There is another point I would like to mention, and that is, when a physician has one of these infectious cases which develops erysipelas he should change the patient's clothing, disinfect himself as though he had seen a case of smallpox, before he sees another surgical or obstetrical

case.

Dr. John E. Owens of Chicago: In the discussion of this paper sufficient emphasis has not been laid upon the treatment by carbolic acid. The author of the paper used the term pure carbolic acid, and by that we mean acid which does not contain any kind of foreign matter visible to the eye, but I presume he meant 95 per cent carbolic acid. The treatment by carbolic acid I consider very valuable, if it is immediately followed by alcohol, as has already been mentioned. But pure carbolic acid, 95 per cent carbolic acid and strong carbolic acid were the terms used, I believe, and I think the author meant 95 per cent carbolic acid.

Recently I encountered a case where an amputation was done at the knee-joint. The flaps sloughed, and were in a state of gangrene when I saw the patient only two or three days thereafter. It goes without saying that the flaps were undermined. When I came to reamputate, after the flaps were cut away and the parts had been pretty well cleaned off, I made new flaps, and lest infection should creep into them I coated them with 95 per cent carbolic acid, and had the alcohol at hand ready, so that I could pour the alcohol over, and almost by magic we saw the white condition of the coagulated tissue, which was caused by the 95 per cent carbolic acid, disappear.

Dr. D. S. Fairchild of Clinton, Iowa: In regard to carbolic acid, when used in the strength of 95 per cent, there is a small chance of absorption. There is danger of absorption when used in weaker solution, in operations upon the knee-joint, in resection for tuberculosis and other conditions, use the 95 per cent carbolic acid, cover the part thoroughly with it, wash it off as Dr. Owens has described and close the joint by

suture.

N

In regard to the treatment of infected fingers, I must take exception to what some of the gentlemen have said, because I think irrigation is bad practice. Furthermore, I think multiple incisions are bad practice. When a case of infected finger comes under my observation I believe it should be treated by warm applications and absolute rest. The patient should be put to bed, put in a condition of rest and not be allowed to go about. If you make multiple incisions in cases of infection of fingers you are sure to open up new avenues for infection through the incisions that have been made. If an infected finger is covered by a copious wet boric acid dressing or a solution of that character, and the patient is put to bed, you will get a result which you could not get by making incisions and allowing the patient to go about. opposed to making incisions in these cases unless I am reasonably certain pus is present. If we have an infected wound and know that pus exists there, then we liberate it by making an incision. In the absence of pus I would not make incisions, but put on copious wet applications and advise the patient to go to bed.

I am

Dr. J. H. W. Meyer of La Porte, Ind.: The local treatment has been variously stated, but very little has been said with reference to the patient himself. When a pa

tient comes to us with a septic finger he is usually suffering from constitutional infection. He needs, therefore, constitutional treatment. fore, constitutional treatment. Nothing has been said in regard to that. A good dose of quinine is good treatment for the alimentary canal, which should generally at that time be looked after, and which is just as important as the local treatment. The carbolic acid treatment is what I use during the operation. I also believe that incision should only be made when we have reason to believe that there is pus present to be evacuated. stead of irrigation I usually resort to loose packing with iodoform gauze, so that the infectious material has a means of getting out. I would advise putting a patient with an infected finger to bed during the treatment. With a good opening for the iodoform gauze packing and boric acid solution, we may expect generally good results.

In

Dr. W. S. Hoy: You stated, doctor, you would not think of making an incision in a case of infected finger without cause. What do you consider sufficient cause for making an incision?

Dr. Meyer: Fluctuation, edema or general swelling of the parts One can tell by exercising his judgment whether there be an abscess, even though there may not be fluctuation. There are so many points in connection with a subject like this that one can hardly touch on all of them in a short discussion.

Dr. Baker of Missouri: With reference to this subject of infection of the fingers, I want to say a word or two in regard to incising the parts. My observations lead me to cut about the fourth or third day, or earlier if necessary, when there is the formation of pus. When there is the formation of pus the patient cannot very well hold his hand down, but he should hold it up, and you may know whether or not there is pus present. It may not be more than a mere drop. Many a time in this class of cases I have made an incision and only got a drop of pus. After incising the part I use 95 per cent carbolic acid, etc.

