Page images
PDF
EPUB

albumin, and a trace of reducing substance allied to pyrocatechin. (2) Other fluids contain chlorids, a faint amount of albumen and no reducing substance. The fluid is almost certainly cerebro-spinal (1) if the discharge begins within 24 hours, (2) is colorless and profuse, and (3) continues for some days. These are all variable, however; it may begin weeks after and may last from hours to weeks; in one case it escaped for a month from both ears; in another three pints escaped in five hours.

Rawling regards the temperature as the surest and almost infallible guide to prognosis. A subnormal temperature, rising steadily, is most unfavorable. A subnormal temperature may rise to 101° or 102° and remain so for a short time. This hesitation marks the crisis, a further rise indicating a probably fatal result, while a fall offers hope of recovery. In a third group the temperature remains subnormal or rises to normal and no higher. In the former case the patient never recovered from the stage of collapse, while in the latter, shock being slight, is not followed by reaction.

T. C. English* believes the prognosis of head injuries as regards after effects is much more. serious than usually recognized. His experience is that some degree of mental impairment, though rarely sufficient to be called traumatic insanity, occurs in over 10 per cent. The author's conclusions are based on a series of 300 cases, divided into (a) 100 consecutive fractures examined at intervals of one year or more after the injury; (b) 100 consecutive cases of concussion, contusion and laceration without evidence of fracture, also examined. at intervals of not less than a year; (c) 100 miscellaneous cases, not included in the first two, with the following results:

[blocks in formation]

ly well, provided they submit to the necessary period of mental rest. This accounts for the after effects so frequent in hospital cases.

Series C includes a very important groupvery mild cases of concussion, with loss of consciousness for a few moments only, or even entirely absent. The apparently trivial injury leads to entire neglect or inadequate treat

ment.

Among the after effects were depression, melancholia, suicidal tendency, increased susceptibility to alcohol, and high temperature and traumatic cephalalgia. The latter is by far the commonest after symptom. It was present in 58 out of 69 cases in the first series presenting any symptoms, and in 43 out of 52 in the second series. It may occur alone or combined with other symptoms, and, if the latter, may give rise to or exaggerate some of them. It usually presents as a constant, dull ache, most intense at the seat of injury.

Prognosis must always be most guarded and should never be given until the case has been under observation at least a year. There is no routine treatment, but the author states "it is impossible to emphasize too strongly the absolute necessity of prolonged mental rest.”

CONSOLIDATION OF MOBILIZED FRACTURES.

Extensive experimental research research demonstrates that daily displacement of the fractured stumps does not prevent consolidation. It may be retarded and the callus may be unduly large and misshapen, but the consolidation is very firm. The mobilization was much more vigorous than in therapeutic massage and mobilization. When a pseudarthrosis forms it is due more frequently than generally supposed to interposition of a fragment of muscle. In other cases it is due to the overriding of the fractured bones. A rarefying osteitis may be incriminated in certain cases, and in others a fatty rarefaction of the bone. Syphilis is the only general cause known to date, but certain local causes may co-operate, among them the interposition of a scrap of bone, effusion of blood or suppuration.—(Jour. Am. Med. Ass.)

The Clover Leaf railway will establish a hospital for its employes at Charleston, Ill.

[ocr errors]
[blocks in formation]

"Diseases of the Nose and Throat." By D. Braden Kyle, M. D., Professor of Laryngology and Rhinology, Jefferson Medical College. Third Edition, revised and enlarged, with 205 illustrations of which 27 are colored. Philadelphia, New York and London: W. B. Saunders & Co.; Chicago: W. T. Keener & Co., 1904. Pp. 669, octavo. Cloth, $4.00 net.

The first edition of this work was reviewed in these columns in the issue of December 12, 1899, and its popularity is attested to by the call for a third edition within five years. In the present edition, by comparison with the first, a considerable revision is apparent, with the addition of over 20 pages of new matter covering such topics as keratosis, epidemic in-. fluenza, paraffin injections, and the use of the X-ray, while the sections devoted to hay fever and surgery of the nasal septum have been largely rewritten.

While the publishers, on the title page, modestly claim only "175 illustrations, 24 of them in colors," they evidently neglected to count two new and elegant full-page plates containing nine figures and devoted to the study of keratosis, as well as several other cuts. In fact, a fair and impartial count shows as many as 205 illustrations, of which 27 are colored, while of these 205, as compared with the first edition, 28 are new.

