DISCUSSION OF PAPERS UPON ARTERIO-SCLEROSIS.

Dr. J. Herbert Moore.

Mr. President, fellow members of the State Society:

Investigation into this very important subject of arterio-sclerosis, whether by consulting the authorities, or going into our own clinical records, certainly places us very much in sympathy with Dr. Laidlaw's sentiments, that we are passing through an undiscovered country. At the same time it is through such symposiums as these that the different grains of truth will come to the surface, and perhaps the most important features of the discussions like today is not what we hear, but the suggestions that these thoughts bring out in our own minds.

First as regards Dr. Suffa's paper. I do not want to profess to being an expert at the ophthalmoscope, but this does not keep me from appreciating the great importance that Dr. Suffa brought out in his paper as to the use of the ophthalmoscope in detecting the very first symptoms of this disease. I believe the general practitioner who is not apt at the ophthalmoscope would certainly find it very much to his benefit to be placed in the right way as soon as possible by sending his patients to an expert ophthalmatist, who can discover on the retina the very first signs of disease, just as we send samples of urine to be examined.

As regards the etiology of this disease. I am very glad to find that Dr. Sutherland and Dr. Laidlaw, without any collusion, put the pathology of this insidious disease on a chemical basis, because it does seem that is the most reasonable basis of finding out the first disturbances in the system.

What is

The old saying is that a man is only as old as his arteries. senility if it is not the wear and tear on the delicate structures of the body; the tearing down of the human organs which prevails in every person over fifty years of age?

It seems to me that investigations in the future along these lines will perhaps place the etiology of this disease in a large number of cases on the toxins. It does seem as if the chances of the future would be enhanced by a study of retention of toxins and the results in the very delicate structures of the body.

There was one point which I was very glad to hear Dr. Laidlaw emphasize. That is, that we should not judge the condition of the internal arteries of the system by the effects on the external, such as the radial which we see in the wrist. One can have a very great degree of internal arterio-sclerosis without its manifesting itself on the external surface of the body.

Also another excellent suggestion, that a low blood pressure does not necessarily exclude arterio-sclerosis, that is, arterio-sclerosis can be had with a low arterial pressure as well as with a high.

Dr. Suffa in speaking of blood pressure made use of one adjective, "permanent," high blood pressure. That is what we want. We do not want to decide the condition of a patient who has been through great trial and stress, but what we want is permanent blood pressure.

Just a word in regard to therapeutics. It certainly seems as if our two societies had hit upon the right methods. To my personal knowledge, and in my own experience plumbum from its pathology seems to take the lead.

Just one little point about what the patient should drink. Plenty of soft water. As regards drink at table, no coffee. The ordinary cup of coffee contains three to three and a half grains of caffeine. These patients should omit coffee and tea. If they insist on a hot drink give them cocoa, on account of the theo-bromine in it.

In the matter of fatigue. Perhaps some of you know the excellent work which Dr. Lee, professor of physiology at Columbia University, wrote on the effects of fatigue on the body, and there seems now to be an epidemic of business men walking to and fro from business. Now with arterio-sclerosis patients, we should be careful how we allow them too much physical exercise. Do not allow your patient who is coming down with arterio-sclerosis to take too much exercise. Rest is an important adjuvant in curing this disease.

It seems to me it should be the aim of a high pressure-living professional

man over fifty years of age to so conduct his business, his profession, his everyday life that not too much strain and stress may be brought to bear upon the delicate arterial system.

Speaking again of prevention: there is no prevention of this disease other than right living. Right living physically, right living morally, right living psychically.

The papers were further discussed by Dr. Solomon Fuller of Westborough, who exhibited a number of photographs and drawings of brain sections, and who very ably described the changes induced therein by arteriosclerosis. A number of others then entered into the general discussion, among whom were Drs. J. P. Rand, G. L. Van Deursen, G. R. Southwick, F. S. Piper, H A. Whitmarsh, and Eliza T. Ransom. In the discussion many cases were cited and numerous interesting points brought forth.

CRANIAL INJURIES AND THEIR SURGICAL TREATMENT. *

BY DEWITT G. WILCOX, M.D., Boston, Mass.