Dr. Rhett Goode of Mobile, Ala.: I have been interested in this paper and the discussion which it has elicited. I am induced to add a little to the discussion, although I am aware by giving my experience in comparison with those gentlemen who have had a more extensive experience and a greater number of cases it is rather presumptuous, but still I have arrived at the conclusion that carbolic acid is about one of the most useless remedies one can use except in certain cases. When it is smeared over the tunica vaginalis for the radical cure of hydrocele, and immediately mopped off by the application of alcohol, I have seen it do good in such cases. The acid does not remain there long enough to have very much effect. Possibly its use about joints, as spoken of by Dr. Owens, is very valuable, but as an antiseptic for an infected wound I think bichloride of mercury is better than carbolic acid. If my finger was infected and I had a wound of any kind and had to go to a physician, I would much prefer to have him use bichloride of mercury in order to get rid of any infectious material there than carbolic acid. That is my belief, and I am not disposed to change it even after the able arguments I have heard. to-day. Bichloride of mercury seems to have been entirely ignored in this discussion, and carbolic acid seems

to have taken its place as an antiseptic. This is not in accord with my views and experience.

Dr. Leipziger (closing the discussion): In my paper, in speaking of primary irrigation and packing the wound after the finger was operated on, I believe I mentioned the use of bichloride of mercury solution. However, I am not positive about that. I have a decided antipathy toward carbolic acid in weak solutions, however much good it may do when concentrated.

Referring to the remarks of Dr. Fairchild as to incisions, he stated he did not believe that very early incision was the proper thing to do; that when a patient came at first the infected finger should be wrapped in a warm antiseptic solution and then let the patient go. I am reminded that no less an authority than Koenig states in his last textbook on surgery that the two cardinal sins in the treatment of infected fingers are: First, delay in making an incision, and, second, the use of greasy poultices and things of that kind. The treatment Dr. Fairchild has oulined is responsible, to a great extent, for many fingers which go to the bad, and so many of them have to be cut off, and I believe it is the cause of many cases of sepsis being produced.

I just left a nurse at the hospital at home who had lost two-thirds of the index finger, and a valuable finger at that, who wants to do massage and other work with her right hand, simply because incision was deferred too long, because fluctuation was waited for, and the finger incised then. When fluctuation is found at the end of the finger, the pus is not surrounded in a little sac, as in the case of an appendiceal abscess; maybe it is circumscribed. In some cases it is, and the finger may get well with poultices, and in other instances without anything. My contention is that a far greater number of cases will get well if incision is made early before pus has been allowed to form in the case, and by incision I don't mean lancing. The reason why early incision is followed by trouble and annoyance is because the finger is lanced, not incised, and by lancing I mean that the doctor takes a scalpel, cuts through the skin, and sometimes barely goes through it. It does not do much good, but causes pain

and soreness about the wound.

What I said about the pathology of the disease should be clearly understood, and the operation should be done as skilfully as possible, and I still maintain that it is very essential in the treatment of these cases that when a finger is incised it should be incised down to the bone or over the seat of the bone, regardless of whether pus can be detected externally or not. If, in the first three hours after the patient has pain in the finger there is any evidence of the finger being infected, and a half-inch incision is made through the periosteum and a moist packing applied and the wound kept open, the vast majority of cases will get along swimmingly and the infection will be stopped.

Speaking of the use of carbolic acid again, I recall a case of gangrene which was unquestionably due to the use of carbolic acid solution used on an infected finger, the solution having been very weak or mild. This prompted me to look up the literature of the subject, and I found Czerny had reported some thirty cases, and some writers in this country have written articles on gangrene following the use of carbolic acid solution. I think it is the

consensus of opinion that pure or full strength carbolic acid, especially when it is followed, as has been suggested, by alcohol, the alcohol will invalidate the objection to the acid and remove that danger of gangrene.

Referring to the remarks of Dr. Ortega, I will say that the paper did not deal with infected fingers produced by the physician or surgeon; therefore, the preparation of the nails of the surgeon does not come under the scope of the paper.

ANCHORAGE OF TENDONS IN PARTIAL FOOT AMPUTATIONS.*

BY GEORGE W. CALE, JR., M. D., F. R. M. S., LONDON, CHIEF SURGEON FRISCO SYSTEM, SPRINGFIELD, MO.

Many phases of several methods of partial foot amputations have been widely discussed for years, and good men so differ as to the usefulness of the member after any of the several classical procedures that none of the operations as usually performed are entirely without criticism. In our capacity as railway surgeons it is our duty in all operative work to secure the best physiological result for the patient, compatible with preserving life.

