurisprudence, with Special Reference to Diseases and Injuries of the Nervous System, New York, 1883. Brain, p. 528, Janu- ary, i886. Oppenheim, H. : Archiv ftir Psychiatrie, vol. xvi., p. 743, 1885. Page, H. L. : Injuries of the Spine and Spinal Cord. Nervous Shock, 2ded., 1885. Terrillon : Bull. Soc. de Chirurgie de Paris, vol. xi., pp. 378, 1885. Pourpon : Paralysies Hyst^ro-Traumatiques. L'Encdphale, January, 1886. Outten: Weekly Med. Rev., St. Louis, xiv., 1886. Vibert : Prdcis de meddcine legale, Paris, 1886. Striimpell: Berliner klin. Woch., vol. iii., 1888. Charcot: Arthralgie Hystdro-Traumatique. Progrfes Medical, No. iv., 1888. Oppenheim : Berliner klin. Wochenschrift, No. 9, February 27th, 1888. Thorbum: The Medical Chronicle, December, 1888; January, 1889. Knapp: Boston Med. and Surg. Journal, vol. cxix., p. 421, 1888. Clouston: The Neuroses of Development, London, 1891. Bouveret: La Neurasth&ie, Paris, 1891. Levillain: La Neurasthdnie, Paris, 1891. Wilbrand: Deutsche med. Wochenschrift, vol. xviii., p. 379, 1892. Horwitz: Medical News, vol. Ix., p. 432, 1892. 323 324 RAILWAY AND OTHER ACCIDENTS. Tuke: Diet, of Psych. Med., Philadelphia, 1892. Article " Hysteria," Charcot and Marie. Hirt: The Diseases of the Nervous System. Am. Trans., New York, 1893- La Fevre : Neurasthdnie d'origine toxique. Annales de Psychiatric, 1893. Essais de neurologic clinique neurasthdnie de Beard, etc. Crocq: Les ndvroses traumatiques, Bruxelles, 1893. L. Bremer: Journal of Nervous and Mental Disease, January, 1893. Dana : Hamilton and Godkin's System of Legal Medicine, New York, 1894. Bouchard: Lectureson Auto-Intoxication in Disease. Trans., London, 1894. Favre : Hystero-neurasthdnie traumatique. Thfese de Paris, 1895. Le Foumier : Thfese de Paris, 1896, quoted by Frankel. Preston : Hysteria and Certain Allied Conditions, Philadelphia, 1897. Fauvet: Traitd de la neurasth&ie. Thfese de Paris, 1897. Dorliat : Contributions k I'fitude de la neurasth&ie, Paris, 1898. Prince : Sec. Psych. Research, vol. xiv., 1898. Boston Med. and Surg. Journal, vol. cxxxix., pp. 613, 632 ; vol. cxxxviii., pp. 392, 511, 536, 560, 1898. Gilles de la Tourette: Lemons, etc., sur les maladies du systfeme ner- veux, Paris, 1898. Les dtats neurasthdniques, Paris, 1898. Raymond et Janet: N^vroses et iddes fixes, Paris, 1898. Levillian : Neurasth&ie. Auerbach : Die Hysterischen Hemiplegien, Wurzburg, 1898. Biemacki: Neurol. Centralblatt, vol. xvii., 1898. Eyraud : Contribution k I'^tude de la simulation de I'hystdro-neuras- thdnie traumatique, Lyons, 1898. Sidis : The Psychology of Suggestion, New York, 1899. Babinski: Gazette des HSpitaux, May, 1900. Dana: Text-Book of Nervous Diseases, 5th ed., New York, 1901. Hysteria Major and its Differentiation from Organic Disease. Am. NeuroL Assn., 1902. Frankel: The Medical News, January 5th, 1901. Defendorf: Clinical Psychiatry, article "Traumatic Neuroses," New York, 1902. Langdon : Journal of the American Medical Association, July i8th. Purves 'Stewart: Two Lectures on the Diagnosis of Hysteria. The Practitioner, October and November, 1903. Le Fevre : Les phdnomfenes de suggestion, Bruxelles, 1903. Bailey : Article " Railway Injuries," etc. Peterson and Haines' Text- book of Legal Medicine and Toxicology, Philadelphia, 1903. Accident and Injury, etc., New York, 1898. Insanity. Forbes-Winslow : On Obscure Diseases of the Brain and Mind, Phila- delphia, i860. Spitzka: Insanity, etc.. New York, 1883. BIBLIOGRAPHY. 325 Brower: Alienist and Neurologist, iv., p. 646, 1883. Lippman : Wien. med. Blatter, vol. viii., p. 361, 1885. Clouston : Clinical Lectures on Mental Diseases, Philadelphia, 1884. Guder : Geistesstorungen nach Kopfverletzungen, Jena, i886. Lewis: A Text-book of Mental Diseases, p. 213, Philadelphia, i8go. Regal : Annal. d'hygifene publique, p. 340, April, 1894. Ribot: Diseases of Memory, Am. Trans., New York, 1893. Page : Clin. Joum., London, vol. vi., p. 173, 1895. London Lancet, voL ii., p. 980, 1897. Dent: Article "Traumatism and Insanity." Tuke's Diet, of Psych. Med., vol. ii., p. 1312, 1892. Krosling : Kopftrauma und Psychosen, Tubingen, 1899. Berkley : A Treatise on Mental Diseases, New York, 1900. Frost: Am. Joum. Ins., April, 1903. A. Meyer: Am. Joum. Ins., January, 1904. Head Injuries. Duret: fitudes exp^rimentales et clinicales sur le traumatisme cdr^bral, 1878. Wharton: Phila. Med. Times, July 19th, 1879. Bergmann : Die Lehre von den Kopfverletzungen. Billroth's Chirurgie, Stuttgart, 1880. Watson: Transactions Ophth. Soc. England, vol. xiv., p. 269, London, 1883. Deuchar: Deutsche Zeitschrift fiir Chirurgie, vol. 35, p. 145. Kocher: Deutsche Zeitschrift fiir Chirurgie, vol. 35, p. 433. Clairon : Considerations sur quelques traumatismes de la rdgion latdrale du cerveau, Paris, 1889. Buzzard: ClinicalSociety Trans., vol. ix., p. 145. London Lancet, vol. iv., pp. 405-407, 1888. Cheever: Med. and Surg. Reports, Boston City Hospital, 1889. Ireland: Edinburgh Med. Joum., vol. xxxiii., p. 1073, 1887-88. Fowler: Meth. Episcop. Hosp. Reports, 1887-97, New York, 1898. Dean: Joum. of Pathology, January, 1892. Miles: Laboratory Reports. Ed. Royal Coll. of Phys., vol. iv., 1892. Battle: British Med. Joum., 1890. Henoch : Charit^-Annalen, Berlin, 1890. Klein: Miinchner med. Wochenschrift, vol. xxxvi., p. 659, 1889. Macewen: Pyogenic Infective Disease of the Brain, etc., New York, 1893. Walton: Joum. Nerv. and Mental Disease, vol. xxiv., p. 467, 1897. Mills and Myers: Joum. Nerv. and Mental Disease, vol. xxiii., p. 43, May, 1896. W. Hirsch: New York Med. Joum., December nth, 1897. Voisin: L'Epilepsie, Paris, 1897. Mott: Philos. Trans, of Royal Soc, series B., vol. 191, pp. 211-267; also vol. 194, pp. 437-466. 326 RAILWAY AND OTHER ACCIDENTS. Parks : A Treatise on Surgery by American Authors, vol. 2, 1898. Beevor: Brain, part Ixxxiii., p. 291, Autumn, 1898. Babinski : Gaz. des HSpitaux, May, 1900. La Semaine M^d., July 28th, 1898. McDill: The Railway Surgeon, January 11th, 1898. Jepson: The Railway Surgeon, vol. vi., p. 381, 1899-1900. Warren: The Railway Surgeon, vol. iv., p. 452, 1897-98; vol. vii., 1900-01. Phelps : Injuries of the Brain and Membranes, etc., New York, 1900. Emrooth : Revue de Neurologie, vol. viii., p. 792, Paris, 1900. L. R. Morris : Medicine, July, 1900. Keen and White : Diseases and Injuries of the Head. Am. Text-book of Surgery, Philadelphia, 1892. Dennis: The Medical News, March 21st, 1903. Jacoby : Joum. of Nerv. and Ment. Disease, October, 1903. Starr: Organic Nervous Diseases, Philadelphia, 1904. Spinal. OUivier: Traits des maladies de la moelle dpinifere, Paris, 1837. Hutchinson: London Hospital Reports, tome iii., 1866. Buzzard: Transactions Clinical Society, vol. ix., pp. 145, 151, London, 1876. Bramwell: Diseases of the Spinal Cord, New York, 1882. Thorbum : A Contribution to the Surgery of' the Spinal Cord, London, 1889. Vought: New York Med. Journ., November 21st, 1891. Dennis : Annals of Surgery, March, 1895. Bailey : Med. Record, November 19th, 1898. Walton : Journ. of Nerv. and Ment. Disease, January, 1902. L'Abb^: Le Cytodiagnostic, Paris, 1903. Dana: Cytodiagnosis in Nervous Diseases. Med. Record, January 23d, 1904. Peripheral Diseases.