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thors as "wet brain." I believe it was really a case of obstruction of the venous return at the base and that the decompressing operation caused the brain to resume its work. I also believe that withdrawal of the fluid from the right side. had something to do with the result.

CASE III.

One day I received a call from a friend of mine to meet him at the infirmary, that his brother had been injured, and he very foolishly undertook to deceive me. I found the patient perfectly conscious, able to answer questions and even seemed to be able to walk. I got him on the table and under an anesthetic, and upon examination found the right side of his head all matted with blood and brains. When I separated the hair I immediately recognized the fact that it was powder-burned, and there was a cavity in the skull that I could easily have stuck my thumb in, just about the junction of the parietal with the frontal bone. I shaved off the hair and separated the stellated, blue scalp, and noticed what I at first took to be a piece of knife blade, but which turned out to be a piece of bullet, sticking in the ragged edge of the skull. I then investigated further and picked off a few of these cleaner looking pieces of skull. I introduced my finger into the wound and got out some brains and hair, and these pieces of bone which were lodged down back of the eye-ball. This man had no disturbance of vision, or ecchymosis or anything of that kind. He got well and later married the beautiful girl with whom he had fallen out and shot himself about.

CASE IV.

Several years ago I was called to a house on East Jefferson Street to see a boy with a history that he had been down in the ditch alongside an electric line, and

the "baby-catcher" of a passing car had struck him and landed him in the street. He got up and walked about a block to the office of Dr. Buckle, who examined him and sent him home. I was called and found the right mastoid region crushed in, right over the lateral sinus which was exposed for about two inches. The boy was perfectly conscious and all right before I put him under the anesthetic. I simply trimmed and smoothed off the hole, which was tremendously large, and the wound healed by first intention. put on a leather cap and he got along all right, without any trouble whatever. The dura was not opened in this case.

CASE V.

One day I was called to St. Anthony's Hospital to see a man who had been hit in the head in a collision with a street car. His skull looked as if it had been crushed in with a hammer. I lifted out this piece of bone, made up of the frontal, including part of the orbit and nasal bones. There was no hemorrhage and the man was perfectly conscious, but I found a fracture that went down back of the orbit and he died that same night.

CASE VI.

Some ten or fifteen years ago, while I was sitting in my office, a carriage drove up and a man got out. He could not be gotten to talk. Had a tag on his coat, "Take me to Dr. Ap Morgan Vance at 218 West Chestnut." I tried to get something intelligent from him and asked him a lot of questions, but he simply pulled out his pocket-book and handed it to me. I found $3.50 in it. The only thing intelligible I could get out of him was the name of Dr. Ryland. The only Dr. Ryland I knew of then was at Russellville, Ky., so I had the man taken to Norton Infirmary and wrote to the doc

tor, who replied, giving me all the information he could about the case, and also sending me a letter from the man's mother. The history was that this man, who was 24 years of age, while in the tenderloin district of Louisville, had been struck on the head with a "slung-shot," over the left eye. The reason he came to me was because I had amputated a leg for his brother some years before. As soon as I received permission from his mother to go ahead and do what I pleased, I attempted to do a flap operation. I lifted this piece of bone up from left frontal and temporal region and found that the brain bulged so that I could not put it back, so I removed it. I then opened the dura and found some sut-like dust in spots all over the exposed areas. This I wiped off, closed the wound, put in a drain and put on a very voluminous dressing. There was a discharge of great quantities of serum. In two or three days, instead of the brain bulging outward, it was bulging inward. In a few more days he began to talk, and before he left here he was able to walk. I will say, in passing, that this man had been subject to epileptic attacks, and that he was relieved of these by the operation, and was able to earn his living.

CASE VII.

These are a couple of buttons that are very interesting. They were removed from a little boy who had internal hydrocephalus. He was the child of prominent parents and was about 21⁄2 years old. I removed one button from the right parietal region and the other over the speech center on the left side. All his functions were perfect except the brain. He recovered from the operation and at first seemed to be decidedly improved. He died of pneumonia a couple of years later,

with no evidence that any good had been done by the operation.

CASE VIII.

