236 Academy of Medicine. Per that condition which follows cerebral hæmorrhage, embolism of some vessel beyond the circle of Willis, or sometimes thrombosis in like region. We know that soon after the injury takes place the process of softening begins and gradually advances until a group of convolutions, or even a whole hemisphere, becomes but a creamy mass, containing degenerated nerve cells, masses of dark granules (blood vessels in a state of fatty degeneration), remains of connective tissue, etc., but no pus. The boundaries of such areas of softening are often quite distinct from the healthy brain tissue surrounding, which has led to the opinion that the degenerated substance becomes "encysted." This is particularly true of softening following cerebral hemorrhage. If the skull be opened in such cases the brain and its membranes will often look swollen, and feel as if there were a sacful of fluid beneath, and puncture allows the escape of the softened mass, semi-fluid in consistence, of purulent appearance, but in reality not pus. Here, one would naturally think, is a complete hemiplegia, or a total aphasia, or a hemianopsia, deafness or other manifestation of an obliterative process in the brain, with softening as the pathological condition—a state of absolute hopelessness that should debar even the most venturesome surgeon. haps so, if there be evidences of destruction of a whole hemisphere, but frequently the foyer of softening is but a limited one, as in embolism of that branch of the middle cerebral which supplies the arm centre and the speech This particular region is selected as one for illustration because it is one not infrequently affected by embolism, and because its contiguity to the frontal gyri often causes symptoms of mental irritation, though how often do we see patients affected by hemiplegia without aphasia, due to either embolism, hæmorrhage or thrombosis, presenting evidences of profound irritation or disturbance in those convolutions which preside over the intellect long after the subsidence. of immediate pressure symptoms! We can all call to mind many patients whose characteristics were irritability, irascibility, fits of mental aberration, and even homcoidal and suicidal impulses, of whom we have said to the friends: "You In former must bear with this man as well as you can, as he is not responsible-he has softening of the brain, and nothing can be done for him.' years I made this assertion many times, but now I am not so positive-in fact, I am almost convinced-that such cases are amenable to surgical treatment; not, indeed, as an operation to be made with the object of improving a paralysis or other manifestation of destruction of the cortex or communicating fibres, but of clearing out a quantity of irritating material and substituting one (like the blood serum or cerebro-spinal fluid) which will within a brief period fill the cavity and not give rise to symptoms of irritation. That such an operation is wholly practicable and may lead to improvement I have positively demonstrated. As an illustration the following case is cited: area. CASE.-A. M., of Indian Territory, aged 56 years; cerebral hemorrhage six years At first he was completely hemiplegic and ago, involving speech centre and arm. totally unconscious. After a few days consciousness gradually returned, and later on the use of the leg was restored. At the time of examination the following notes were made: Aphasia is total-i. e., practically so, his vocabulary being limited to "You do, you do," for yes, or acquiescence, and "Um-um" for no, or negation. Agraphia is total, but he recognizes some few written or printed words which have been read or explained to him many times. His memory is fully as good as before the "stroke," and his intellect appears but little affected. Paralysis of right arm is complete, but a fair use of the leg has been acquired. At times he is very irritable and has repeatedly threatened the life of his wife; for this, subsequently, he is very penitent, and indicates that the impulse is beyond his control. He regrets to a marked degree his mental irritability and moral irresponsibility; complains of a band-like sensation around his head, and often suffers intensely from headaches. Upon examination I made a diagnosis of softening of the brain, involving the region of the lower part of the Rolandic fissure and possibly also a part of the spheno-temporal lobe, as well as some of the parietal convolutions. I explained to him and to his physician that no one beside myself had ever even made the proprosal to operate for cerebral softening pure and simple. that it was purely experimental, as well as not wholly without danger. The reply was that anything would be encountered for a bare possibility of even in complete relief from the sometimes fearful, maddening sensation in the head. Under such circumstances, on June 27, 1892, assisted by Drs. J. F. Binnie and J. D. Griffith, I removed a considerable portion of the skull over the affected region. On turning back the dura there was