- Mitchell: Diseases and Injuries of Nerves, 1872. Am. Journ. of the Med. Sciences, vl. bocxvi., p. 17. Trdflas: Bull, et Mdm. de la Soc. de Chir., vol. viii., p. S34, 1882. Vieusse: Bull, et Mdm. de la Soc. de Chir., vol. viii., p. 650, 1882. Cdnas : Revue de Mddecine, p. 479, 1884. Lauth : Rev. de Chirurgie, p. 560, 1884. Ross: The Diseases of the Nervous System, vol. i., 1886. Gowers : A Manual of Diseases of the Nervous System, Philadelphia, 1886. Israel: Gaz. Hebdom. de Mdd., p. 281, 1884. Callender: St. Barthol. Hosp. Reports, vol. v. Bowlby : Injuries and Diseases of Nerves, London, 1889. Golebiewski : Atlas and Epitome of Disease Caused by Accidents. Am. Trans., Philadelphia, 1900. BIBLIOGRAPHY. 327 Simulation. Caspar: A Handbook of Forensic Medicine. Sydenham Trans., vol. iv., London, 1864. Harlan: Amer. Joum. of the Med. Sciences, October, 1873. Stoeber: Archives d'Ophth., 1883. Penrose-Watson : Journal Amer. Med. Assn., August, 1889. Seeligmiiller : Centralblatt fiir Neurologie, No. xx., 1889. Mobius: Munchen. med. Wochenschrift, No. 50, 1890. Bosc: Thfese de Montpelier, 1890-91. Knapp: Bostpn Med. and Surg. Journal, December 26th, 1890; Sep- tember 28th, 1893; and Hamilton and Godkin's A System of Legal Medi- cine, vol. ii., 1894. Seguin: Annual Univer. Med. Science, vol. ill., 1891. Lauenstein: Deutsche med. Woch., April 14th, 1892. Schmidt-Rimpler: Deutsche med. Wochenschr., 1892. Bremer: Journal of Nervous and Mental Disease, January, 1893. Witthaus and Becker; Med. Jurisprudence, Forensic Med., and Tox., vol. ii., 1894. Peterson and Haines : A Text-book of Legal Medicine and Toxicology, vol. i., Philadelphia, 1903. Punton : Kansas City Med. Index-Lancet, 1903. Baudry: Injuries to the Eye, etc. Am. Trans., Philadelphia, 1900. GLOSSARY. Aboulia : Without will. Abrasion : Removal of the cuticle. Accommodation : The action of the eye for the perception of objects that may be near or far. Achilles jerk : Ankle clonus. Ageusia : Loss of taste. Agraphia : A cerebral loss of power to write, dependent upon a lesion of the "writing centre." Akinesis : Without force. Akinesis algera : Weakness due to the fear of movement and consequent pain. Alalia : A speech defect of an atactic or paralytic kind. Alexia : Word blindness. AUochiria : Sensation felt in one member when the other is irritated ; trans- ferred sensation. Amaurosis : Blindness. Amblyopia : Dulness of vision. Amnesia : Loss of memory. Amyotrophy ; Muscular atrophy, applied to a form of spinal sclerosis. Amyosthenia : Muscular weakness. Analgesia: Insensitiveness to painful impressions. Anamnesis : A recollection. Anemia : Deficiency of blood. Anesthesia: Want of sensibility, insensitiveness. Angina pectoris : A painful affection of the heart, due to degeneration of the coronary arteries. Ankle clonus : An exaggeration of the deep reflex which is evoked when the Achilles tendon is stretched. Ankylosis : Knitting together of bones through disease at their point of articulation, resulting in immobility. Anode : The positive pole. Anosmia : Loss of smell. Aphasia : A speech disturbance. The term is usually applied to a defect in the motor centres of speech in the anterior and lateral part of the brain on the left side. Aphonia: Loss of voice due to inaction of the vocal cords. Apraxia : Loss of power of gesture communication. Arachnoid : The middle membrane of the brain and cord. 329 330 RAILWAY AND OTHER ACCIDENTS. ' Argyll-Robertson pupil: A symptom which consists in the failure of the pupil to react to artificial light, but to undergo alteration in connection with accommodation. Arteriosclerosis : Hardening of the arteries. Arthralgia : Pain of the joints. Arthritic : Pertaining to the joints. Asemia : An inability to understand any sign or symbol of thought, whether spoken, written, or acted. Asthenia : Weakness. Asthenopia: Weakness of vision. Astigmatism : A state of irregular refraction in the eye. Ataxic aphasia : A disturbance of speech depending upon inco-ordination of the muscles of articulation. Ataxia : A disorder dependent upon muscular inco-ordination. Ataxiagraph : An instrument invented by Dana to measure the swaying movements of the patient. Atrophy : A wasting. Atropine : The alkaloid of belladonna. Aura : A subjective sensation preceding an attack of epilepsy. Automatism : The habit of subconscious action. Autotoxis : Self-poisoning. Babinski reflex : The dorsal flexion of the great toe as a result of irritation of the plantar surface. Bacillus : A rod-like micro-organism. Basal : Pertaining to the floor of the skull or inferior part of the brain. Binocular convergence : Change in the axes of vision due to muscular dis- turbance of the eyeballs, so that the point of convergence is reduced. Box of Flees : An apparatus for testing simulated blindness. Brachycardia : Abnormal slowness of pulse. Brachycephaly : A cranial defect in which the head is too short. Brachial plexus : A network of nerve trunks formed by the junction of the four lower cervical and first dorsal nerves and terminating below to form the median, ulnar, musculo-cutaneous, musculo-spiral, and circumflex nerves. Bronzing : A brown color of the skin due to the deposit of pigment. Buccal : Pertaining to the mouth. Bulbar symptoms : Those depending upon lesions of the medulla oblongata. Bulla : An eruption of vesicles. Callus : A substance formed about the ends of broken bones for their sup- port and facilitation of union. Carcinoma : Cancer. Cardiac affections : Those of the heart. Caries : Inflammation with destruction of bone. Casts : Evidences of disease of the kidney found in the urine. Catalepsy : A state of unconsciousness with peculiar rigidity of the joints ; probably a form of hysteria. GLOSSARY. 