From

Patient J. M., a great big six-footer, who came to me about twenty years ago, and I sent him to St. Joseph's Infirmary. The history I obtained from his father was that, twelve years before, this fellow had gone on a spree in New Albany, and during a scrimmage in a livery stable, some one had struck him on the head with a shovel. He remained unconscious for three days, and was totally paralyzed on the left side for three weeks. that time on he was subject to attacks of epilepsy. They would come on whenever he got a little liquor in him, and the intervals between between the attacks varied. Twelve years later, while on a spree, he went back to the same livery stable, and asked a man there who had hit him? This man, seeing that he was drunk, laughingly pointed out a man in a rival livery stable across the street. He immediately went over there, grabbed up a big iron rake and brained the fellow. He was placed in jail and staid there for three months, at the end of which time his father bailed him out and brought him to me. I sent him to the infirmary, and about six o'clock the next morning one of the sisters called me up and said that the man had gone crazy and she could not keep him in the ward. I started down there in my buggy, and met the man coming along the street, with a little. grip-sack in his hand. I took him to the City Hospital in my buggy and did not lose sight of him again until I had him under chloroform. The only sign of the injury he had received was a scar on the right side of his head, which was exquisitely tender, the area of tenderness being about as large as a five-cent piece. With a trephin I removed this button, which

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was adherent to the dura. I used an oldfashioned trephin and the opening was about twice as large as this button. then closed up the wound and he went along and made a complete recovery. The only remains of the paralysis that this man had previous to the operation was an anesthesia of the left thumb, and during his stay in jail he had gotten this thumb against a red-hot stove and burnt off possibly half an inch of it. When I had removed the button this thumb began to give him a good deal of pain, whereas before that he had not paid any attention to it. He lived a long time after that, but finally died of pneumonia.

One humorous feature of the case was that I sent this man a bill for $250.00. Some time afterwards he called to see me, and thanked me for what I had done, and as he was about to leave he turned to me and said: "O, by the way, Doctor, I believe I owe you two dollars and a half."

CASE IX.

Some time ago Dr. Thompson asked me to operate on a young man, 24 years of age. The history was that, when four years old, he had fallen into a cistern, striking some bricks and sustaining an injury to his head at just about the hairline, in front, near the middle. There was an irregulaf jagged scar there, and some evidence of depression. He had been subject to regular Jacksonian epileptic attacks. I advised operation, which was carried out and I found the depression, removed a clover-leaf- shaped piece of bone, getting rid of a good deal of depressed bone a little to the left of the center. The wound healed up and the patient seemed to be in much better condition. He went along without an attack for a considerable length of time. Then he became very much worried about some

business matters, and it seemed that whenever this occurred, these attacks would return in a mild form. I have not seen him for six months. He will probably get over these attacks.

CASE X.

About a year ago, one of our prominent citizens came to see me about a little boy in the country who, eighteen months previously, had fallen against the hub of a wheel and sustained an injury to the left. side of his head which had left a scar. He had suffered with epilepsy for more than a year. The boy was brought here. and I lifted out a button about the size of a half dollar, and the boy has been perfectly well ever since. This was practically a decompressing operation; also relieving some cortical irritation.

CASE XI.

A few days after that, I saw a man who gave a history of having fallen from a freight car, several years ago, injuring his head. He had a depression, the result of a compound comminuted fracture, and was subject to regular Jacksonian epilepsy. Upon opening the skull I found that the broken bone pressed into the brain, and that the meninges were incorporated down in the brain, making a rather aggravated condition. I cleaned it out and closed up the wound. That was about a year ago. Before the operation his head was continually bruised as a result of falling. Since the operation he has had no bad falls, but he is still "dauncey."

CASE XII.

I was called one night to a house on Camp Street to see a boy with the following history. While walking along the street with some companions, one of them had grabbed his cap and thrown it out

in front of a passing street car. Without thinking, the lad ran out to get it and the car struck him, rolling him under the motor. The car was lifted with jacks, the boy crawled out and was carried about a square to his home, where I saw him. I elevated the bed and put warm water bottles around him, and told the family I thought he would die, but if he re-acted I would come back. I was called later, and when I went in I was handed this piece of bone, which was all covered with street dirt, and told that it had been found in the street where the boy had been injured. It is the right parietal bone. Upon examination I found that the boy had been scalped on both sides with a bridge of scalp between. side was perfectly clean while the other was full of mud and other debris of the street. I washed the wounds and put on separate dressings. I watched this case from December 13th until Christmas morning, during which time there had been a good deal of discussion among the family as to why I did not soak the dressings off, but I knew if I did this there. would be trouble. Therefore, they dismissed me from the case and called in another doctor, who soaked the dressings off and 36 hours later the boy was dead.

CASE XIII.

One

This specimen was removed from a boy who was hit on the head with a brick. and became crazy and epileptic. I took a button out of the right side, over the leg center, but it did him no good. He was later sent to a lunatic asylum.

