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NOTES.

SULPHUR is recommended as an antiseptic wound dressing.

ASAFETIDA is recommended in all nervous phenomena incident to pregnancy.

SAW palmetto in ten drops of the fluid extract is said to be a specific for sick headache.

FOR a hoarse barking cough without secretion, lippia mexicana is reported to be practically a specific.

INHALATIONS of a twenty per cent. solution of menthol is said to give most satisfactory results in certain forms of asthma.

A HYPODERMIC injection of nitro-glycerine, in doses of one one-hundredth of a grain, is said to relieve asphyxia from illuminating gas.

IT has been recently stated that convallaria acts particularly on the right side of the heart, while digitalis acts principally on the left.

ARSENIC is said to control repeated attacks of herpes. It may be necessary to continue the treatment over a period of two or more years.

ONE gramme, three or four times daily, of salophen in acute articular rheumatism answers every purpose when the salicylates are not well borne.

*

CHLORAL hydrate, in doses of two or three grains in a teaspoonful of syrup, every three or four hours, is said to exert a powerful influence for good in scarlet fever.

AMERICAN ACADEMY OF RAILWAY SURGEONS.

Rail

THE following titles for papers have already been received for the Second Annual Session of American Academy of Railway Surgeons, to be held in Chicago, Ill., September 25, 26 and 27, 1895: A Practical Way of Testing Railway Employes for Color Blindness, Dr. D. C. Bryant, Omaha, Neb. way Sanitation, Dr. W. M. Bullard, Wickes, Montana. Transportation of Injured Employes, Dr. F. H. Caldwell, Sanford, Fla. Traumatic Neurosis, Dr. Henry W. Coe, Portland, Ore. Concussion of the Brain, Dr. W. H. Elliott, Savannah, Ga. The Use of Gold Foil in Fractures of the Cranium and Resulting Hernia Cerebri, Dr. W. L. Estes, S. Bethlehem, Pa. Wounds that Open the KneeJoint, Treatment, Dr. C. D. Evans, Columbus, Neb. Treatment of Wounds of the Face and Scalp, Dr. Chas. B. Fry, Mattoon, Ill. Sanitary Regulations Governing Railways, Dr. L. E. Lemen, Denver, Col. Injuries of the Hands and Fingers, Dr. John McLean, Pullman, Ill. How to Differentiate Between the Use of Heat and Cold in Railway Injuries, Dr. Wm. Mackie, Milwaukee, Wis. IntraVenous Injection of Neutral Salt Solution in the Treatment of Desperate Injuries; Exhibition of Apparatus, Dr. C. B. Parker, Cleveland, Ohio.

The Baltimore & Ohio Railroad maintains a complete service of vestibuled express trains between New York, Cincinnati, St. Louis and Chicago. Equipped with Pullman Palace Sleeping Cars, running through without change. All B. & O. trains between the East and West run via Washington. R. B. Campbell, General Manager; Chas. O. Scull, General Passenger Agent, Baltimore, Md. Principal Offices: 211 Washington Street, Boston, Mass. 415 Broadway, New York. N. E. Cor. 9th and Chestnut Sts., Philadelphia, Pa. Cor. Baltimore and Calvert Sts., Baltimore, Md. 1351 Pennsylvania Avenue, Washington, D. C. Cor. Wood St., and Fifth Ave., Pittsburg, Pa. Cor. Fourth and Vine Streets, Cincinnati, O. 193 Clark Street, Chicago, Ill. 105 North Broadway, St. Louis, Mo.

Delegates and visitors to the Chicago meeting will find the equipment of the Baltimore and Ohio trains complete in every detail, affording speed, safety and comfort.

Two or three cases of severe hemorrhage of the brain, which have come under my care in my service at the Emergency Hospital, all of which ended fatally, have prompted me to report them to this Society. I will simply make a few preliminary remarks and then show you the brains, which have been in formaline.