The headline, "Diseases of the Nose and Throat," used at the top of each left hand page in the first edition, has been wisely omitted and in its stead is given the general subject being considered, hence the section sought is the easier found. A particular improvement is noted in the index which has been enlarged to the extent of 50 per cent, as compared with the first edition.

While the clearness of the type and the beauty of the illustrations add to the pleasure derived from the perusal of this work, its great value is due to the logical classification of dis

eases given, and to the clear and concise manner in which both etiology and treatment are presented. EDWIN PYNCHON.

"Manual of Clinical Microscopy and Chemistry."

By Dr. Herman Lenhartz. Authorized translation from the fourth German edition with notes and additions by Henry T. Brooks, M. D., with 148 illustrations and 9 colored plates. Philadelphia: F. A. Davis Co., 1904. Price, $3.00

net.

This work occupies very much the same field as von Jaksch's "Clinical Diagnosis." By using type of two sizes and printing compactly, a great deal of matter is incorporated in its 400 pages. The book is written for beginners as well as for more advanced workers, and in consequence it begins in an elementary fashion. The viewpoint of the clinician is maintained throughout. It is clearly written and fairly well illustrated. One misses some of the most

recent procedures of accepted value, as, for example, the Wasserman-Uhlenhuth test for blood, and the hematokrit, making possible the volume index of Capps.

The work of Brooks is well done. The volume should be of great value to the practitioner and to the laboratory worker.

W. A. EVANS.

"Manual of Materia Medica and Pharmacy." Specially designed for the use of Practitioners and Medical, Pharmaceutical, Dental and Veterinary Students. By E. Stanton Muir, Ph. G., V. M. D. Instructor in Comparative Materia Medica and Pharmacy in the University of Pennsylvania. Third edition, Revised and Enlarged. Crown Octavo, 192 pages, interleaved throughout. Bound in extra cloth. Philadelphia: F. A. Davis Co., 1904. Price, $2.00 net.

This little work, originally published some eight years ago, is intended to give a concise account of the drugs of most use, without going into minute details. Only those are considered which are in everyday use and of recognized therapeutic value. The writer has done well to arrange them alphabetically, since no classification is entirely satisfactory. Both metric and apothecaries' weights are given, and the work will be found useful in reviewing one's knowledge and for quick reference.

'Obstetric and Gynecologic Nursing." By Edward

P. Davis, A. M., M. D., Professor of Obstetrics in the Jefferson Medical College and in the Philadelphia Polyclinic. 12 mo., 402 pages, fully illustrated. Second edition, thoroughly revised. Philadelphia, New York, London: W. B. Saunders & Co.; Chicago: W. T. Keener & Co., 1904. Polished buckram, $1.75 net.

The usefulness of this book to the nursing profession is manifest by the fact that a second edition has been called for. It is necessary for an obstetric nurse to possess some knowledge of natural pregnancy and of its consequent diseases; and as gynecologic nursing is really a branch of surgical nursing, special training and instruction are required to meet the conditions

arising. This book just fills the need, everything that the obstetric and gynecologic nurse should know being included. The second edition shows evidence of having been carefully revised throughout, and considerable new matter has been added. It would be well if every trained nurse possessed a copy of this book, for it certainly is of inestimable value.

"Progressive Medicine," Vol. II, 1904. A Quarterly Digest of Advances, Discoveries and Improvements in the Medical and Surgical Sciences. Edited by Hobart Amory Hare, M. D. Octavo, 334 pages, 47 illustrations. Per annum, in four cloth-bound volumes, $9.00; in paper binding, $6.00, carriage paid to any address. Philadelphia and New York: Lea Brothers & Co. The present issue introduces the topics of abdominal surgery, including hernia, by W. B. Coley; Gynecology, by J. G. Clark; Diseases of the Blood, etc., by Alfred Stengel, and Ophthalmology, by Edward Jackson. Coley's article covers 126 pages, and the author gives a synopsis of recent surgical progress in the treatment of affections of the stomach, liver, and other abdominal viscera, including 17 pages on hernia. The aim of the editors has not been to summarize all that has been written within the sphere of their respective subjects; their purpose is to give the best, most reliable and truly progressive contributions to modern theory and practice, and to skillfully weld this new material into the great structure of modern medicine.