Operators differ as to the advisability of making a Smye, a Pirogoff or leg amputation rather than a Chopart, and while it is not my purpose to discuss their several advantages, I wish to detail the results in a couple of Chopart's that have come under my observation during

the last fourteen months.

On February 25, 1901, B. M. P., conductor, was brought to the hospital suffering with an evulsion of the foot at the medio-tarsal joint. He had stepped between two box cars of a slowly moving train to uncouple them, pulling the pin by hand, as the chain which should have held it to the lever rod was broken. He had taken but a few steps when his foot caught in a frog. He knew a fall would mean the loss of his leg, if not death, and holding firmly to the grab iron of the car in front of him he twisted and tore the foot off at Chopart's joint, the bones and covering of the metatarsus and toes hanging to the sole flap. He hopped along behind the car for about 200 feet before the train was stopped. He was taken to the hospital soon afterward, the accident occurring only a short distance from Springfield. He was particularly anxious to have no operation on the leg, and I promised to try to save the ankle-joint and as much of the foot as possible. The soft parts were torn in such a manner that it was difficult to cover all the desired surface with the sole flap without twisting it. The part corresponding to the underside of the small toe was stitched over the head of the astragalus. The extensor proprius hallucis had been torn from its entire bony attachment, and when I took hold of its tendon it came away whole.

In order to secure as useful an ankle-joint as possible I decided to suture the tendons of the tibialis anticus and extensor longus digitorium to the strong plantar fascia, which formed part of sole flap-the action of these muscles, of course, being opposed to the posterior tibial group. The Achilles tendon was not divided, as is usually done, but a posterior splint was adjusted to prevent extension

* Read at fifteenth annual session I. A. R. S., St. Louis. April 30-May 2, 1902.

of the stump until the sutured tendons had became firmly united to the flap. Had the tendons been long enough I would have anchored them to the periosteum of the anterior surface of the os-calcis, or to the long calcaneocuboid ligament.

The patient made a good recovery, and to-day his ankle-joint is as useful as the uninjured one. He had an artificial foot made in Chicago, but after wearing it a short time discarded it on account of the pain and inconvenience it gave him. He now uses his foot with an ordinary shoe, stuffing the front part of the shoe with hair. He has been walking this way for several months and limps no more than he would with an artificial foot. The Achilles tendon is not shortened, and he has practically as much power to flex the stump on the leg as in the uninjured foot.

On September 24, 1901, R. H. McA., brakeman, was brought to the hospital, the anterior part of his right foot having been crushed between a car wheel and a rail. A Chopart amputation was done, and the same procedure practiced as in the case just cited, namely: Anchoring the extensor tendons of the foot to the fascia of the sole flap and the application of a posterior splint to the leg and heel. The result is equally as satisfactory as in the first case, the patient using his shoe by simply filling the front part with hair.

When I did these operations I thought the idea of anchoring the tendons mentioned to the periosteum of the calcaneum, the plantar fascia of the sole flap, or the long calcaneo-cuboid ligament was original, not having seen it mentioned in any publication; but shortly afterward I saw in Senn's Practical Surgery and in Warren & Gould's late work that the authors had practiced the method for sometime. The deduction can be easily made a useful ankle-joint is of inestimable value, besides the leg is not shortened as in a Syme or Pirogoff. Helferich has recommended opening the astragalo-tibial joint after completion of the operation, removing the cartilage with a sharp spoon, and immobilizing the joint for the purpose of bringing about ankylosis, but we are all agreed, I think, that it is of the highest importance to preserve the usefulness of a joint wherever possible, especially such a one as the ankle. I believe in all amputations in front of the ankle the several tendons should be made fast either to periosteum, fascia or the thick sole flap in order to secure a more useful foot.

DISCUSSION.

Dr. S. S. Thorn of Toledo, O.: I have been very much interested in the paper of Dr. Cale. In my early practice I made two or three Chopart amputations. The shortening of the foot was not, to my mind, the principal objection to the operation, but the flexion of the tendon of the large muscles, which brought the foot into an undesirable position, and dividing the tendon did not, so far as I could see, relieve or overcome that objection to the operation. The method outlined by Dr. Cale is undoubtedly a distinct advance in the surgery of the foot. It is often asked, where should we amputate, and some of us have been afraid to make any section lower than the middle third-that is, to sacrifice a part of a man's walking apparatus. A successful effort of this kind will make it a more desirable operation than an operation at the point of election.

I wish to thank Dr. Cale for bringing this subject and the modified operation forward, although it may not be new to some of us.