Cerebral hemorrhage is generally treated first by the general practitioner and afterwards the neurologist gets him for the paralysis. Cerebral hemorrhage is the result, of course, of rupture of the blood vessels of the meninges or of the brain itself and the escape of blood into the adjacent tissues. If the extravasation be meningeal, its effects are exerted chiefly on the gray matter of the convolutions, if within the substance of the brain, tracts of fibers are torn across by the escaping blood and thus are separated from their connection with the cortex. Sometimes if the hemorrhage be within the brain, if the blood does not enter the ventricles, it exerts pressure on them and stops the flow of cerebro-spinal fluid.

The artery most frequently ruptured when the hemorrhage is on the surface is the middle meningeal. It is particularly liable to be involved in direct injuries to the head, as I will show you in one of the brains directly. Its area of

distribution corresponds to that involving the motor areas and for this reason the blood extravasated from that artery is particularly prone to press on the motor convolutions beneath. If the escape of blood is sufficiently large, actual damage may be done these cortical centers, but if it is small, the brain is simply rendered anemic at the seat of pressure. If the clot can be located and removed by trephining, the functions may be regained, or if the clot be gradually absorbed, the same thing would happen but I doubt if it is ever completely absorbed. The inhibitory influence of the brain being cut off, there is generally exaggerated knee-jerk and frequently ankle clonus. It is also said that it is due to a structural change in the motor convolutions, followed by a descending sclerosis of those fibers that are anatomically associated with the cortical cells destroyed. This sclerosis can often be traced into the substance of the spinal cord.

The most common seat of intra-cerebral hemorrhage is within the substance of the caudate nucleus and lenticular nucleus of the corpus striatum and the thalamus of either hemisphere, what is commonly called the internal capsule. The right side appears to be more frequently affected than the left. The pons varolii and the cerebellum are often the

seats of clots. There is usually a loss of consciousness in attacks of cerebral hemorrhage. Duret as quoted by Hammond accounts for it in this way. The caudate nucleus of the corpus striatum and the thalamus of each hemisphere enter into formation of the ventricles, hence any lesion of these ganglia would be liable to cause displacement of cerebro-spinal fluid and it is the displacement of the cerebro-spinal fluid that causes the loss of consciousness; also frequently in cerebral hemorrhage, the senses of sight, hearing, smell, taste and tactile sensibility are affected because their fibers run into the internal capsule. Gray describes five different ways of recovery from hemorrhage into the brain. substance.

1. The clot generally becomes encapsulated by the formation of a false membrane; the surrounding tissue is at first edematous and pultaceous. The capsule may be a thin layer of thickened neuroglia or occasionally by the formation of actual fibrillous connective tissue.

2. A serous exudation combined with fatty metamorphosis softens and dissolves the clot and the débris of brain tissue and changes them into a yellowish fluid.

3. Bands of connective tissue form from the sides of the cyst so produced and traverse it in all directions.

4. After a lapse of time these connective tissue bands contract and draw the sides of the cyst in apposition, the fluid contents becoming absorbed to a greater or less extent.

5. A stellate and pigmented cicatrix often forms. A so-called apoplectic cyst may be formed, by absorption gradually taking place of the retrograde fatty metamorphosis of the fibrin of the clot and injured nervous elements, thus forming a cavity which is filled with a clear fluid, surrounded by a smooth wall.

Apoplectic cysts may assume two forms. 1. Where the blood is collected into a circumscribed mass, making what is called an apoplectic focus. 2. Where minute points of capillary extravasation are alone detected.

In regard to the most frequent seat of hemorrhage into the brain, An

dral reports 386 cases, in which he found that the corpus striatum was involved in 61, the optic thalamus in 35, the centrum ovale in 27 and the centrum ovale and basal ganglia together in 202, and other writers give statistics which practically correspond with those of Andral. It thus appears that the lenticular and caudate nuclei of the corpus striatum were attacked in a very large percentage of all the cases and that the optic thalamus ranks next as the most frequent seat of hemorrhage.

