OPIUM-POISONING.-The onset of the symptoms, if high specific gravity. Sometimes it contains albumin, but no tube casts, unless there is some renal complica. this is known, the equal and contracted pupils, the slow tion. Convulsions are more common in lesions of the respiration, the normal temperature, and the absence of cortex; vomiting is most frequently met with in lesions all hemiglegic symptoms, would point to opium poisonof the cerebellum. ing. If the symptoms began suddenly with a general or a partial convulsion, chloral, opium, and alcohol poisoning could be excluded. In nearly all cases, except the severer ones, in which there may be complete relaxation of all the voluntary muscles of the body, there are local, or one sided symp toms. The most pronounced ot these is the hemiplegia involving the leg, arm, and face on the same side. In rare instances there is crossed paralysis, with affection of the leg and arm on one side, and of the face on the opposite side. When the hemiplegia is incomplete, the arm is most affected, the leg next, and the face least of all. The distal portions of the extremities are more affected than the proximal. Immediately after the shock the deep reflexes are abolished on both sides They return first on the unaffected side, but they soon return on the paralyzed side and become more pronounced than in the unaffected limbs. The superficial reflexes not infrequently remain absent on the para lyzed side for several weeks. One pupil may be dilated and fail to respond to light, or both may be dilated or contracted. The eyeballs are usually fixed, and more commonly they deviate to the paralyzed side, although there may be conjugate deviation of the eyes with turn ing of head toward the unaffected side. The facial paralysis is limited to the lower part of the face, and the affected cheek puffs out during expiration. If the patient is able to protrude the tongue, it deviates toward the paralyzed side. Even when the unconsciousness is profound, the muscles on the affected side are not so completely toneless as those on the unaffected side. The local symptoms vary according to the seat of the hemorrhage. In a given case of supposed cerebral hemorrhage, during the apoplectic state, the diagnosis has to be made from a similar condition caused by syncope, or by chloral, opium, or alcohol poisoning, or by uremia, epilepsy, hysteria, embolism, thrombosis, the apoplectiform attacks occurring from cerebral congestion or from the cerebral state found in paretic dementia, and from "simple apoplexy" in the aged. Syncope from cardiac failure is easily distinguished from cerebral hemorrhage. In the former the heart's action is exceedingly weak; the pulse is small, very feeble, and almost imperceptible; the face is blanched; the lips are very pale; respiration is shallow, or it may be sighing and irregular; reflex action is rarely abolished; the sphincters are not relaxed; the pupils are equal and widely dilated, and there are no hemiplegic symptons. CHLORAL-POISONING-In profound unconsciousness from chloral the subject is in a peaceful and undis turbed slumber; not a voluntary muscle moves, and all is calm. Breathing is rather slow and shallow, the pulse is soft, weak, and infrequent, and the temperature is usually slightly subnormal. There is complete absence of all local symptoms. ALCOHOLIC UNCONSCIOUSNESS.-An alcoholic odor of the breath, a coma from which the patient may be temporarily aroused by loudly calling his name, equal pupils, nearly normal temperature, and the absence of unequal temperature on the two sides of the body, point to alcoholic poisoning. Violent struggling, when it occurs, strongly indicates alcoholism. There are no localizing brain symptoms. UREMIC COMA.-Albumin and tube-casts in the urine suggest uremia, but albumin is frequently found in considerable quantity in the urine in cases of cerebral hemorrhage, especially if attended with convulsions, but tube casts are usually, if not always absent, except when kidney disease has preceded the hemorrhage. It must be borne in mind that renal disease, especially the senile form (granular disease of the kidney), occurs in about one third of the cases of cerebral hemorrhage. The peculiar physiognomy of renal disease, with local dropsy, equal pupils, less profound coma, and usually nearly normal temperature (according to Gowers it is always subnormal, except in cases in which local inflammation exists), the presence of the odor of urine in the breath, and the absence of hemiplegic symptoms occurring in a young subject, are usually sufficient to diagnosticate uremic coma. Gowers states: Rigidity of limbs or local muscular twitching during the coma is, if constant in seat, in favor of cerebral mischief; if variable in position it is in favor of uremia. COMA OF EPILEPSY. -If the history of the patient is known and the onset of the attack has been witnessed, no difficulty will occur in the differential