331 Cathode : The negative pole. ■Cauda equina : The extreme lower part of the spinal cord, named from its resemblance to a horse's tail. Centrifugal: Flowing from within out. Centrum ovale — See plate V. Cephalalgia : Head pain. Cerebellum — See plates V., VI. Cerebral : Pertaining to the brain. Cerebral tension : Increase of blood pressure in cranial cavity. Cervical : Pertaining to the neck. Cervical vertebrae : Those of the neck, the first seven. Cheyne-Stokes respiration : A state of irregular breathing characterized, first, by entire cessation for some time, then by an almost imperceptible return of respiration, and finally by violence and quickness, subsequent subsidence ; all of this occurring perhaps within a minute. Chiasm : The decussation or crossing of the optic nerve fibres. Choked disc : A swollen condition of the optic nerve due to compression. Cholin : A toxin derived from decomposition of lecithin as the result of the destruction of nerve tissue. Chorea: A spasmodic affection; St. Vitus' dance. Chromidrosis : Yellow sweating. Cicatrix : A scar. Circus movements: Associated with disease of the cerebellum, which cause the subject to turn when walking or to fall in certain directions. Clonic : A term applied to a spasm characterized by interruptions and vary- ing muscular contractions. Cocci : Spherical forms of bacteria. Coccyodynia : Pain in the coccygeal bone at end of spinal column. Color sense : The faculty of distinguishing colors. Coma: Stupor. Compound fracture : A fracture of bone with wounding of tissue and com- munication externally. Compression myelitis : Inflammation of the spinal cord produced by actual pressure of displaced bones or thickened membranes. Concentric vision : Constriction of the visual field. Concussion : The results of shock or impact. Cone-bulging : A peculiar change of position of the skull or membranous sacs containing cerebro-spinal fluid, as the result of force applied at a distant point. Condyles : Bony eminences for articulation. Conjugated : A conjoined movement ; here used to express the direction of the eyes to one side or place. Conjunctiva: Mucous membrane lining the eyelids and reflected over the front of sclerotic and cornea. Contracture : A more or less permanent or recurring contraction, often con- nected with an organic change of the parts. Contracted pelvis : A deformity resulting from premature bony union. Contraction of visual field : Limitation of vision. 332 RAILWAY AND OTHER ACCIDENTS. Contre-coup : Counter-stroke. Contusion : A result of an injury, consisting usually of swelling without any superficial wounding ; a bruise. Contusio cerebri : Contusion of the brain. Cord : Spinal cord. Cornea : The concaval convex part of the eye in front of the iris and pupiL Corpora quadrigemina^ — See plate V. Corpus callosum — See plate V. Cortex : The peripheral gray matter of the brain. Cortical epilepsy ; Epilepsy due to irritation of the motor centres in the convolutions of the brain. Costo-spinal articulation j Articulation of ribs with spine. Cremasteric reflex : A reflex shown by contraction of the cremaster muscle in the scrotum. Crura cerebelli : The peduncles of the cerebellum. Crural nerve : Large nerve supplying the muscles and skin upon the anterior part of the thigh and knee and the capsules of knee and hip joints. Crusta : The upper part of the crus cerebri. Crutch palsy : That form of paralysis due to pressure made in the axilla. Cuneus — See chart I. Curetting : An operation for the removal of tissue by scraping. Cyanosis : A condition of blueness depending upon disturbances of circula- tion. Cystitis : Inflammation of the bladder. Decubitus : A bedsore. Delusion : A false belief (see Insane delusion). Delusions may be sane or insane. Dementia : A form of insanity the chief symptom of which is a loss of memory and the inability to receive fresh perceptions and form ideas. The important forms are those of early life, the senile, and the organic or secondary ; the two latter are always incurable and progressive. Dementia paralytica : General paralysis of the insane ; " paresis." Depressive insanity : Melancholia, stuporous insanity, atonic insanity. Dermal : Pertaining to the skin. Descending neuritis : A form which is the result of extension of disease in central parts. Diabetes : A disease characterized by the appearance of sugar in the urine Diastases : Points of separation. Direct electrization : Application of a current to the muscle to be excited. Diplegia: Double paralysis — on both sides of the body. Diplopia: Double vision. Disassociation : Disaggregation; separation. Disuse atrophy : Wasting from non-use of muscles. Dolichocephaly : A cranial defect in which the head is abnormally long. Dorsal : Pertaining to the back. Dorsal vertebra : Twelve bones composing the middle section of the spinal column. GLOSSARY. 333 Dorsum : Back. Dural : Pertaining to the dura mater or external membrane of the brain. Dyesthesia : Disordered sensibility, numbness, prickling, sensation of crawling insects. Dynamometer : An apparatus for determining muscular force. Dystrophies : Primary muscular atrophy of peripheral origin. Dysuria : Difficulty in urination. Ecchymosis : An escape of blood in the superficial tissues due to local injury. £czema : A skin disease characterized by a vesicular, pustular, papular, fis- sured, and exfoliated lesion, usually symptomatized by redness, itching, exudation, crusts, and desquamation. Eczema appears chiefly on the scalp, beard, genitals, hands, and feet. Edema : A swelling or puffiness of the tissues (oedema). £lectrode : The terminal pole of a galvanic apparatus ; an instrument to apply electricity. Endometritis : Inflammation of the interior of the uterus. Epigastrium : The region below the breast bone and between the right and left hypochondriac regions. Epistaxis : Nose-bleed. Erosion : A wearing away. Erysipelas : An inflammation of the skin and subjacent tissue due to a spe- cific bacillus. Esophageal : Pertaining to the esophagus. Etiology : Inquiry into cause. Eustachian tube : A canal extending from the throat to the middle ear. Exophthalmus : Prominence of one or both eyes. Extensor longus poUicis : A muscle concerned in the extension of the last phalanx of the thumb. Extradural : Outside the dura mater. Facies : Facial expression. Fauces : The upper part of the throat. Festination : A gait attended by pitthing forward upon arising from the sit- ting position. Fibrillary twitching : Contraction of muscular fibres or a part of a muscle ; vermicular tremor. Fibula : The outer bone of the leg. Fissura calcarina — See chart II. Fixed idea : Persistent idea ; usually applied to fixed delusion. Flaccid paralysis : The form without rigidity. Flexors : Those muscles which bend or flex. Foci : Plural of focus. Folie de doute : Doubting insanity ; Griibelsucht. Fontanelle : A space usually open in young children, which marks the union of various bones of the head, and is later closed. Formication : Subjective sensation of ants or other insects crawling on surface. 