DISCUSSION.

DR. JNO J. MOREN: Dr. Vance has certainly reported a remarkable series of cases. While the doctor was speaking, I was thinking of the many articles that are constantly appearing on the subject

of brain disease, and I think the lesson we have learned from this report is that, whenever we have a case of this kind, the skull should be opened and the exact nature of the trouble ascertained.

I recall having seen two of the cases mentioned by Dr. Vance. Dr. Keller's case was one on which he used to make a report at every meeting of the Practitioner's Club. I also had the pleasure of witnessing the operation on Mr. X., and if ever I saw a man who appeared to be absolutely moribund, it was this one. Like Dr. Vance, I do not know how to explain the trouble, unless it was what is called "wet brain," which, by the way, is a very interesting condition. Last year I saw, in the country, a man who gave a history similar to that of Mr. X. I made diagnosis of wet brain, and told the doctor in charge of the case that if the man developed fever he would die, and that I had nothing to offer in the way of treatment other than general measures for the treatment of alcoholism. On the second day after that the doctor called me up and asked me to make a second visit. I told him I did not know of anything I could do for the patient, and advised to call a surgeon. He called Dr. Dugan, who went to see the patient. but would not venture upon any operative procedure. If that man had been operated upon, possibly the result would have been something like that obtained in the case of Mr. X. If there is a history of injury, I would advise opening the skull, particularly over the site of the injury, but in congenital disturbances, I do. not think surgery offers any hope of relief.

I have under observation at the present time a young man, possibly 21 years of age, upon whom Dr. Butler operated four years ago. The history in this case was that, while standing on top of a fence.

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he had fallen, striking the back of his head and in a very short time he was unconscious. Dr. Butler was called and trephined over the lower portion of the occipital region, with good results. the course of three or four years this boy developed epilepsy and Dr. Butler sent him to me. I do not know exactly what prognosis to give in this case. Dr. Butler said he did not want to expose the brain unless he had to. I gave the boy bromides and corrected his diet which had been very irregular, and he had been in the habit of drinking one or two cups of coffee with each meal: He went home and his improvement was remarkable, as I thought. The epileptic attacks absolutely ceased and he had no trouble until last fall, when he reported having had two attacks. I asked him about the coffee and he admitted that he had again been drinking one or two cups at every meal. I got the gastro-intestinal tract cleaned out and made him quit the coffeedrinking, and he is now a great big strapping fellow and shows absolutely no physical signs of any trouble. At one time, following one of these attacks, he complained of a numbness in his right arm. I am very uncertain about this boy's future, and hardly know how to advise him, but I am of the opinion that he will have further trouble from adhesions from the old operation.

As to the value of symptoms in locating different lesions that occur in the brain, I have great faith in at least one symptom. Not long ago I saw, with Dr. Marvin, a man who was having convulsions, and I told the doctor that, in my opinion, the man had a brain tumor. heard nothing more of the case until one day I received a message to go see this patient at the City Hospital. The internes there had examined the urine and found two or three percent. sugar. There was

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absolutely no localizing symptoms whatever. I had this patient before the class, and it was suggested that possibly his condition was hysterical, but I still held to the opinion that he had a brain tumor. The next time I saw the patient was when I was called by Dr. Schachner to see him at Sts. Mary and Elizabeth Hospital, and I also told Dr. Schachner that I thought he had a brain tumor. By that time the patient had anesthesia of the face, convulsions, typical choked disc, and there had been quite a change in his mentality. Dr. Schachner did a decompressing operation. When he lifted the bone the brain substance bulged out, and it was as tight as a drum-head. No tumor of any kind could be detected upon opening the dura. However, the doctor did not make any extended search, but closed up the wound. The patient rallied from the operation, but developed an immense hernia of the brain and died two months after operation. Dr. Schachner was able to get a post-mortem and he considered the cause of death to be hemorrhage at the site of operation.

DR. J. GARLAND SHERRILL: This is an extremely interesting series of cases, showing how much trauma can be done to the brain and still the patient will recover. I have under observation at the present time a boy, about seventeen years of age, who received a blow on the right side of the forehead, with a piece of castiron pipe, crushing in a triangular piece of bone 31⁄2 inches long and 11⁄2 inches wide at its base. The main symptoms were slow pulse and impaired mentality. He was conscious, but was very restless and irritable. I was unable to take his temperature because he fought every time the thermometer was placed under his arm. The depression was readily detected-just a groove in the forehead. and I immediately operated to raise the

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