Dr. A. C. Bernays of St. Louis: I was pleased to hear Dr. Cale's advocacy of this modification of the transtarsal operation. Apparently this modification is better than all the transtarsal operations, such as Hey's, Lisfranc's, Chopart's, perhaps also that of Pirogoff. If I am allowed to go to the blackboard and make a diagram, I think I can make it plain what we are driving at. If this is the lower end of the tibia, and this the astragalus, and this the os-calcis (indicating), the amputation is made in Chopart's joint here, in Lisfranc's joint at this point, and in Hey's at that point. The tendo-Achillis is attached to the os-calcis, the tendon reaching around under the oscalcis in this manner (illustrating), and the gastrocnemius muscle exercises a powerful pull in the direction of this arrow, so that the anterior end of the stump will strike the floor first. Dr. Cale proposes to take the tendon of the tibialis anticus, or, in fact, take any tendon of the muscles except this muscle (indicating), and attach it by means of a stitch or two to the periosteum in front, so that the pull of the gastrocnemius muscle will be counteracted by the pull from some other muscle of the leg, thus causing the foot, which would otherwise point down this way, the stump of the Chopart point down in this direction, to hold it level, and to enable the patient to move the stump. There is no doubt in my mind but what that simple technical innovation will become universally adopted, because it takes but a moment to isolate the tendon and attach it, by means of a stitch, to the periosteum, the end of the bone, either the scaphoid, or one of the three cuneiforms here in front of the axis of the foot. I do not think there is any argument necessary, because, our attention having once been called to this technical point, we will unquestionably adopt it. That is all I have to say on Dr. Cale's paper.

for two

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While I have the floor, permit me to indulge or three minutes in the matter of amputation. son why we do not have primary union in many cases after amputation is because of the fact that the stump is not properly immobilized, and I wish to say that in recent years, in every amputation of the foot at the ankle or of the leg, the hand, forearm, the thigh, I have in every single instance put a plaster-of-Paris cast upon the joint above the seat of amputation.

About five days ago I made an amputation of the thigh on account of gangrene of the toes in an old lady, and in her case the amputation was followed by the application of a plaster-of-Paris cast around the pelvis and to within a few inches of the end of the stump, thus insuring complete mechanical rest to the stump. I do not stand here in the hope of teaching you anything in regard to amputation, and if I make use of the expression that a plasterof-Paris cast adds materially to the quickness of the healing process, I mean to supplement that statement by saying it should not be put on in every case. But I say it must be put on in every case after an amputation. For twenty years I did not put on these plaster-of-Paris casts, and I know the results we achieved after amputations were all right. The patients got well. But now, after an experience of twenty-five years, I am prompted to say that in every case of amputation of the hand the meta

carpus, the carpus, the forearm, the same of the lower extremities, the limb should be encased in plaster-of-Paris above the point of amputation, leaving the end of the stump free, putting at rest the extremity above the point of amputation. If you desire the quickest possible result, if you desire the most painless, the most aseptic, the most comfortable and quickest union, then, gentlemen, I recommend that you put your limbs in plaster-of-Paris casts, for the simple and only reason that you will in that manner obtain complete rest. There is not a man in this room, perhaps, who has not read the great book by Mr. Hilton on "Rest and Pain," and who does not know that nature does her work of repair most perfectly and most quickly under the influence of rest.

A PAINLESS AND BLOODLESS AMPUTATION OF AN INJURED FOOT OF A BRAKEMAN, WITH A SIMULTANEOUS INJURY OF THE SPINE.*

BY W. N. YATES, M. D., FAYETTEVILLE, Ark.

Late in the afternoon of May 19, 1898, Brakeman Robt. H., in attempting to make a coupling between an engine and a box-car, missed the coupling in some way, and in falling upon the track sustained the following injuries: The right foot, to a point above the ankle, was ground into a pulp. The shaft of the right femur was broken about its middle. There was complete paraplegia -absolutely no motion or sensation of any part of the body below the thorax. As all hemorrhage had ceased in the injured foot, and as the shock was quite profound, Dr. Gregg and myself decided, after trimming away all hanging tags and shreds, to wash the injured extremity in a hot antiseptic solution, apply a moist sublimate dressing, then address ourselves to the treatment of the shock. By morning the patient had recovered fairly well from the shock, which was quite profound. At this time, with the assistance of Drs. Gregg and Welch, I amputated the right leg at the junction of the middle and upper thirds. As sensation was totally abolished in the lower half of the body, it was not necessary to administer an anesthetic, the patient watching the steps of the operation with as much interest as anyone in the room.