disclosed a cloudy infiltrate in the pia and an apparent fluidity beneath. Taking sharp-pointed scissors I plunged them into the middle of what should have been the third frontal convolution and withdrew them, open. There followed a gush of broken-down brain and other débris of creamy consistence to the amount of fully a pint. The large cavity was carefully washed out with sterilized solution (no antiseptic solution ever being permissible inside the skull, except possibly in cases of abscesses), left filled as nearly as full as possible with the same fluid, the dura was replaced and stitched and the scalp sewed in place without drainage, after careful arrest of all bleeding, and a firm compress of bichloride gauze applied. The operation lasted but a few minutes, and the patient was put to bed without shock. He slept better that night than for months, awakening the next morning with the smiling indication that his head was better. There was a rise in his temperature to 994° on the second day, when he insisted upon sitting up in a rocking chair. On the third day he was up around the halls of the hospital with a profoundly cheerful, "You do, you do," in reply to inquiries if he felt better. The improvement was not temporary, as was predicted by some who heard for the first time my proposition that such cases can be relieved by operation. To this day he has had no recurrence of the bad symptoms, is passing an enjoyable life in traveling, and has sent me, I believe, six other cases for trephining, and with his grateful "You do, you do" is spreading the good news that for such hitherto helpless cases there is a probability of relief in surgical interference. Of course there is no improvement in his speech nor in the use of his arm, but he thinks he has far better control of the leg than before the operation. Such cases as this, it seems to me, are more convincing than any theoretical objection, and especially are more powerful than all the verbal arguments based upon the conservatism of the days of preantiseptic surgery, and the erroneous idea that the cranium should be invaded only in cases of urgent necessity. In an experience in intra-cranial surgery, which now covers, I believe, more cases than that of any other surgeon in America, I have learned that an exploratory trephining is fully as justifiable as an exploratory laparotomy, and that many cases heretofore regarded as beyond the help of the physician may with propriety be turned over to the surgeon, among which may be reckoned certain selected cases of cerebral softening.-University Medical Magazine. CORRESPONDENCE. SECTION ON GENERAL SURGERY, PAN-AMERICAN CONGRESS. The Section on General Surgery extends a cordial invitation to all medical gentlemen engaged in the practice of Surgery; as teachers or practitioners in any of its branches, to participate in all its meetings, and contribute papers for the general information. Such papers should conform to the requirements, as set forth in the general regulations of the Congress. In view of the wide extent of the constituency of the Congress and the varied human environment necessarily under observation, it is suggested that the topic of endemic or surgical disease prevalent in each country might fittingly receive a large share of attention from the members of this section; but carefully written papers upon any topic connected with Surgical Bacteriology, Surgical Pathology, or Operative Surgery of the Regions, will be welcomed by the Section. Chicago, Ill. JOHN B. HAMILTON, Executive President. PLEURISY COMPLICATED WITH GASTRITIS. On June 14, I was called to see Orman W. General health poor, predisposed on mother's side to tuberculosis. Has been sickly most of his life. No previous severe sickness or injury. Hygienic surrounding not of the best, parents poor. Date of present trouble not definite. Date of seizure June 14. Dyspnoea, rapid breathing (62), pulse 122, temperature 104.2° F., pain in left side, and especially marked in stomach. Tongue slightly coated, bowels rather loose, loss of appetite, some headache, urine appeared normal. Position dorsal decubitis. Face pale, anæmic, skin dry, rather waxy hued, not much thirst, bowels distended with gas. I was struck at once with the marked disturbance of pulse and respiration ratio. Auscultated and percussed lungs. Respiratory murmur normal on right side, appeared to me good on left side but there was a pleuritic frictrion low down posteriorly on left side, but only once. The area of cardiac dullness appeared rather increased, Some cough, breath fœtid. I diagnosed a slight pleurisy but gave most attention to the intense gastralgia. Treatment: Sinapism over left side. Phenacetine to reduce temperature, 6 grains every hour for 2 or 3 doses. 