The fact is being borne in upon us with a persistency which we can no longer disregard that this delicate and intricate organ which we call the brain is the victim of traumatic misfortunes to a much greater degree than we have yet realized. It is possible that I may be guilty of allowing my fancy to run away with my more sober anatomic and pathologic knowledge, when 1 say that the time is not far distant when we no longer shall prejudge and condemn a man or woman who is eccentric, a pervert, a kleptomaniac, an occasional criminal or even a homicide without first making a careful physical study of his entire life from the hour of birth to the commitment of the first crime, and thereby determine, if possible, whether or not his brain has been the victim of some traumatism inflicted either at birth or later.

The impetus given the subject in the last few years by such men as Cushing of Baltimore, Ballance of London, Starr of New York, and Kocher of Berne, and the pioneer work done by Sir Victor Horsely of England, and Ferrier of France has been productive of much good, placing the whole matter upon something like a scientific basis.

Cushing in a recent article advocates the cultivation of what he calls the neurologic surgeon. He says, "In no department of medicine today is there greater promise of immediate scientific reward or greater need of extensive surgical cultivation than exists in Neurology, which so far as the possibilities of operative therapy are concerned is about the position occupied by gynecology twenty-five years ago. There is urgent need and wide opportunity for a group of men, rigorously trained in general surgery, in the neurologic clinic, and the experimental laboratory who can serve as pathfinders in surgery of the central nervous system; men who are not only capable of exposing the brain and cord with full respect to the dire consequences of rough methods, but who stand abreast with the growing maladies to which these structures are heir." So much for the neurologic surgeon.

* Read before the American Institute of Homoeopathy, at Narragansett Pier, R. L, June, 1911.

1

Let us for a moment view the brain of the new born child at the moment when it is about to assume the majestic responsibility of governing a new-made life. An all wise Creator has so modelled the head of the child still in utero that it can be greatly compressed in all directions in its passage through the bony pelvis without doing serious damage to the brain which as yet has not awakened to its full duties. Indeed the brain of the new born child seems especially tolerant of the roughest kind of treatment without entering a pathologic protest. This is due partly to the fact that the brain is as yet undeveloped and in a state of partial stupor. But tolerant as this sleeping brain may be, there is, nevertheless, a limit of tolerance, and the wonder is, not that there are occasional lesions, but rather that there are so few.

In a protracted forceps delivery where much compression is imperative, there must be much overlapping of the cranial bones ere the delivery can be effected. This overlapping must of necessity cause a loosening of the pericranium along the line of sutures where the bones rub one against the other. If this loosening be extensive there must of necessity be some torn blood vessels and a hemorrhage between the pericranium and the skull. Thus a blood clot may form between the dura and the pericranium and after the bone closes it becomes an epidural clot. As the overlapping of the bone is greatest at the sutures where the parietal bones join we find, as Cushing has pointed out, the greater frequency of blood clots upon the parietal lobes of the brain.

This explains the greater frequency of motor paralysis of the lower extremities rather than the upper in the new born, because the motor leg centre is nearest the suture line. This hemorrhage, or extravasation, may be bi-lateral or uni-lateral.

Little, an English surgeon, was the first to call attention to the fact that a history of difficult birth could be obtained in a large percentage of the children who later in life suffered from Lilateral spastic paralysis. Hence the name "Little's Disease" or "Birth Palsy."

It has been pointed out that a violent fit of coughing during a paroxysm of whooping cough may cause a rupture of one of the delicate blood vessels connecting the cortex and dura and thus induce death or local paralysis. This fact has been demonstrated in autopsies.

The extent of brain surface which these hemorrhages may cover, varies from a small point to an entire cerebral hemisphere. It is rare, however, that both hemispheres are involved.

The question may arise, Why do we not have more cases of death or paralysis from these intra-cranial hemorrhages? It is because of the open membranous fontanels which are so elastic as to allow an expansion outward and thereby overcome compressive symptoms. Were the same amount of bleeding to take place in the closed cranium of an adult which probably takes

place in a great number of new born infants there would be an alarming number of deaths or cerebral defects.

Let us now see what are some of the pathological evidences of these intra-cranial hemorrhages which may be revealed either by operation or post-mortems.

First. There may be only a thickening of the meninges with adhesions over an old superficial scar, or we may find a shallow defect filled with blood.