334 RAILWAY AND OTHER ACCIDENTS. Fossa : A depression or low cavity. Fourth ventricle : The small ventricle at the posterior part of the brain and formed in part by the medulla ; of importance because the floor is the place of origin of cranial nerves. Fulgurating pains : The explosive or lightning pains of locomotor ataxia. Genitalia : The genital organs. Girdle pains : Those extending from the spinal cord horizontally to a point in front of the body. Glans penis : Expanded and sensitive end of penis. Glioma : A tumor composed of neuroglia. Glossy skin : A shiny condition of the skin due to a trophic change, often found with neuritis. Glutei muscles : Those of the buttocks. Glycosuria : The passage of urine containing sugar. Goitre : A disease of the thyroid glands ; Graves' disease. Grand hysteria : Major hysteria. Graves' disease : Goitre. Gyrus : A convolution. Gyrus angularis — See chart I. Gyrus fusiformis — See chart II. G.yrus lingualis — See chart II. Gyrus uncinatus — See chart II. Hallucination : A perception without a real object, of purely cerebral origin. Hematemesis : Vomiting of blood. Hematomyelia : Hemorrhage into the substance of the spinal cord. Hematorrhachis : An escape of blood between the membranes and cord or the spinal membranes themselves. Hemianesthesia : Loss of feeling on one side of the body. He-michorea : Clonic spasm on one side of the body, usually associated with paralysis, the lesion being in the cortex of the brain. Hemiopia : A condition of blindness of half the eye. Hemoglobin : The coloring matter of the blood. Herpes : A skin disease often associated with trophic disorders, neuralgia, and residual pain. Herpes zoster : An encircling crop of herpes. Homonymous : A symmetrical lateral condition ; a lesion which affects the same side in both eyes is homonymous. Hydrops : A collection of water, dropsy. Hyperidrbsis : Excessive sweating. Hyperalgesia : Increased sensibility to pain, tenderness. Hyperemia : Increase of blood ; fulness of vessels. Hyperesthesia : Increased sensibility to impressions. Hypermetropia : Far-sightedness. Hypnotic : Pertaining to sleep ; a soporific drug ; suggested sleep. Hypoesthesia : A minor degree of anesthesia. Hypochondriasis : A disease characterized by introspection, exaggeration, and the formation of subjective delusions. GLOSSARY. 335 Hypoglossal nerve : Twelfth nerve ; motor nerve of tongue. Hypostatic : A condition connected with the dependent position, usually with a determination of blood or other fluid to a lower level. Hypotonia : Lowered tone, weakness. Hysteria : A disease or condition characterized by emotional instability, de- fective volition, and disturbances of sensibility ; erroneously supposed to be an affection of the pelvic organs of woman. Hysteroid : Pertaining to' hysteria. Idiopathic : Developing without cause or without any preceding disease ; in reality, a primary morbid state. Illusions : False perceptions of actual objects, distortions of real things. Indirect electrization : Excitation of a muscle through a nerve. Induced electricity : A current induced in a coil from another through which a current passes. Inhibition : Control which regulates, stops, or suspends function. Inner table : Lowermost layer of cranial bone which is separated from the upper table by the diploe. Innervation : Supplying with nerve force. Insane delusion : A false belief in something which has no existence except in the diseased imagination of the person, and which cannot be removed by evidence of its falsity. Insistent idea : Obsession, compulsive idea, morbid impulse. Insomnia: Inability to sleep, wakefulness. Intercostal : Between the ribs. Internal capsule — See plate V. Intervertebral canals : Those between the vertebras through which the spinal nerves emerge. Intervertebral cartilages : Those between the vertebra. Intervertebral discs : Cartilages between the vertebrae. Intramedullary : Inside of the cortex. Ischuria : Suppression of urine Katatonia : A form of insanity characterized by expressions of depressed and excited states, with a peculiar muscular condition resembling that of catalepsy. Knee-jerk : A deep reflex produced usually by striking the patella tendon. Kyphosis : A spinal deformity consisting in an angular projection. Latissimus dorsi : Large muscles in the back concerned in the movement of the arm downward and backward, raising the lower ribs and drawing the trunk forward. Laparotomy : An incision through the abdominal walls. Lead line : A peculiar blue line above the gums in those saturated with lead and supposed to be due to the combination of the metal and the prod- ucts of decomposed food about the teeth. Leptomeningitis : Inflammation of the arachnoid and pia, sometimes in con- nection with the dura. Lesion; An injury, wound, or point of disease. 336 RAILWAY AND OTHER ACCIDENTS. Leucocytes : White corpuscles of the blood. Lithemia : An excess of uric acid in the blood. Lumbar : Applying to the region of the five vertebras between the dorsal and sacral. Main-en-griffe : Claw hand, a peculiar deformity following paralysis of the ulnar nerve. Major hysteria : Grand hysteria. Malingerer : One who feigns or simulates disease. Mammary : Pertaining to the breasts. Masseter : The great lateral muscle concerned in the movement of the lower jaw. Materies morbi : Diseased matter existing as a cause. Mastoid process : A protuberance of the temporal bone below and behind the ear. Meatus: A passage; the external opening of some canal, e.g.^ the urethra, the ear. Medulla : The marrow ; here applied to the medulla oblongata or bulb at the superior part of the spinal cord. Megalopsy : Visual increase in size of objects seen. M&i^re's disease : A form of auditory vertigo dependent upon disease of the ear itself. Meningitis : Inflammation of the investing membranes of tlie brain and spinal cord. Meningomyelitis : Conjoined inflammation of the spinal cord and its mem- branes. Menopause ; Change of life. Menses : The monthly periods of women. Metacarpal : The long bones of the hand between those of the wrist (carpal) and the phalanges. Metastasis : Transfer of a disease from one point to another by infection or transmission. Meteorism : A peculiar projection of the abdomen owing to defective tone in its walls. Micro-organism : A minute organism ; a microbe. Micropsy : Visual diminution of objects seen. Micturition : The act of urinating. Migraine : A form of paroxysmal headache. Milliampferemeter : An instrument for measuring the thousandth part of an ampfere. Mixed nerve : One containing motor and sensory filaments. Monocular polyopsia: Duplication of objects, seen with one eye; usually hysterical or due to astigmatism. Monoplegia : Paralysis of one muscle or part. Muscae volitantes : Flying motes ; a subjective expression of disturbed vision. Myelitis : An inflammation of the spinal cord. Myoclonus : A clonic muscle spasm. Myographium : An instrument for recordmg muscular contractions. GLOSSARY. 