10 grains of bismuth and nux vomica, grain, to allay grastric disturbance. This seem to have the desired effect and next day he was up and around again. I did not hear any more of an unfavorable nature till June 22, when I was called again and found about same conditions present with pulse 140, respiration 68, temperature 104.6° F. I I put him on antipyretics, salol and phenacetine, 3 grains each, every hour for several doses (until perspiration set in) then only if fever again arose. applied sinapism over stomach and left side. Fever never came lower than 102, pain and dyspnoea continued more or less severe, respiration once got as low as 38. On 27 his condition becoming alarming I had consultation with Dr. J. K. Lewis, of this city. His temperature was 105, respiration 78, pulse 140 in the morning, somewhat less when Dr. L. saw him. He seemed some better in the afternoon. During the night he became worse, drowsy, sordes collected on teeth, by next morning was comatose, continued so till eve and died about 7:30 on 28th. During last 36 hours would hardly swallow any medicine. Case being unsatisfactory to me I requested and obtained a post mortem. Held 29th, 11 a. m. On opening abdomen found colon greatly distended with gas. (General aspect of body emaciated, well formed, however, and no glandular enlargement detected or scars, etc.) Mucous membrane of stomach inflamed, stomach empty. Bowels contained much bile, some fæcal matter in colon. Bowels had not moved nor urine been passed for 36 hours preceding death. Spleen appeared fatty as did also kidneys and liver, but it seemed to be in isolated spots suggesting miliary tubercle. Mesenteric glands were found to be enlarged and cheesy on incision. Gall bladder full. On opening thorax heart was found to be rather large, there appeared to be an excess of pericardial fluid. Heart was taken out and examined. Right heart was flabby, cutting open in auricle overhanging tricuspid valve was a fatty mass attached to left wall of auricle by one end only. Auricle and ventricle seemed normal as to size, valves in good condition; but in pulmonary artery was a long clot which had its attachment to the wall of ventricle. It consisted of fibrinous tissue. On inspecting and incising left heart it was found to be enormously hypertrophied, valve (mitral) seemed normal, as were also the valves of aorta, but in aorta was also found a large clot with attachments to the ventricle. No pleurisy was found, on right side pleura seemed healthy, but in spots there seemed to be a consolidation and apex also of a caseous character. On passing hand into left pleural sac I found extensive adhesions and a quantity of caseous pus, firm and extending through meshes of adhesions from about the region of left nipple down and backwards covering an area perhaps as large as a good sized hand. This explained the cause of the high fever. I got a history of a cold feeling but no chill or rigors. The condition of the heart set at rest my quandary as to cause of dyspnoea. The inflamed stomach the cause of the gastralgia, but as to what started the inflammation of stomach I could not ascertain. Respectfully, Argentine, Kas. G. F. MESSER, M. D. THE WOMAN'S CLINIC, UNIVERSITY MEDICAL COLLEGE. Herewith is given the quarterly report of the Woman's Clinic of the University Medical College, Kansas City, Mo. Total number of cases seen during March, April and May, CASES OPERATED ON, SAME PERIOD. Perineorrhaphy-laceration of perinæum, complete or incomplete, Laparotomy for diseased tubes and ovaries Hysterectomy-cancer of uterus, Currettement of uterus, Total number of operations from clinical material, 440. 80. 8. 6. 5. 1. 10. 30. The new cases seen were classified according to history and diagnosis, as follows: Uterus, either normal in size, subinvoluted, retroverted, antiverted, adherent or not-with or without laceration of os or perinæum, but in every case with evidences of recent or remote intra-pelvic inflammation causing distortions, diseased conditions of tubes and ovaries, interference with circulation and nerve reflexes, Total, Cases without recognizable uterine disease, 1. 4. 2. 4. 1. 1. 2. 3. 2. 1. 5. 4. 34. 75. 5. Total new cases, 80. CHAS. W. ADAMS, A. M., M. D., The third annual meeting of the American Electro-Therapeutic Association will be held in Chicago, September 12th, 13th and 14th, at Apollo Hall, Central Music Hall Block. Members of the Medical Profession interested in Electro-Therapeutics are cordially invited to attend. Augustin H. Goelet, M. D., of New York, is President, and Margaret A. Cleaves, M. D., is Secretary. OBSTETRICAL CLINIC, UNIVERSITY MEDICAL COLLEGE. The following is the quarterly report of the Obstetrical Clinic of the University Medical College of Kansas City, Mo. First stage,...........9 hrs. | Second stage,........ .1 hrs. | Third stage,...........35 min. A Practical Treatise on Materia Medica and Therapeutics, with Especial Reference to the Clinical Application of Drugs. By John V. Shoemaker, A. M., M. D., Professor of Materia Medica, Pharmacology, Therapeutics, and Clinical Medicine, and Clinical Professor of Diseases of the Skin in the Medico-Chirurgical College of Philadelphia; Physician to the Medico-Chirurgical Hospital; Member of the American Medical Association, of the Pennsylvania and Minnesota State Medical Societies, the American |