Second. We may find a large cavity occupying an entire lobe filled with blood.

Rogers, of Chicago, who has recently operated upon a number of children for cranial injuries mentioned finding a calcareous deposit like fish scales on the meninges. This deposit is the remains of blood fibrin wherein the clot has been largely absorbed, leaving only the lime salts behind.

A far more interesting question, however, is what is the ultimate state of these children mentally, morally and physically, who have been the victims of parturient accidents? Fortunately many of them do not live more than a few days after birth. Those which do survive are, in the majority of instances, most pitiable objects. Not infrequently the respiratory centre seems. to be the one most embarassed and the child has great difficulty in breathing. It has been demonstrated that many of the cases of still birth are due to hemorrhages into the pons of cerebelAgain we find these infants showing difficulty in swallowing, hence the child suckles badly and is in consequence poorly nourished. A Cheyne-Stokes respiration is indicative of such local hemorrhage.

There may be pupillary inaction or inequality. The fontanels may be hard and tense, showing great intra-cranial pressure. Twitchings and eventually convulsions may be manifest. All these symptoms are likely to occur early, within the first few days after birth. It should be remembered that rarely is there any evidence of motor paralysis in early life as the motor centres are more or less dormant, the spinal cord and cerebellum being the real actors of the central nervous system.

If now the child survives the early infant life the next group of symptoms will interest us still more. The parents ere this have become aware that the child is not fully normal, and they are watching with anxious solicitude for the first awakening signs of mentality. Not infrequently there is a period of improvement following the first symptoms of compression, a period when false hopes are raised only to be shattered later by failure of normal mentality to assert itself. It is now only a matter of time when this child must be classed with the simple minded, the epileptic, the spastic paralytic, or the hopeless idiot.

With such a picture before us is there not the greatest possible incentive to arouse ourselves to the double responsibility which rests upon us; first, the prevention of these unfortunate, (and I think to a great extent preventable) accidents of parturi

tion whereby hemorrhage and compression take place; second, the early recognition of these accidents when manifested by the line of symptoms just outlined, and a scientific, skilful effort to correct them by surgical means in so far as they are surgically accessible?

I seriously question whether the average obstetric physician has before him a full comprehension of the grave dangers of these cranial hemorrhages to which the new born child is subject and the dire consequences of such injuries to the mental and physical welfare of the child in after life.

Allow me to cite an interesting case as an illustration of this kind of intra-cranial hemorrhage. The case came under observation of a Boston surgeon some eighteen months ago. A child of four days old, instrumental delivery, no complications otherwise, a healthy boy of nine pounds. On the third day he became stupid and finally slept continuously. Twitchings appeared in the right hand and leg, also the left eye and left side of the face. The father of the child, being a physician, was easily induced to have a surgeon called. Fortunately the surgeon had been doing some brain surgery, and an exploratory trephine was made over the leg and arm centre on the left side of the head. A small sub-dural clot was found and removed, and the child made a good recovery with the entire disappearance of all symptoms of compression. Eighteen months have now elapsed and the evidences are that no further hemorrhage has occurred.

Cushing reports twelve cases of trephining for hemorrhage following delivery, with six recoveries.

From these reports it will be seen what possibilities for relief lie in surgical measures. The indications for operation are as marked and the demands are as imperative as they are in the same class of cases in adults.

Dr. Rogers of Chicago reports the following case:

"A boy aged four entered Willard Hospital March 15, 1909. Mother says he was a large baby, labor long and difficult. She was finally delivered with instruments. Baby seemed well and the physician noted nothing wrong, but the child cried a good deal and did not move his arms and legs as did her other two babies when they were young. The mother said the child never made any attempt to move his left hand. At six months the mother discovered that the left arm and leg were paralyzed. He cried nearly all the time he was awake. At the age of one year he still made no attempt to sit up. At this time a physician was consulted, and the mother was informed that the baby was paralyzed on the left side and the paralysis would be permanent. He sat up when he was two and a half years old, and would hop about, using his right arm and leg. This was his mode of travel when I saw him at the hospital. He could stand on his right foot if supported, or could get hold of some object, as a chair, table, etc. He had never talked, nor could be taught.