337 Myopic : Short-sighted. Myotonia : A condition of tonic muscle spasm. Necrosis : Death. Neoplasms : New growths. Nephritis: Inflammation of the. kidney ; Bright's disease. Neurasthenia : Nerve weakness (nervous asthenia — Fordyce Barker). Neuraxon : The axis cylinder; the central part of the nerve. Neuritis : Inflammation of the nerve. Neuroglia : The tissue binding together nervous matter proper. Neuromata : Nerve tumors. Neuroraimesis : The unconscious simulation of disease. Neuropathologists : Those who study the morbid anatomy of the nervous system. Neurosis : A functional nervous disease. Neurotic : Pertaining to the nerves ; predisposition to nervous disease. Nystagmus : A movement of the eyeballs in a lateral or rotatory manner. Obsession : A dominant and fixed idea. Occipital : Pertaining to the occipital or great posterior and inferior bone of the skull. Oculomotor : Pertaining to the movement of the eyeball. The oculomotor is the third nerve supplying all the muscles but two. Odontoid process : A toothlike projection of the axis bone, which projects into the anterior part of the spinal foramen of the atlas; it is con- cerned in the rotation of the head. Olecranon process : A bony protuberance from the upper extremity of the ulnar bone forming the elbow. Ophthalmoplegia : Paralysis of the ocular muscles. Optic atrophy : Wasttng of the optic nerve or retina. Optic canal : That through which the optic nerve and its vessels pass to the orbit. Optic thalamus — See plate V. Orbicularis sign : Inability to contract the orbicularis palpebrarum alone, though possible with its fellow. Orbital : Pertaining to the orbit. Organic paralysis : Paralysis dependent upon some disease of the brain or spinal cord destroying the motor tracts or centres. Osteal: Pertaining to bone. Otitis media : Inflammation of the middle ear. Outer table : External surface of a cranial bone separated from lower table by the diploe. Oxycephaly : A defect of the skull expressed by abnormal height. Pachymeningitis : Inflammation of the dura mater. Palpebral opening : That between the eyelids. Paracentral : Applied to the gyri or convolutions about the central or Ro- landic fissure. Paralysis agitans : Shaking palsy, Parkinson's disease. 22 338 RAILWAY AND OTHER ACCIDENTS. Paramnesia : Literally a disturbance of memory ; an hallucination of mem- ory ; pseudologiafantastica. Paraplegia : Paralysis of both lower extremities. Paresthesia: Disturbed sensibility, dysesthesia. Parasyphilis : An irregular form of syphilis, at first latent. Paretic dementia : General paralysis of the insane ; " paresis." Paresis : A light grade of paralysis, sometimes improperly used to denomi- nate general paralysis of the insane or paralytic dementia. Parkinson's disease : Paralysis agitans, shaking palsy. Parietal bone : A large quadrilateral bone of the skull articulating with its fellow above and with the frontal, temporal, and occipital. Patella: Kneecap. Pelvic organs : Those contained in the cavity of the pelvis. Pelvis : A combination of bones at the base of the trunk which contains some of the organs of generation, the lower gut, and certain important vessels and nerves, and affording articulation for the lumbar vertebra? and the thigh bones (femora). It is composed of the following bones : sacrum, coccyx, and two innominata, the latter being developed from the union of the. ilii, ischii, and pubes. Pemphigus : An eruption consisting of large blebs or blisters. Petechia : An appearance on the skin of small spots due to minute extrava- sations, and often found after epileptic convulsions. Petit mal : A minor epileptic attack, usually transitory. Perineum : The crotch — that part of the body between the thighs extending from the anus to the vulva or scrotum in woman or man. Perimeter : An instrument for measuring the extent of the field of vision. Peripheral : Pertaining to the surface of the body. Peripheral myelitis : Inflammation of the circumference of the cord. Peripheral nerves : Those nerves principally concerned with, the innervation of voluntary muscles or the surface of the body. Phalanx (plural, phalanges) : Terminal bones of fingers and thumbs. Phonendoscope : An instrument for auscultation ; a variety of stethoscope. Photophobia : Fear or intolerance of light. Phrenic nerve : An important nerve supplying the diaphragm and concerned in respiration. Plantar reflex : Reflex obtained by irritating the sole. Plumbic : Pertaining to lead. Pneumogastric nerves : The tenth pair which preside over respiration and digestion. Poliomyelitis : A disease of the anterior horns of the spinal cord with mus- cular paralysis and atrophy and conserved integrity of sensation. Polyopsia : Visual duplication. Polyuria : Copious urination. Pons — See plate VI. Porencephaly : A defect in the cerebrum with disappearance of tissue due to old and advanced disease. Pott's disease : An inflammation of the vertebral column with possible caries and deformity. GLOSSAR Y. 33g Preataxic stage : The first stage of locomotor ataxia. Presenility : Premature ageing. Priapism : A persistent erection. Ptosis : Drooping of the upper eyelid as the result of paralysis of the third nerve. Pseudo-hypertrophic paralysis : A disease characterized by a muscular en- largement, paralysis, and subsequent atrophy. Pseudo-tabes : False or irregular locomotor ataxia. Psychasthenia : Mental weakness or tire. Psychical : Pertaining to the mind ; mental. Psychical equivalent : A state of mental disturbance which takes the place of an epileptic convulsion. Psychiatrist : One who practises psychiatry ; a specialist in mental diseases. Psychosis : A condition of mental derangement ; an insanity. Pyelonephritis : Purulent inflammation of the pelvis of the kidney. Pyogenic: Pus-making. Pyramidal degeneration : Progressive destructive disease in the pyramidal columns of the spinal cord, usually following a lesion in the brain. Quadriceps extensor : Those muscles uniting in a tendon attachment to the patella. Rachialgia : Back pain. Raynaud's disease : An affection characterized by a local interruption of blood supply, changes in temperature, and in color of the fingers, and possibly gangrene. Reflexes: An involuntary muscular contraction following a peripheral irrita- tion. Reflex paralysis : A loss of power due to a lesion at a remote point. Regurgitation : A flowing backward. Renal : Pertaining to the kidney. Retina : The innermost nervous membrane of the eye. Residual shortening : Shortening of a muscle after paralysis. Rhinoscleroma : A disease of the nose causing enlargement and peculiar deformity. Romberg symptom : Static ataxia. Sarcoma : A malignant growth composed of either large or small cells and often due to trauma. Sacral cord : That part of the spinal cord enclosed in the sacrum. Scaphocephaly : Keel-shaped skull. Schnautz-Krampf : A peculiar contortion of the mouth and nose which is a symptom of certain insanities. Sclerosis : A hardening. Scotoma : A defect in the visual field, a dark spot. Sepsis : Contamination by putrefying or morbid substances. Septic : Pertaining to an animal poison. Serous fluid : The fluid secreted by the serous membranes which lie in the internal cavities of the body. 340 RAILWAY AND