diagnosis. If the patient is first seen in post epileptic coma, without any knowledge of his previous history, the absence of hemiplegic symptoms and the short duration of the coma would serve to distinguish the case from one of cerebral hemorrhage, except in the status epilepticus (a state rarely, if ever, reached without the history of the patient being known) when in the absence of a history of the case it would be almost impossible to exclude cerebral hemorrhage in which no hemiplegic symptoms are present. Fortunately for the diagnostician, in nearly all cases of eerebral hemorrhage at tended by convulsions following each other in rapid succession, unilateral symptoms exist, but multiple thrombi and emboli may give rise to a condition resembling the status epilepticus without a single unilateral symptom. HYSTERICAL COMA.-I have yet to meet with my first case of hystericyl coma in which difficulty has been found in excluding cerebral hemorrhage. In the cases that I have seen, the absence of all positive symptoms of organic disease and the presence of hysterical stig. mata have rendered the diagnosis easy. The face is rarely, if ever, paralyzed in hysteria. The danger of most difficult diagnoses that the physician is called upon mistaking cerebral hemorrhage for hysteria is much to make. Gowers states that "Some writers contend greater, and in some cases can only be avoided by a careful search for symptoms of organic origin. that we can be sure of our diagnosis in only one third of the cases." He does not agree with this broad statement, and believes that by a careful analysis and comparison of the symptoms an accurate diagnosis can much more frequently be reached than might be inferred from the writings of some physicians. APOPLECTIFORM ATTACKS OF CEREBRAL CONGESTION. -In this condition the symptoms are general, with less profound unconsciousness than is found in cerebral hemorrhage. There are no local or hemiplegic symp. toms. There is usually a history of previous similar at tacks which have passed off without leaving any weak ness of muscles. Gowers is inclined to the opinion that in first attacks of this character a positive diagnosis points of each: cannot be made. APOPLECTIFORM ATTACKS IN PARALYSIS OF THE IN SANE. The previous history of the patient is usually sufficient to put the physician on his guard. The seiz ure is ushered in suddenly with convulsions, local in seat, clonic and tonic in character; the head is drawn to one side; the muscles of the eyes and face may keep up a constant twitching for hours; unconsciousness is profound; the face is dark; respiration is shallow and rapid; the pulse is quick and weak; 'the temperature is elevated; a profuse perspiration covers the body, and the whole aspect of the patient points to speedy dis solution. An accurate diagnosis is of considerable importance because the treatment of the two conditions is entirely different. I will give the most important diagnostic THROMBOTIC SOFTENING. 1. Prodomata frequent. arteries of the limbs. 4. Heart feeble, dilated, and 5. Coma less marked in depth and duration. 6. Following grief and other depressing influences. 7. Local convulsions more frequent. 8. Slight initial temperaturedisturbance. 9 Slight variation of the temperature within a few hours. 10. Secondary inflammatory marked. CEREBRAL HEMORRHGAE. I. Prodomata infrequent. 2 Turgid face and strongly beating arteries of the neck. 3. High arterial tension, regardless of the size of the pulse. 4. Heart hypertrophied and beating strongly. 5. Coma more intense and longer in duration. 6. More likely to be induced by mental excitement. 7. General convulsions more frequent. 8. Often great initial temperature-disturbance. 9. Often a considerable rise of temperature from twelve to twenty-four hours after the attack. 10. Secondary inflammatory symptoms less in frequency and in degree. The seizure lasts for a few hours or a day, and is followed by a sleep from which the patient slowly wakes and gradually recovers consciousness. A day or two later, however, the patient is apparently as well as he was before the attack, except that mental deterioration becomes more rapid, with a tendency to the formation of bed sores and the development of other trophic dis symptoms frequent and wellturbance. If one were called to see a patient in a first attack of this character without a history to guide him, The foregoing is only an attempt to arrange the chief a diagnosis from cerebral hemorrhage would be impossi- diagnostic points of thrombotic softening and cerebral ble. The same character of attacks occurs as a mani- hemorrhage side by side, but it must be evident to festation of cerebral pachy meningitis, and it is probable everyone that any one of the symptoms may be so that these seizures in paralysis of the insane are due to modified by conditions and circumstances as to render it hematoma of the dura, and the immediate cause is entirely valueless, e. g, sudden fall of temperature, suchemorrhage. ceeded a few hours later by a rise of several degrees, inSIMPLE APOPLEXY.