There had been an injury to the femoral artery at the point of fracture of the femur, and the resulting thrombosis had completely obliterated the lumen of the vessel. There was no arterial hemorrhage during the amputation, both the anterior and posterior tibial arteries being empty. There was just a little oozing from flaps and sawed ends of bones. No care was taken to ligate vessels -none was necessary.

After the amputated stump was dressed and the broken femur suitably splinted, we proceeded to make a thorough examination of the spine. There was absolutely no external evidence whatever of an injury to the spine-not even a contusion. The spinous processes were in perfect line, no crepitation, no increased mobility discoverable anywhere. What could be the nature of the injury to the spinal medulla? Could it be extravasation of blood, a hematomyelia? Or had an intervertebral disk been forced

*Read at fifteenth annual meeting I. A. R. S., St. Louis, April 30May 2, 1902.

out into the spinal canal, thus compressing the marrow? Or, again, was some part of the neural arch driven in upon the medulla-a fracture of the pedicle or lamina? The lesion, no matter what its nature, was below the fourth and fifth cervical vertebræ because the phrenic nerve had escaped paralysis. There was the customary pain in the arms, the hyperesthetic zone, that usually follows injuries to the cervico-dorsal region of the spine.

In the absence of all visible or palpable signs of fracture or dislocation, an intradural extravasation of blood somewhere in the cervical enlargement of the spinal medulla seemed to offer the most probable explanation of the complete motor and sensory paralysis. Taking this view of the case, no operation upon the spine was advised. Of course, there was complete rectal and vesical paralysis; cystitis developed by and by, followed by an asthenic grade of fever. There was never any improvement in the paraplegia, and after some seven weeks of a life that was more dead than alive, the patient succumbed. No autopsy was permitted.

The amputated stump behaved in a way that is worthy of mention. All oozing, never profuse, ceased after twenty-four or thirty-six hours. The limb remained blanched and exsanguinated. This condition of the member was doubtless intensified by reason of the splints and bandages about the broken femur. No dressing that would hold the fractured bone could be maintained without in some measure constricting the circulation in the limb. There was an effort at union by first intention in a portion of the wound flaps; at other points they were not adherent. The whole stump mummified, looking for the last two weeks of the man's life not unlike half-dried beef.

The points of interest about this case were:

Ist. The complete traumatic paraplegia without a visible mark or scratch upon the back.

2d. The amputation of the leg without an anesthetic, either local or general.

3d. The amputation of the leg and the section of several large arteries without the application of a ligature.

CONCUSSION OF THE BRAIN.*

BY S. A. BUCHANAN, M. D., PHILADELPHIA, PA.

In trying to select a subject that would be of interest to railway surgeons, it appeared to me that the field of railway surgical topics had nearly been exhausted; therefore, I decided to briefly discuss a few points which occurred to me in reference to a condition which is liable to occur in any railroad accident, viz., "concussion of the brain."

In presenting this subject to you, I am cognizant of the difficult task before me in trying to discriminate or diagnose this condition from other lesions of the brain. There is considerable diversity of opinion as regards concussion of the brain. Some contend, because shock and concussion may accompany each other, and that the symptoms being similar, that they are the same. In fact, some eminent authorities, like Phelps, Duret, Keen and Eskridge, are of the opinion that concussion of the brain, when considered from a surgical and neurologic aspect, is really due to a contusion or laceration of brain tissue.

*Read before the B. & O. Surgeons' Association at Atlantic City, N. Y., June 28, 1902.

Phelps and Eskridge have been so pronounced in their opinions as to say that concussion of the brain does not exist. But, in accordance with present knowledge and with the views that prevail among the best authorities on the subject, the application of the word "concussion" is restricted to a condition of pure traumatic shock, following head injuries, in which the brain symptoms are of a pure dynamic character, indicative solely of vascular disturbances in the endocranial circulation, and so transitory in duration that they preclude the possibility of permanent organic lesion.

As the mechanism of its production is probably different from that of ordinary surgical shock-as this is brought about by traumatism in other parts of the bodyit must be recognized as a clinical entity that has the right to separate existence by the side of the graver states, known as general contusion, laceration and hemorrhage.