AMERICAN EDITION OF NOTHNAGEL'S PRACTICE.

of

"Tuberculosis and Acute General Miliary Tuberculosis." By Prof. Dr. G. Cornet, Berlin. Edited, with additions, by Walter B. James, M. D., Professor of the Practice of Medicine in the College of Physicians and Surgeons, New York. Octavo, 806 pages. Philadelphia, New York, London: W. B. Saunders & Co.; Chicago: W. T. Keener & Co., 1904. Cloth, $5.00 net; half morocco, $6.00 net.

This is the seventh volume to be issued in Saunders' American Edition of Nothnagel's Practice, and the remaining four volumes are in active preparation for early publication. The present work is very timely, in view of the interest lately awakened both in the profession and laity concerning the ravages of "the great white plague." Professor Cornet's researches on this subject are widely known, and this volume may be looked upon as an authoritative presentation of the latest knowledge. It is divided into three parts: I, Etiology, of 320 pages,

contains a full and exhaustive account of the Koch bacillus, comprising its staining, biology, and a very important account of the chemistry. Also mode of invasion, infection and heredity. Part II, 280 pages, is devoted to Pulmonary Tuberculosis in extenso, and Part III, 58 pages, to Acute Miliary Tuberculosis. In addition there is a bibliography of 85 pages and a double column index of 27 pages. As in other volumes of the series, the editor has made additions where necessary to bring the work down to date.

"International Clinics." A Quarterly of Illustrated Clinical Lectures and Especially Prepared Original Articles. Edited by A. O. J. Kelly, A. M., M. D. Vol. II, Fourteenth Series, 1904. Philadelphia: J. B. Lippincott Co.

A good proportion of this issue is devoted to "Diseases of Warm Climates" by nine different authorities. Among various other valuable features is an interesting clinic by Billings. and a lengthy article by Abt on Bronchopneumonia in Children. The volume, as a whole, is lavishly illustrated and of permanent value.

Personal.

Dr. J. N. McCoy, of Corydon, Iowa, has been appointed company surgeon for the C. B. & Q.

Dr. E. H. Robb, of Newton, Iowa, has been appointed surgeon for the Newton & Northwestern Railway.

Dr. Robert B. Williams, Oakland, Cal.. has been appointed chief surgeon of the North Shore Railroad, with headquarters at Sausalito.

Dr. William L. Buechner, of Youngstown, Ohio, was killed on September 10th by being thrown over an embankment in a runaway accident.

Dr. F. H. Coe, of Seattle, Wash., died suddenly on July 16th. He had been surgeon for the Northern Pacific and Seattle & International for the past ten years.

Dr. J. W. Bowling has been appointed local surgeon for the B. & O. and L. & N. railroads at Shawneetown, Ill., filling vacancy caused by the departure of Dr. J. F. Barton.

Dr. D. C. Brockman, of Des Moines, Iowa, has been elected president of the Iowa State Medical Association, and Dr. D. S. Fairchild Jr., of Clinton, chairman of the Section on Surgery.

[merged small][merged small][graphic][merged small][merged small][merged small]

INJURIES TO THE HEAD IN THEIR the immediate relief of the patient and to in-
RELATIONS TO NERVOUS AND
MENTAL DISTURBANCES.*

[blocks in formation]

The inquiry often arises in injuries to the head as to the remote effect upon the functions of the brain and as to the probability of a permanent impairment of the mental faculties. Conversely in mental impairment, the inquiry extends to the relation which may exist between such impairment and a former injury.

Head injuries which involve a fracture of the skull may or may not produce serious damage to the brain and may or may not leave permanent effects on the mind or nervous system, but the cases presenting well marked and definite objective evidence rarely become the subject of controversy. The cases over which legal conflicts arise are the ones which present moderate or slight local evidence of injury and which produce unconsciousness of only short duration, or only a dizziness with mental uncertainty for a few minutes, with some nausea.

It can not be denied that injuries of the head without fracture may cause serious brain disturbance, which may lead to organic changes and which may impair the mental faculties or radically change the mental character of the individual.