-In persons advanced in life a dicates cerebral hemorrhage, but in occlusion of the condition sometimes occurs with a train of symptoms basilar artery the temperature may rise four, six, or that perfectly resembles that of cerebral hemorrhage, but at the autopsy no trace of hemorrhage or other gross cerebral lesion can be found. Such attacks are truly "mysterious" in their nature, and it frequently happens that they cannot be distinguished from cere bral hemorrhage. even eight or more degrees, a few hours subsequently to the occurrence of the apoplectic symptoms. TREATMENT OF CEREBRAL HEMORRHAGE-I must reiterate what I have said on former occasions in connection with the treatment of a patient while in the apoplectic state from cerebral hemorrhage, that most of such patients would do better without medicine than they do when medicine is simply administered with the hope of doing some good, but the administration of which is not governed by any logical or rational principle. EMBOLISM.-The younger the patient, with the presence of endocardial disease or syphilis, the greater the chances are in favor of embolism against hemorrhage, except in cases in which the apoplectic symptoms have been very severe, coma profound and long in duration. The parturient state favors embolism. The less the If we bear in mind that in hemorrhage into the cereprimary disturbance of temperature, provided the paral-bral substance, not traumatic in character, the imme. ysis is extensive, the less the chances are in favor of diate cause of the hemorrhage is the bursting of a mihemorrhage. THROMBOSIS.—The differentiation of thrombotic softening from cerebral hemorrhage is probably one of the liary aneurism, we shall appreciate how futile must be our efforts to arrest such a hemorrhage by the adminis tration of medicine. Immediately after the occurrence member that no hard and fast rules can be laid down in regard to the use of strychnin. I have seen cases in the acute stage in whicn this drug, in combination with aromatic spirit of ammonia, has done good service. When electricity is applied, and, as a rule, it should not be before the end of the fourth or sixth week, the extensor muscles only should be stimulated, and during the application the extremities should be held in their normal positions. Massage, systematic exercise, Swedish movements, and time, do most to overcome the residual paralysis of intra-cerebral hemorrhage. free by post. of the event the indications are to allow the effused employed when contractures are present, or when the blood to coagulate, to promote the flow of the venous deep reflexes are greatly exaggerated. We must ra blood from the head, to quiet the heart's action, to allay the restlessness of the patient, when such exists, and to prevent an undue amount of blood being carried to the head. We can render the best service in aiding the coagulation of the effused blood by keeping the patient absolutely quiet. The flow of the venous blood from the head is promoted by slightly elevating the head and shoulders, and not allowing the head to be bent forward and thus compressing the veins of the neck. The heart's action is best quieted by the careful administration of small and frequently repeated doses of aconite, when there are no contra indications to the use of this drug. Restlessness, when considerable, is most effectually relieved by a hypodermatic administration of one fourth A Medical Directory of the State of Conof a grain of morphine; when it is slight, sodium necticut is being issued by the Danbury Medical bromide is effectual. Various means are at our com Printing Co, of Danbury, Conn. It will contain a list mand to lessen the flow of blood to the head; sometimes of all the medical practitioners of the state, the various one or two, sometimes all should be employed. Brisk medical societies, all the dentists and dental societies, purgation should almost always be resorted to. If the druggists and pharmaceutical societies, nurses and trainstomach is not irritable, one drop of croton oil in ten ing schools for nurses, hospitals, etc. Price, $1, deivered drops of sweet oil should be placed on the tongue every hour until the bowels are opened freely. When the stomach is irritable ten grains of calomel should re A Treatise on Ophthalmology. For the place the croton oil. Whether calomel or croton oil is general practitioner. By Adolf Alt, M.D. Second employed, an enema, consisting of one ounce of salts, a edition, revised and enlarged. 