It must be recognized, however, that while concussion may exist as a form of shock, its presence is so intimately linked with grave organic lesions that it is practically impossible to separate it from such conditions when they exist in complicated cases. I believe nearly every case of concussion is accompanied with shock; therefore, it is only by the careful observation of individual cases, and after a sufficient length of time has elapsed after the injury, that one can eliminate shock, or concussion (stunning, as it is called by the laity), and establish the existence of the graver states that are recognized as contusion, or "bruising," of the brain.

It seems absurd for a common practitioner to controvert anything said by such eminent authorities on diseases of the brain as Phelps, Duret and Eskridge, but common, everyday experience has certainly led me to believe that there is some difference between shock, concussion and contusion of the brain. I will relate my experience with two patients, which probably will vividly impress upon our minds the symptoms of concussion:

Mr. George D. attempted to board a trolley car, which he supposed would stop, but, unfortunately, only slackened enough to cause him to miss his hold and throw him violently to the ground. He got up apparently unhurt, but when he reached his destination he found that he was dizzy and staggered. His wife immediately brought him to my office, stating that "George acted awful queer," that he complained of pain in the head and back; also weakness. I observed a temperature of 102 degrees, pulse 85; he was pale and anemic in appearance, had a worried look, pupils dilated and a staggering gait. He did not tell me that he had fallen off the car, as he seemed dazed or stunned. After a hasty examination I told his wife to take him home. When I called the next day the wife said he had been flighty all night, seemed much indisposed to speak or answer questions, or pay any attention to surrounding objects. If roused by a question he would answer peevishly or angrily, turning as if displeased at the interruption. His posture was peculiar; he would lie on one or the other side, curled up with all his joints more or less flexed, and if a limb would be touched he would draw it away with an air of annoyance. There was hemorrhage from the nose and ears, showing there was extravasation, also hematuria and nausea. After the period of cerebral irritation, which lasted sev

eral days, had subsided, he became loquacious and complained of severe headache. After five or six weeks he made a perfect recovery.

Another case-a little boy, aged 10 years, was sent on an errand. Boylike, he stopped to take a slide on the ice and received a fall and struck his head. Though stunned, he knew enough to get home, but all he could say was "yes" and "no" repeatedly. This condition was kept up for three days and nights, with some peevish symptoms, as related in the former case. Finally his brain cleared up and he complained of some headache. In each case they were temporarily stunned, i. e., that the brain was so shaken up that its functions had been temporarily arrested; at least something had happened to it of sufficient importance to suspend the intelligence.

Take, for instance, in an ordinary prize fight, where one is knocked out by a stiff blow on the head; as a result he is rendered senseless for the time being. There is neither contusion nor laceration of the brain, but he has a concussion which lasts for a long or short period of time, according to the blow he gets on the side of the head. Furthermore, it is not always necessary to get the blow on the head; a thump on the carotid artery will produce the same result; you send a wave of blood through the brain with such force as to produce a concussion, or the same thing as concussion-he becomes pallid, confused, giddy and may be nauseated and even vomit, but after a period of rest he will gradually recover. The same effect may be produced when one jumps off a freight car or from a horse and lands on his buttocks; there is a tumefaction or a shaking up of the brain substance, so that it is stunned. It knocks him senseless for the time being, without necessarily producing shock, as his feet and hands do not get cold, and he does not have any rupture of a blood vessel. It is in such cases of head injury, where there is no recognizable fracture of the skull, or when this occurs without depression, and in which partial or complete unconsciousness exists without definite localizing symptoms, that are likely to puzzle the railroad surgeon, especially when there are so many impostors or maligners ready to sue railroad companies for damages.

Now as regards diagnosis. That old examination question which confronts every student before he receives his "sheepskin" now presents itself: "How would you diagnose the difference between injuries to the brain from alcoholic intoxication, opium poison, apoplexy and uremia?" A man is picked up in the street by the police and is carried to the hospital without any previous history and the surgeon must be on his guard lest he mistake any one of these four conditions for a serious injury to the brain. In cerebral injuries there will usually be an evidence of the accident in a bruise or cut, though, of course, the man may have fallen when intoxicated, or may have been suddenly attacked by apoplexy and in falling have received a more or less serious wound. In intoxication the accident will usually be comparatively slight, possibly his appearance giving evidence of intemperate habits may be some guide to diagnosis, but this may easily mislead us. His breath may be alcoholic, but it must be remembered that alcohol may have been given to the man to revive him after serious brain injury. A drunken man, although stupid, is not unconscious, nor is he paralyzed or hemiplegic. His pupils are not dilated, as in concussion, but