Vascular changes in the vast majority of subjects have preceded the rupture of the cerebral vessels, unless it be dependent on traumatism. Among the conditions that tend toward rupture, miliary aneurism, atheroma and fatty degeneration of the vessels stand foremost. The various causes of embolism and thrombosis may also indirectly produce a hemorrhage. Increase of arterial tension may be a cause but the arteries are already diseased. In the general endarteritis which is associated with hypertrophy of the left ventricle, hemorrhage is rather frequent. Certain diseased organs may be factors in producing cerebral hemorrhage; for example, hypertrophy of left ventricle or valvular disease of heart, chronic nephritis, which induces changes in the coats of the blood vessels, miliary aneurism, compression of the jugular veins, certain blood diseases as chlorosis, scurvy, syphilis, typhus, gout, chronic alcoholism, rheumatism, etc.

Age has quite an influence, being more liable to occur after about 40, but Ranney says from 20 to 60. Men seem to be more liable than women.

There are usually some prodromal symptoms, such as headache, vertigo, insomnia, flushing or pallor of the face, bleeding from the nose, ringing in the ears, specks before the eyes, nausea, disturbance or thickness of speech.

Ranney regards epistaxis in old people as a bad sign. The actual symptoms of an apoplectic attack are modified by 1. The amount of blood that escapes. 2. The damage done to brain cells or nerve fibers. 3. By the seat of the clot. The onset may be sudden or gradual.

A hemorrhage into the ventricles or in the medulla, pons or cerebellum, is liable to cause the patient to fall to the ground without a moment's warning, just as if struck by a blow, even though the hemorrhage is small. These are not typical, however, because they are so much less frequent than those in which the hemorrhage is upon the hemispheres.

The onset of a typical case of apoplexy is when there is loss of consciousness, which may be sudden and complete or gradual. During the comatose state, the face is usually flushed and swollen or pale and clammy, the eyes fixed, the pupils dilated (but this is not always the case), slow and probably stertorous respiration, pulse slow and full and limbs inert, sometimes there may be clonic convulsions or paralysis of an arm or leg or some particular muscles of the face. The temperature is generally subnormal, going down sometimes to 96°F. Conjugate deviation of the eyes, with rotation of the head away from the paralyzed side and toward the hemisphere which is affected often occurs as a temporary symptom. Death occurs in some cases in several hours or may be delayed. In favorable cases consciousness returns after a short time. The patient is liable to have cerebritis, beginning within the second week.

As said above, the internal capsule is the most frequent seat, as the anterior portion where the motor fibers come down from the hemispheres. When

contractions of the affected limbs take place it is always a bad sign. It is of interest to note that in cases of monoplegia, the lesion is almost sure to be in the cortex. Ranney's formula for differentiating these lesions is as follows; 1. Cerebral paralyses occur chiefly on the opposite side of the body below the head; this is true of both sensory and motor paralyses. 2. Motor paralysis of cerebral origin is liable to be associated with more or less disturbance of sensation when the lesion is non-cortical. This is not the case, as a rule, when the lesion is situated upon the surface of the brain. 3. When sensory and motor paralysis coexist as a result of cerebral lesion, they are upon the same side; the

reverse is true of spinal lesions. 4. Lesions within the cranium that cross the mesial line are liable to produce paralysis on both sides of the body. 5. Lesions of the base of the brain are more liable to produce paralysis of the cranial nerves than are those of the hemispheres or basal ganglia. Vomiting and choked disk are frequently observed in these cases. 6. The sensory areas of the cortex commonly give rise (when circumscribed lesions tend to impair or destroy their functions) to disturbances of vision, hearing, smell or touch. If the lesion be very extensive, hemi-anesthesia may be produced. On account of its having to be so extensive, it is seldom of cortical origin. 7. Consciousness is not usually lost with purely cortical lesions. Apparent exceptions to this statement occur, but they are attributed to the effects produced by the lesion on deeper parts. 8. Epileptic attacks (whose paralysis is of a transient character after the fit) indicate an irritation of the cortical motor centers by the lesion. This is what is usually termed Jacksonian epilepsy.

2.