8vo., pp. 346. With half ounce glycerin, and four ounces of water, should one hundred and forty illustrations. St. Louis: J. H. be thrown up the large bowel as soon as possible after Chambers & Co. 1893. Price, $3.50. the occurrence of the hemorrhage. Mustard plasters We have been aware of the fact for some little time applied to the back of the neck, the front of the chest, that the presert edition was being prepared by the and on the calves of the legs, aid in lessening the quan author. The additions and improvements made have tity of blood carried to the head. Blood-letting is some perceptibly increased its dimenstons and added to its times indicated, but cases necessitating the withdrawal usefulness. The author has retained his first idea, that of blood by opening a vein are probably rare. In of furnishing an easily understood guide to the general regard to the administration of ergot in the cases of practitioner. As he states, it is not a work written for cerebral hemorrhage under discussion, I do not believe specialists, and this will account for the fact that in certhat it does a particle of good, and there is a possibility of its doing harm. The practice of applying cold to the head, especially ice, in cases of non traumatic, intra cerebral hemorrhage, is I believe, reprehensible. It seems rational to suppose that it may increase the en. gorgement of the intra-cerebral vessels. When the face is turgid, the head warm, and the carotids throb bing, ice-cloths or iced poultices may reduce the heat of the head and promote the coagulation of the effused blood. It will be seen that the only routine treatment recom mended for intra-cerebral hemorrhage is brisk purgation immediately after the occurrence of the accident, to which may be added the application of mustard plasters to various portions of the body. In the subsequent treatment, during the acute stage indications must be met as they arise. In the chronic stage electricity and strychnin must be used with judgment and great caution. The routine employment of these two agents to overcome the paralysis does much harm in causing ir removable contractures of the arm and leg of the affected side. In this stage strychnin should not be tain parts a subject seems to be rather summarily dealt with and disposed of. The entire practical domain of ophthalmic therapeutics is well covered, and that of dioptrics and other optical questions connected with the eyes have been judiciously omitted as they are of too abstruse a nature for the readers for whom the book is intended. Taken all in all this treatise will prove a valuable one in the hands of its readers. It is well illustrated, diagrammatic and other pictures being introduced wherever they may prove of help. No instruments are shown, the author referring his readers to catalogues which al ways contain a large number of representations of oph thalmological instruments. The matter has been carefully written and well edited. Whilst never prolix it is sufficiently full to be easily understood. The mechanical work is a credit to the publishers. The type is large and clear, the illustrations show up well, and the paper is strong and thick. The binding is very neat, and, taken altogether, it speaks well for all those interested in the issuance of the work.-St. Louis Medi cal and Surgical Journal. ABSTRACTS cess, and has been adopted in many institutes for the cure of inebriety as a part of routine practice. Experience seems to be daily justifying some portion at least of the claims made for this drug by the enthusiastic advocates of its use in the treatment of alcoholism (and not the least of its merits is said to be its wonderful power of sustaining the heart under conditions of extraordinary depression), but it cannot be relied on to the exclusion of other remedies as nerve sedatives and hypnotics, or of the proper hygienic treatment. Treatment of Alcoholism by Large Doses of Strychnia.-The treatment of alcoholism by strychnia has found many advocates in Russia, espec ially since the clinical observations of Tolvinsky and Partivisky in 1887. They gave strychnia by the mouth in doses increasing from the sixtieth to the thirtieth of a grain three times a day. These doses seem small, but the results reported were favorable. The experiments Ocular Affections in Cerebro-Spinal Feof Jarokeosky on dogs in 1888 led him to formulate the ver.-It would seem that all epidemics of cerebroconclusion "that strychnine enables the animal organ spinal meningitis have one or more eye symptoms in ism to receive large quantities of alcohol for prolonged common, and probably those most often met with are periods without any apparent injury to the central the changes in the pupils and conjunctivitis. But nervous system." >> every extensive epidemic is apt to be associated with a Pombrak, another Russian authority, found strychnia special type of eye affection. Thus Knapp, Dreitmair, a valuable remedy both in cases of chronic alcoholism Oeller and Jacobi observed most often suppurative inand in those of dipsomania, "not merely curing the flammation of the uveal tract and make no particular attacks, but abolishing the desire for drink." Even attacks of delirium tremens were influenced beneficially. He began with doses