OTHER ACCIDENTS. Sinus : A venous canal as here used. Skiagraph : A picture made by aid of the Roentgen rays and a sensitized plate ; an ;ir-ray photograph. Spastic : Rigid or stiff. Sphincter ani : The constrictor muscle guarding the anus. Sphygmograph : An instrument for graphically recording the pulse. Spiculum : A splinter. Spine : The vertebral column — a more or less slender, bony process or point. Spinous process : Posterior projection from the laminae of the vertebra. Splanchnic : Referring to the internal viscera and their nerve supply. Staphylococci: Fungus bacilli often found in the mouth, where they are innocuous; but they may be dangerous indications of a septic process if found elsewhere. Stasis : A stoppage or determination of blood. Stellate: Star-shaped. Sterno-cleido-mastoid muscles : A pair of muscles extending from the ster- num (breast bone) and clavicle (collar bone) to the mastoid process of the temporal bone and to the occipital bone (back of the head). Sternum : Breast bone. Stertor : Term applied to a peculiar, noisy form of respiration. Stigmata : Marks of disease. Strabismus : Cross-eye or squint. Strangury : A painful vesical spasm with scanty urine. Streptococcus pyogenes : A chain-forming micrococcus which occurs in ab- scesses and is associated with septic processes generally (von Jaksch). Suggestion : An influence directed to the subconscious self. Symptom complex : A particular combination of symptoms. Synovial sacs : Lubricating cavities. Syphilophobia : Fear of syphilis. Systemic: Pertaining to a system or arrangement; usually applied to dis- ease of definite and organized parts, expressed by classical symptoms. Tabes : Wasting locomotor ataxia, degeneration of the posterior columns of the spinal cord. Tabetic : A person affected with tabes or locomotor ataxia. Tachycardia : Extreme rapidity of pulse. Tactile anesthesia : Insensibility to touch. Talipes equinus : A peculiar deformity of the foot, usually due to paralysis of muscles in front of leg and contraction of the Achilles tendon. Tegmentum : The lower division of the crus cerebri. Temporal: Referring to the region of the temporal bone. Tetanic ; A violent tonic spasm or contraction. Tetanus : Lockjaw. Thenar : Relating to the base of the thumb. Thermo-anesthesia : Insensibility to heat or cold. Thoracic : Pertaining to the thorax or chest. Thrombosis : A condition of inflammation and consequent closure of a blood- vessel. GLOSSARY. 341 Thyroidal : Pertaining to the thyroid glands. Thyroids : Two ductless glands at the anterior part of the neck. Titubation : A staggering, unsteady walk. Tonic : A term applied to spasm in which there is continued and uninter- rupted muscular contraction. Torticollis : Wry-neck. Toxemia: Poisoning. Toxin : A poison, used here in its organic sense. Trapezius : A muscle of the upper back which in contraction draws the head backward. Trauma : A wound or injury. Triceps : A three-headed muscle on the back of the humerus and concerned in the extension of the forearm. Trigeminus : The fifth nerve. Trophic : Relating to nutrition. Tubular union : A means of joining the ends of divided nerves by placing their ends in pipes or canals made of some substance which is eventu- ally absorbed. Turgescence : Swelling with congestion. Tympanites : A distention of the abdomen due to gas in the intestines. Tympanum: The ear-drum. Ulnar nerve : A large and important nerve supplying the flexors and abduc- tors of the hand, the elbow, and wrist joints, and the palmar and dorsal integument of the little finger and half of the ring finger. Umbilicus : Navel. Uncinate gyrus — See Chart II. Unilateral : On one side. Uremia : A condition characterized by the retention of excrementitious sub- stances in the blood. Vagus : The sensory portion of the pneumogastric nerve. Vasomotor : A term applied to states of constriction or dilatation of a blood- vessel and their results. Velum palati : The soft palate. Ventricle : A cavity in the brain communicating with others and containing cerebro-spinal fluid. There are five of these. Vertex : The vault of the skull. Vertigo : Dizziness and giddiness with subjective sensations of rotation or confusion. Vermicular contractions : Wormlike contractions of fibres in the body of a muscle. Volitional tremor : Tremor increased by intentional effort. Wrist drop: A deformity of the hand due to paralysis of the extensor muscles. Zone : A limited area. INDEX, Abbe, 72 Aboulia, accident, 15 Abscess of brain, 128 Accident aboulia, 15 aboulia, obsessions in, 19 aboulia, the neurasthenic type, 20 insurance, 5 Accidents during sleep, 18 Ageusia, 68 Agraphia, 126 feigned, 321 Alcinesia algera, 34 Alalia, 125 Alexia, 125 Algonesia, 32 Amblyopia, 65 Amount of damages, 4 Amyosthenia, 47 Analgesia, 50 Andral, 21, 139 Anesthesia, 59, 60 disassociated, 187 due to spinal lesions, 179 gauntlet form, 61 hysterical, 61 Ankle clonus, 59, 123 Anosmia, 68 Anterior tibial nerve, paralysis of, 230 Aphasia, 73, 105 in Bright's disease, 126 Aphemia, 126 Apraxia, 126 Argyll-Robertson pupil, 194, 197 Arthralgia, hysterical, 71 Asemasia, 126 Asemia, 126 Astasia abasia, 50 Asthenopia, 36 Ataxia, 124 hysterical locomotor, 200 locomotor, 193 recurrent, 202 tests for, 246 Atrophy, progressive muscular, 190 Auditives, 33 Autosuggestion, 16 Average loss by damages, 4 Axenfeld and Huchard, 55 Backache, 23 Back injuries, 164 Babinski, 48, 123 sign, 48, 122 Bailey, i6, 59, 146, 192, 193, 195, 286 Base of skull, fracture of, 99 Beard, 20 Berkely, 22 Bernhardt, 75, 81 Binet, 149 Binocular convergence, loss of power of, 66 Blindness, feigned, 315 Bloodless areas with anesthesia, 61 Blows to head, 88 Bouchut, 21 Bourguinon, 21 Box of Flees, 318 Brachet,2i Brachial plexus, injury to, 173 Brachycardia, 40 Brain, abscess of, 128 contusion of, 93 foreign bodies in, 265 injury, Keate's case of, 270 laceration and contusion of, 92 343 344 INDEX. Brain lesions, general symptomatol- c^y of, 120 tolerance of, 270 Briquet, 21 Brodie, 15 Brown-S^quard, 140 Brown-Sdquard's paralysis, 181 Bulbar lesion, 119 Bull, C. S., loi Burcq, 62 Calcaneus, 218 Catalepsy, case of, 80 Cephalalgia, 29 Cerebellum, lesions of, loS tumor of the, 114 Cerebral compression, 94 • compression, death from, 95 cortex, tolerance of, 95 disease, infective, 127 disease, sensory symptoms in, 124 disease, symptoms of, 120 disease, tremor in, 123 hemiplegia, 122 meningitis, 131 paraplegia from pressure, 95 Cervical paralysis, 172 plexus, disease of, 219 sympathetic, paralysis of, 176 vertebra, sprain of, 165 Charcot, 16, 62, 63, 77, 198 Cheyne-Stokes' respiration, 95 Chipault, 273 Choked disc, 115 Clevenger, 16 Clonus, ankle, 59, 123 Clouston, 22, 144 Coccyodynia, 31 as result of labor, 176 Coccyx, injury of, 174 Color sense, tests for, 66 Combined paralysis, 231 Commotio cerebri, 93 Comparison