Cortical lesions may be indicated by 1. Monoplegia of the opposite side. By disturbance of some special sense. 3. By the presence of consciousness at the time of the attack. 4. By an early rigidity of the paralyzed muscles. 5. By circumscribed pain at the seat of the lesion, which may be elicited or increased by percussion over the lesion. 6. Possibly by Jacksonian epilepsy.

Trephining would be contra-indicated if sensory and motor disturbances coexist in a purely cortical lesion, because it would necessarily be a large hemorrhage to cover both motor and sensory areas of the cortex.

One peculiarity of persons affected with cerebral hemorrhage is that they are very emotional, they cry or laugh without a just cause. I have noticed this many times myself, but do not remember having read of it in any textbook. If I were to go on into the various special types, it would make this paper very much too long, but one point seems important to remember, that if the facial muscles are paralyzed and

hemiplegia coexists, the seat of the lesion is within the pons varolii. If in the upper part of the pons, the facial and body paralysis will be on the same side. If in the lower part of the pons, the facial and body paralysis will be on the opposite side..

The line of treatment of the cases that have come to our clinic has been very much the same. If a syphilitic history can be made out, we put them on the mercury and iodide treatment, or even if it is not syphilitic but of recent date, I put them on the same treatment. If it is an old case, he gets statical electricity to the paralyzed muscles and large doses of strychnia. Hammond claims that much better results can be obtained by giving the strychina hypodermically but it has been impossible for us to do that there as we only hold two clinics a week.

I have brought three or four brains here and before showing them to you, I will give a short history of the cases. I do not know anything of the previous history of any of them, as they were all brought in the ambulance and nobody could tell me a thing about them.

CASE I. — A man about 70 years of age was seen to fall in Lafayette Park. The ambulance was summoned and he was carried to the Emergeney Hospital. I saw him soon after. He was in a state of deep coma and it was impossible to tell whether he was paralyzed more on one side than the other. In fact, he did not move a muscle. The right pupil was contracted and the left dilated. Breathing was deep and stertorous and decidedly Cheyne-Stokes in character. The respiration finally got so slow as to number only about two per minute. It was thought that on account of the disturbed respiration, there was a clot in the fourth ventricle. He died in about four hours and this is his brain; it has been in formaline. You see these large clots, one in each lateral ventricle and a small one in the fourth ventricle. There was also a large quantity of blood at the base of the brain.

CASE II. —A colored man was brought in the ambulance. He was in a state of coma, both pupils contracted, his

right side paralyzed. He would move his left arm and leg slightly when stuck with a pin. His coma became deeper, his respirations slower and he died in about six or eight hours after admission. This is his brain. You observe a very large clot in the left lateral ventricle, with only a small one in the right. This man's condition was very much like that of Case I.

Albu

CASE III. This case is one of great interest and I hope the members of the Society will discuss it thoroughly, because as yet, the diagnosis is not perfectly plain. A woman was seen to fall in an alley and was found in an unconscious condition and brought to the Emergency Hospital in the ambulance. On examination I found that she was paralyzed on her right side, with the comatose condition still existing. The urine was drawn and examined. men was found but no. casts and no sugar. The next day she had recovered consciousness and could slightly move her right leg but could not move her right arm and while she could make sounds, she could not talk distinctly or even call the correct words, although she apparently understood exerything that was said to her. She was very emotional and wept whenever I spoke to her. I thought that the aphasia and paralysis of the right arm and partial paralysis of the right leg indicated a hemorrhage on the left cortex of the brain, involving the speech, arm and partly the leg centers and was of the opinion that trephining would be of benefit. So I consulted Dr. James Kerr, the surgeon to the Emergency Hospital, and he agreed with me exactly about operating. She was put under ether and Dr. Kerr trephined her and I assisted him. No clot was found; a small probe was introduced in different directions to see if there could be a clot or abscess or tumor, but nothing was found, except the convolutions immediately under the trephine were a little softer than the surrounding ones. The operation was rather long and tedious and she never seemed to rally very well and died about the fourth day from the operation. I examined her brain and sliced it up