of one thirtieth of a grain; in more severe cases with one fifteenth of a grain. mention of any other ocular complication. Wilson, Niemeyer, Ziemssen and Hess met with keratitis, while Hirsch, in his wide experience, saw nothing more serious than conjunctivitis, which was an invariable conIt is worthy of note that Luton of Rheims first dition). The type of eye symptoms peculiar to the called attention to the remedial effects of nux vomica epidemic which I have just described seems to have in alcoholism nearly twenty years ago. He was in the been a remarkable tortuosity and distension of the reti habit of administering one half grain of the extract or nal veins and more or less congestion of the optic disk ten drops of the tincture three times a day in alcoholic The degree of venous engorgement in some of the cases trembling, in the cerebral troubles due to alcoholic was, in my experience, a unique condition, the blood appoisoning, etc. It was Luton who called nux vomica pearing almost black and as though actually stagnant. the medicine of drunkards. Luton, however, recog. The tortuosity of the veins, too, was striking. The nized that nux vomica can have no beneficial effect turning points of the veins were so abrupt that they rewhen the alcoholism has arrived at the phase of plastic sembled small hemorrhages, and as such I regarded infiltrations and of granulo-fatty degenerations. Luton afterwards made trial of strychnine in hypodermic in jections, and found that this drug when thus administered had marvellous efficacy in delirium tremens. Dujardin Beaumetz adopted this mode of treatment in delirium tremens, with equally favorable results. He uses the following prescription: A hypodermic (Pravaz) syringeful contains five milli grammes (one-twelfth of a grain). In cases of furious delirium he makes an injection every half hour till four injections are given; then every hour, till the delirium is subdued. It is not an uncommon thing to practice these injections till two to four centigrammes (onethird to two-thirds of a grain) of strychnia are thus administered; and this treatment is pronounced "safe". Lecuye, a pupil of Luton, who in 1882 wrote a treatise on "Alcohol and Strychnine," reports similar successes in the use of strychnine, and considers this drug as the remedy par excellence of the nervous, cardiac and gastric them in one case till I was enabled later to make a more thorough examination, when I found that what I took to be hemorrhages were very abrupt turns in the veins where the circulation must have been almost at a standstill. These conditions are quite analogous to what was discovered in the brain in every case where a post-mortem was made. I was not present at any of the autopsies, but Dr. Porter told me that the tortuosity and distension of the veins on the surface of the brain reminded him forcibly of my description of the retinal veins, and the changes in these vessels I think can readily be understood from the condition of the brain revealed at the autopsy. It is clear, then, that in all epidemics of cerebrospinal meningitis a systematic examination of the eyes should be made with the ophthalmoscope, and that frequently when other eye symptoms are absent and the general symptoms are misleading, changes in the fundus of the eye will be discovered which will throw light upon the case. And again, the existence of good vision does not mean a sound optic nerve or retina, for not unfrequently do we meet, in every-day work, with a troubles of alcoholism. choked disk where the visual disturbances are insigniThe strychnine treatment of alcoholism has been ficant. Of the thirty-six cases which I examined, not tried in this country and in England with varying suc- counting those which were affected with diplopia, only three complained of their inability to see distinctly. I virtue of its disinfectant properties, but that probably it regard the existence of eye symptoms, especially those possesses a specific action upon the inflamed mucous where the fundus is involved, as indicating a particular- membranes, stimulating the regeneration processes. The ly grave case. Wherever I found the condition which following observations of Dr. Roskam in two cases of I have described very pronounced, I felt justified in purulent cystitis point in this direction. In the first speaking positively as regards the prognosis. I think case, which had been 41, months under treatment, inthat this type of eye symptoms is of more value as injections with boric acid and corrosive sublimate during dicating the condition of the brain than the symptoms the first 3 months had been without success, and eventdescribed by other writers, such as panophthalmitis, sup purative choroiditis and keratitis, affections which, in my opinion, would be likely to have their origin in a general infection and not likely to be the direct result of the purely cerebral changes. R. L. Randolph, Johns Hopkins' Hosp. Bull. ually the patient lost all hope and withdrew from treatment. The patient was then treated with Phenosalyl in the following manner: After irrigation with boric acid a 2 per cent solution of Phenosalyl was injected into the bladder and the liquid removed after one minute by means of a catheter. A second injection of Phenosalyl was then made, which the patient rePhenosalyl.