between mortality of steam and electric roads, 3 Compression, 94 myelitis, 143, 181, 182 Compression of spinal cord, 173 Concentric limitation, 65 Concussion, 88 involuntary discharges in, 90 loss of memory from, 148 of brain, 89 pathology of, 90 pulse in, 90 pupils in, 90 spinal, 15 symptoms of, 90 Condition immediately after acci- dent, 18 Cone bulging, 92 Contraction of visual field, 36 Contracture, feigned, 297 of lower extremity, 54 of upper extremity, 54 Contre coup, 92 Contusions, 87 of brain, 93 Convulsions, 122 Cord, contusions of, 167 lesions, symptomatology of, 172 Cranial injuries, 87 nerve paralysis, 114, 115, 116 Crossed hemiplegia, 107 Crutch paralysis, 234 Cruveilhier, 190 Cytoscopy, 94 Damages, 4 Dana, 16, 23, 42, 43, 49, 57, 59, 61, 164, 286 Deafness, feigned, 319 hysterical, 67 Death from cerebral compression, 95 Defendorf, 26, 158 Degeneration reaction, 50, 210 Delayed' sensation, 125 Deltoid, paralysis of, 232 Dennis, 89, 91 Depressive insanity, 24 Derby's spectroscope, 316 Dermography, 40 Determination of " reasonable cer- tainty," 257 INDEX. 345 Development of symptoms of acci- dent aboulia, 17 Diabetes, 177 Disaggregation of consciousness, 85 Disassociation of anesthesia, 187 Dislocation, 169 Disturbance of equilibrium, 198 Doran case, 280 Dorliat, 5 Dorsal cord, injury of, 173 lesions, 179 nerves, disease of, 20 Dream ideas, 84 Drug habits, 45 Duchenne, 27, 190, 194 Duret, 91 Dynamometer, 239 Dysesthesia, 31,60 Dystrophies, 191 Ebranlement, 2 Edema as sign of fracture, 98 neurotica, 75 Effects of blows on head, 147 Eisenlohr, 16 Electricity and fraud, 284 Electrical examination, 241 reactions in hysteria, 50 reactions in paralysis, 209 tests, 211 Elevation of temperature after fract- ure, 99 Epilepsy, 138 Brown-Sdquard's, 140 congestive, 139 feigned, 305 from cicatrices, 138 Jacksonian, 123 prognosis of, 275 reflex, 140 Erb's paralysis, 231 upper and lower arm types 233 reaction charts, 212 Erichsen, 2 Erysipelas of scalp, 133 Esthesiometer, 62, 243 Estimate of damages, 253 Exaggerations, 4 Examination and the possibility of error, 238 Facial spasm m hysteria, 49 False fatigue, 38 Fatality of hysteria, 264 Fear of movement, 34, 167 Feigned agraphia, 321 blindness, 315 deafness, 319 hemiplegia, 297 insanity, 309 pain, 306 paraplegia, 299 unconsciousness, 309, 314 Ferrier, 104 Festination, 137 Fixed idea of insomnia, 28 Flechsig, 104 Flint, 80 Flitting scotoma, 116 Folie du doute, 25 Football players' liability to acci- dent, 10 Foreign bodies in brain, 265 Forms of hysterical contraction, 55 Forster's shifting type of contrac- tion, 36 Fournier, 264 Fracture of skull, 92, 96 and insanity, 145 base, 99 consequences of, 100 development of other dis- eases through, 100 prognosis of, 267, 268 varieties of, 96 of spine, appearance of patient in, 179, 180 spinal, 169 Fraud, 280 Frankel, 264 Friability of bones, 88 Friedreich, 56 Gait in hysterical paralysis, 49 Galton, 67, 72 346 INDEX. Gallon's whistle, 67 Genito-crural nerve, disease of, 226 Gilles de la Tourette, 21, 195 Girdle pains, 185 Gliosis, 187 Glossy skin in neuritis, 213 Gluteal nerve, disease of, 228 Glycosuria in spinal injuries, 177 Godding, 109 Glosso-pharyngeal nerve, function of, 119 Great sciatic nerve, diseases of, 229 Guder, 146 Hallucinations, hysterical, 71 Hammond, 139 Handfield-Jones, 21 Headache, paroxysmal, 30 Head injury a cause of dementia, 159 injury, localization of cerebral symptoms, 102 pain, 124 susceptibility to injury, 88 Heat and cold tests, 244 Hebephrenia of traumatic origin, 155 Hematemesis, 41 hysterica, 75 Hematomyelia, 186 Hematorrhachis, 184 Hemianesthesia, 61 Hemiplegia, 47 cerebral, 122 crossed, 107 feigned, 299 hysterical, 47 Hemorrhage from the ear, 98 into the cord, 184 in cranial fracture, 98 Heredity in neurasthenia, 21 Hernia cerebri, 99 Hirt, 26, 121 Hitzig, 104 Hodges, 15 Homonymous hemianopsia, 115 Horsley, 104 Huchard and Weil, 31 Hydromyelia, 187 Hyperalgesia, 60 Hyperesthesia, 60 of organs of special sense, 72 Hypoglossal nerve, lesions of, 119 Hysteria, 44 anesthesia in, 59 aphonia in, 73 cataleptoid phase of, 79 etiology of, 86 fatality of, 264 forms of, 44 hemiplegia in, 47 interparoxysmal state of, 78 liability of races to, 86 major, 78 memory in, 78 mental condition in, 77 moral weakness in, 80 motor symptoms, 47 mutism in, 73 pathology of, 81 physical defects in, 45 religious manifestations of, 77 schematic illustration of fields of consciousness in, 82 sensory symptoms of, 59 spasms and contractions in, 51 splanchnic, 75 suggestion in, 83 suppression of urine in, 77 the reflexes in, 59 tremor in, 57 trophic alterations in, 45 troubles of respiration in, 74 Weber's table, 63 Hysterical amblyopia, 65 arthralgia, 71 contractures, 51 deafness, 67 hallucinations, 71 hemiplegia, 47 locomotor ataxia, 200 paralysis, 47 paralysis, gait of, 49 Hysterogenesic zones, 6i, 70 Idea of required effort, 24 Incontinence, simulated, 300 Infection, 252 INDEX. 347 Infective cerebral disease, 127 Injury of coccyx by fracture of hy- draulic pump, 174 of cranial nerves, 99 of peripheral nerves, prognosis of, 278 of the cranium and its contents, 87 of the vertebral column, 163 Incisors, condition of, in hysteria, 45 Insanity, depressive, 24 feigned, 309 primary traumatic, 146 traumatic, 143 traumatic, in predisposed sub- jects, 150 Insensibility to pain, 12 Insomnia, 28 Insurance, accident, 5 Intention tremor, 58 Intercostal neuralgia, 31 Intestinal autotoxemia, 43 Intolerance of stimulants in insanity, 145 Introduction, i Ischuria, 77 Jacksonian epilepsy, 123 Jacoby, 101 Janet, 16, 29, 77, 149 Keate, 270 King, 56 Kirchoff, 27 Knapp, 16, 286, 309 Knee-jerk, 59 Kocher, 90 Kowaleski, 196 Kronthal, 75 Kummel's disease, 170 Kyphosis, 170 Laceration and contusion of brain, 92 Lavillain, 22 Lead paralysis, 235 Leffebre, 16 Le Grand du Saulle, 159 Leptomeningitis, 133 Lewis, Bevan, 144 Limitation of visual field, 65 Litigation psychosis, 9, 15 Localization of cerebral lesions, 121 of cortical centres, 103, 104 Locomotor ataxia, 193 symptoms of, 196 traumatic, 195 Lombroso, 12 Loss of color sense, 66 of memory, 146 , of memory due to concussion, 148 of taste, 119 Lumbago, 167 Lumbar injury, 165 lesions, varieties of, 173 nerve, disease of, 225 puncture, 44, 195 Lyle Smith, 102 McDiLL, 127 Macewen, 130 Main-en-griffe, 53, 192, 209 Major or grand hysteria, 79 Mannkopf test, 70, 307 Marie, 195 Mathieu, 24 Maudsley, 22 Median nerve, neuritis of, 214 nerve paralysis, 226 Medulla oblongata, disease of, 114 Megalopsy, 67 Memory, loss of, 146 Mendicans facies, 27 M&ifere's disease, vertigo of, 114 Meningeal hemorrhage, 184 Meningitis, cerebral, 131 spinal, 178, 181 Meyer, 143, 264 Micropsy, 67 Middle meningeal arteries, rupture of, 99 Miles, 91 Mimicries, nervous, 34 Mitchell, 262 Monocular polyopsia, 67 348 INDEX. Morris, iii Motives of litigant, i