The surgeon with large experience in general surgical practice is called upon to determine the course of treatment to be employed for

*Read at Joint Meeting, Chicago, June 1, 2, 3, 1904.

cidentally estimate the results of the injury upon the brain in relation to the effect upon the mind. The treatment, in so far as immediate relief is concerned, rests on the basis of experience in the employment of well determined surgical principles. As to the future results, the opinion must be somewhat speculative, for it is quite impossible to determine at first how much damage the brain has sustained, or what pathologic changes may take place.

In legal controversies, the time when they will come up in the history of the case will bear such a relation to the time of the injury that the opinion will be less speculative in character, and the surgeon feels that a careful examination will reveal the existence of brain change by objective evidence or mental changes by logical sequences.

Going over my experience of thirty-five years which covers every variety of head injury, and which will differ from other surgeons' only in the exceptionally large number which have come up for special inquiry-I have learned to consider them from the nature of the force which has caused them and the regions of the head upon which the force has been applied: First, slight bruises and lacerations upon the scalp by force directly applied. Second, more severe application of direct force of small surface of impact which has caused a fracture with momentary or permanent depression with or without extradural hemorrhage. Third, direct application of penetrating force with small surface of impact which has caused a penetration of the skull and a laceration of the mem

branes of the brain surface. Fourth, the direct application of force with a large surface of impact, with or without fracture of the skull and depression. Fifth, falling from a height or be ing thrown from a rapidly moving train, with or without fracture of the skull and depression.

In the first division of the application of force-that is, bruises and lacerations of the scalp and jars which are said to injure the brain-are found the greatest number which claim damage for alleged nervous or mental disturbances. In these cases the evidence is almost always subjective, and often these claimants are malingerers.

The symptoms are impairment of memory, - want of concentration of thought, dizziness, headache, nervousness, sleeplessness, etc. These may be legitimate claims in the early days or weeks after the injury, but as time passes and the days and weeks lapse into months, or even years without the additional evidence of brain disease, a reasonable or certain doubt will arise in the mind of the surgeon as to the truth of the claim.

Very recently I examined a veterinary student who entered a claim just before the statute of limitation expired, and when the claim came up for final consideration, alleged as an im portant element in his case that he could not keep up with his classes. This part of his claim could be easily accepted, but not on the basis of his injury; evidently nature had not been kind to him.

A minister of the gospel who had received similar injury declared that his memory had been impaired so that when he went out to preach he sometimes forgot to take his manuscript sermon with him, and made a claim on this account.

A carpenter received a bruise on his scalp at the hands of a neighbor, and for more than six months he could not trust himself with tools or climb on a building, indeed was obliged to steady himself with a cane and sometimes with a crutch, and this condition continued a whole day after the verdict was rendered.

Many cases of this kind could be cited, too frivolous and too unimportant to be seriously considered, all based on slight head injuries which only involved slight scalp wounds and would not appear among serious claims, if it

were not for the grave apprehension expressed by overthoughtful doctors.

Fractures of the skull without laceration of the membranes or brain substance when the force is a direct blow of comparatively small surface of impact are not generally serious in their remote effects upon the functions of the brain or nervous system if they are promptly and properly treated.

The well established principle that fractures of the skull with objective evidence of depression in adults whether accompanied with symptoms or not, will always lead to such treatment as will elevate the depressed bone, release the brain from pressure and the membranes from the irritation which has so many times led to chronic thickening and remote changes. The latter have a most serious effect upon the brain in the development of Jacksonian epilepsy, and deterioration of the mental. faculties which the best directed late treatment has not often been able to relieve.

It sometimes happens the fractured bone springs back into place to such an extent that the objective sign of depression is not appreciated by the ordinary methods of examination, or there is a fissure fracture with so little depression that it is overlooked and goes untreated unless a branch of a meningeal artery is lacerated and an extradural hemorrhage ocEven this is sometimes not recognized, being confounded with cerebral concussion which is presumed to result from the blow.

curs.

In these cases, if the scalp is not shaved and a flap turned down, the result can not always be determined, for it may happen that the remote effect on the brain may be as serious as an untreated depression.

I have operated on several patients where unconsciousness continued for several days after the injury had occurred in this class of cases, to find a clot of considerable size lying between the skull and dura with a depression not sufficient to be appreciated by surface scalp examination. The possible serious remote effect of unrecognized and untreated fracture of the skull upon the brain and upon the mental faculties demands of the surgeon an absolute knowledge of the condition of the skull obtained by such means as may be necessary to arrive at a correct conclusion as to the fact.

« PreviousContinue »