-Dr. J. de Christmas, Paris, says: tained in the bladder a few minutes and then spontaMy experience (published in the "Comptes rendues de neously evacuated. After 4 such injections within 48 la Societe de Biologie" of January 23, 1892 and in the hours the patient was healed. In the second case a "Annales de l'Institut Pasteur VI") has induced me to woman, 65 years old, passed urine containing an enor. recommend an antiseptic combination "Phenosalyl") mous quantity of purulent matter. She suffered from (The preparation is manufactured by the "Farbwerke violent pains in the lower part of the body and had a vorm. Meister Lucius & Bruning in Hoechst on the continual desire to urinate; copious irrigations with Maine".), which according to bacteriological and clini boric acid, corrosive sublimate and silver nitrate solu cal experiment appears to possess many advantages tions, as well as with salol, turpentine oil, etc., had been over ordinary antiseptic substances, and the employ tried without result. Two injections of 2 per cent ment of which in surgery has been sufficiently extensive Phenosalyl solution made in the above manner effected to permit a reliable opinion as to its value to be formed. a complete cure within 48 hours. Dr. Roskam ex. Phenosalyl, a clear sirupy liquid, consists of a mixture amined both patients again 4 months after their reof carbolic, salicylic and benzoic acids melted together covery and found no return to the previous condition! and dissolved in lactic acid. The solution partially These results appear to indicate a further action upon crystallises at low temperatures, but if a small quantity the mucous membrane than that of a mere antiseptic. of glycerine be added a clear solution is formed which does not again crystallise, is easily soluble in warm water, to the extent of 6 per cent in cold water, and very soluble in alcohol and ether. The results of all bacteriological trials with the mix ture have shown that it possesses an antiseptic power considerably superior to carbolic acid. This solution, the antiseptic power of which is sufficient to kill the bacteria of pus after 1 minute's contact has no corrosive action on instruments and does not ir ritate the skin. In Cornil's hospital division this solu tion has been employed in all surgical and disinfecting operations since July 1892. The results obtained have been very satisfactory. Professor Fraipont in Luttich has recently published the results of his clinical experience with Phenos alyl. He has employed Phenosalyl in 100 major operations and in 68 confinements and expresses himself to be very well satisfied. In the conclusion of his communication he summarises the advantages of Phenosalyl over other antiseptics as follows: Easy solubility in water, no danger of toxic symptoms, a pleasant and not persistent odor, which does not cling about the hands and clothes. The solutions have no corrosive action on the skin; the mucous membranes remain smooth and slippery, and are not dried up, as is the case after washing with car bolic acid and corrosive sublimate. (Dr. Berger of Paris has communicated to me orally an exactly similar case of purulent cystitis healed by Phenosalyl injection). Very rapid cures were also observed by Dr. Roskam in two cases of severe eczematous im petigo. After 48 hours' applications of compresses saturated with 1 per cent Phenosalyl solution healing was effected. In his reports upon the treatment of gonorrhea with Phenosalyi he says that he has been less fortunate with this treatment. A diminution of the suppuration was indeed observed immediately after the injection of a 1 per cent solution, but recovery only progressed at the usual rate. Duloroy furnishes a detailed account of the course of several cases of endometritis and uretritis treated with 2 to 10 per cent Phenosalyl pencils. In several cases an extraordinarily rapid recovery was effected, and in one case of Endometritis puerperalis, the febrile temperature that had been maintained for 5 days disappeared after cuvettage of the uterus and subsequent Phenosalyl injections. Phenosalyl also appears to have given equally good results in ophthalmic practice in the hands of Dr. E. Berger of Paris, whose observations have not yet been published. Dr. Berger has employed Phenosalyl as an ointment in blepharoadentitis (1 part Phenosalyl in 100 to 160 parts Vaseline), and as 0,2 to 0,4 per cent aqueous solution in different forms of conjunctivitis, without obIt appears that Phenosalyl is not only valuable in serving any irritation of the mucous membranes. |