Motor centres, localization of, 103 points, 241 Mott, 138 Movement and gait in spinal fract- ures, 180 Multiple cerebro-spinal sclerosis, 135 Mumford, 268 Munk, 104 Muscae volitantes, 30 Muscular atrophy, professional, 192 Musculo-spiral paralysis, 234 Mutism, 73 feigned, 320 Myelitis, compression, 163 Myers, 77 Myoclonus, 57 Myokamia, 56 Myotonia acquisita, 56 Nerve injuries, peripheral, 207 Nervous mimicries, 34 Neuralgia, intercostal, 31 Neurasthenia, alcohol in, 23 backache in, 25 blood in, 42 cephalalgia in, 29 circulatory disturbance in, 40 condition of urine in, 43 digestive function in, 42 facies in, 27 hematemesis in, 41 hypochondriacal type of, 26 illusions in, 30 indecision in, 24 insomnia in, 23, 28 loss of will power in, 24 mental condition in, 24 motor symptoms of, 38 obsessions in, 25 quasi-hallucinations in, 33 rachialgia in, 29 reflexes in, 23, 39 sensory symptoms of, 29 sweating in, 40 symptoms of, 23 tobacco, syphilis, lead, intestinal autotoxis, lithemia, influenza, malarial poisoning, gout, dia- betes as causes of, 22 Neurasthenia, traumatic 15 tremor in, 38 vasomotor disorders in, 40 vertebral tenderness in, 31 vertigo in, 37 visual changes in, 36 Neurasthenics, emotional condition of, 24 Neuritis, trophic changes in, 213 of median nerve, 214 Neuromimesis, 85 Neurosis, epileptoid, 13S Neurotic edema, 75 Nystagmus, 108, 163 Objective, 13 Obscure fracture of skull, 97 Obsessions, 78 Obturator nerve, disease of, 226 Qidema. See Edema, 98 Olfactometer, 68 Olfactives, 33 Operation in spinal injury, 273 Oppenheim, 15, i6 Optic-nerve atrophy, 115 Organic anesthesia, 178 Osier, 75 Otitis media, 130 Pachymeningitis interna haemor- rhagica, 131 spinal, 181 Page, 9, 16, 161, 289 Paget, 85 Pain, feigned, 306 insensibility to, 12 referred, 245 Papillitis, 113 Paralysis agitans, 136 agitans, hysterical, 58 Brown-S^quard's, 181 cervical, 172 of diaphragm, 172 Erb's, 231 feigned, 297 INDEX. 349 Paralysis, hysterical, 47 musculo-spiral, 234 of deltoid, 232 of median nerve, 236 of serratus magnus, 232 of supinator longus, 234 of ulnar nerve, 236 peripheral, 209 peripheral, prognosis of, 278, 279 sciatic, 237 wrist-drop in, 234 Paramnesia traumatica, 311 Paramyoclonus multiplex, 56 Paraplegia, 47 from injury of cord, 173 hysterical, 47 Paresthesia, 31,, 60 Paretic dementia, 158 contractures in, 162 symptoms of, i6o Parks, 265 Parkinson's disease, 55 Perimeter, 64 Peripheral nerve injury, 207, 217 scheme of, 217 nerve paralysis, 209, 216 Persistent ideas of heat and cold, 72 Petit, 196 Phelps, 99, 268 Physical defects., 45 Pick, 155 Pitres, 196 Pneumogastric nerve, lesions of, 119 Poliomyelitis, 233 Polyopsia, monocular, 67 Polyuria, 77 Pomme, 21 Popliteal nerve, disease of, 230 Position and appearance of patient with spinal fracture, 179 Pott's puffy tumor, 98 Precocity in hysteria, 45 Preparedness, 10, 17 Pressure paralysis, 208 Preston, 40, 262 Prince, 10, 15, 16, 32, 57 Primary traum.atic insanity, 146 Prognosis in neurasthenia, 259 in relation to the verdict, 251 in traumatic neurosis, 254 of fracture of the skull, 267 of head injury, 265 of peripheral paralysis, 279 of traumatic epilepsy, 275 Progressive muscular atrophy, 190 Psychasthenia, lo Ptosis, 117 Pudic nerve, 228 Pyogenic infection of brain, 133 quasi-hallucinations, 33 Rachialgia, 29 Railroad employees, liability to acci- dent, 10 "Railway spine," 15 Rapid respiration, 75 Raymond, 16 Raymond-Janet, 55 Raynaud's disease, 188 Reaction of degeneration, 50, 210 Recurrent ataxia, 202 Referred pains, 245 Reflexes, 241 in cerebral disease, 122 in hysteria, 59 in spinal-cord injury, 179 reinforcement in, 242 Respiration, Cheyne-Stokes', 95 rapid, 75 Richet, 55, 77, 149 Rigal, 150 Rogers, 109 Rumpf's test for tactile sensation, 243 Russell-Reynolds, 15 Sacral nerve disease, 227 Sandras, 21 Sciatic paralysis, 237 Schultz, 16 Schultze, 56 Scotoma, flitting, 117 Seguin, 63 Sensation, delayed, 125 350 INDEX. Sense, temperature, 187 Sensory areas, localization of , in cor- tex, 104 symptoms, feigned, 306 symptoms of Cerebral disease, 124 Serous fluid, escape from ear, 98 Serratus magnus, paralysis of, 232 Shock, 8 Sidis, 83 Signs of old epilepsy, 277 Simulated anesthesia, 306 Simulation, 297 of motor symptoms, 297 Skey, 21 . Skiagraphs, 249 Skull, fracture of, 96 Sleep, accidents during, 18 Slowness of development, 256 Small sciatic nerve, disease of, 228 Smell, tests for, 248 Smith and Herter, zi. Special forms of cerebro-spinal dis- ease due to injury, 135 Spee'ch disturbance, 125 centre, localization of, 104 Spinal concussion, 15 fracture and dislocation, 169 injury, prognosis of, 273 meningeal hemorrhage, 184 tumors, 183 Spine, railway, 15 Splanchnic hysteria, 75 Spondylitis, traumatic, 170 Statistics of killed and injured, 3 Stendhall, 126 Stereogenesic sense, 60 Stigmata, 255 Stimson, L. M., 96 Striimpell, 16 Subjective, 13 noises in ear, 30 Substitution of disease, 290 Suggestion, auto-, 16 susceptibility to, 8 Sweating, 40 Symptomatology of cord lesions, 172 SyringomyeHa, traumatic, 187 trophic changes in, 188 Tabes, 193 Taches, 40 Tachycardia, 40 Tactile anesthesia, 60 Tardieu, 2, 15 Temperature in spinal paralysis, 178 Tests for anesthesia, 64 for feigned anesthesia, 308 ■ Thermo-anesthesia, 60 Thomsen's symptom-complex, 52, 55 Thorburn, 273 Thrombosis, 129 Tolerance of cerebral cortex, 95, 276 Transverse section of cord, 172 Trauma, 32 Traumatic diabetes, 177 hysteria, 44 insanity, 143 insanity, acute dementia in, 155 insanity, confusional condition in, 148 insanity, dangerous form of, 144 insanity, hypochondriacal mel- ancholia, 153 insanity in the predisposed, 150 insanity, intolerance of alcohol in, 145 insanity, katatonia in, 156 insanity, loss of memory in, 146 insanity, moral changes in, 145 insanity, organic form of, 144 insanity, paranoic form, 151 insanity, paretic form of, 158 insanity, periodical form, 151 insanity, shock as a cause of, 146 locomotor ataxia, 195 lumbago, 167 neurasthenia, 15 neurosis, 15 pachymeningitis, 131 paralysis, 209 paramnesia, 311 spondylitis, 170 syringomyelia, 187 Tremor, 38 INDEX. 351 Tremor, hysterical, 57 in cerebral disease, 123 of alcoholism, 39 of Graves' disease, 39 of metallic poisoning, 58 of sclerosis, 39 simulated, 297 Trigeminal nerve, lesions of, 117 Trophic changes in cerebral disease, 127 Tumor, cerebral, 114 spinal, 183 Ulnar nerve paralysis, 236 Unfallheilkunde, 5 Unconsciousness, feigned, 314 simulated, 309 Vaporeuses maladies, 22 Vertebral column, fractures and dis- locations of, 169 Vertebral column, sprain of, 164 Vertigo, 37 Vibert, 139 Visual changes in neurasthenia, 36 field, 65 Visuals, 33 Vomiting, 134 Walton, 16, 56, 195, 273 Weeks, 112 Westphal, 16 Wharton, 265 Whittaker case, 314 Word blindness, 125 Wounds of scalp, nature of, 87 Wrist-drop, 218, 234 Wunderlich, 264 Zones, hysterogenic, 61, 70 Zwaardemaker, 68