If the bladder is full, catheterization may be necessary.
Treatment of the Reaction (or the Sub acute Stage).—Here there is still some shock, an actual destruction of brain tissue, a compression of adjacent tracts by the extravasation, and an inflamma tory reaction of immediately-surround ing parts. We have little to offset this. Counter-irritation can hardly act that deeply. Iodides, to favor quick absorp tion of clot, are the routine treatment.
Trephining, with evulsion of clots, would be in order in this condition, although, owing to difficulty in exact localization and the usual depth of the focus below the surface, such operative relief is rarely feasible. During this period we may have to continue de pressants, and wait with nux vomica or its alkaloids. ":\Tegatively the usc of digitalis in a patient who has once suf fered from brain-lu-emorrhage is ever after a risky matter." Case of traumatic llinorrhage into the white brain-snbstance followed by aphasia, hemiparesis, and Jacksonian epilepsy. Recovery after surgical inter ference.
Conclusions: 1. Extravasations of blood of traumatic origin can be removed from the brain-substance by surgical methods, as well as contused anct destroyed brain substance, and in the same manner pathological and circumscribed portions of brain-matter. 2. -It is possible that extravasations of blood other than those of traumatic origin may be removed by surgical interference. 3. The brain does not resent surgical procedures more than any other part of the body. Borsuk and Wizel (Archiv f. klin. Chin, B. 54, H. 1, '97).
Two eases of cerebral luernorrhage treated by trephining- with a view to evacuation of the clot. In the first case a luernorrhagic cavity was exposed in the right parietal lobe, and several clots mixed with detritis of cerebral sub stance were removed, the opera,tion re sulting in a, rapid and complete eure. In the second ease a clot could not be found, lent the patient gained consider able benefit from the relief of intro cranial pressure due to the exploratory trephining. The author, in discussing the question of surgical intervention in cases of cerebral lilemorrhage, puts on one side the proposal to liga,te the com mon carotid. The benefit to be derived from this operation he holds to be il lusory, as it cannot influence existing lesions, and that it can do good in pre venting renewed hremorrhage has not been proved. -Moreover, it is undoubtedly
a grave procedure and may by itself cause death. In the author's opinion, the surgeon should endeavor to expose by trephining the seat of hremorrhag,e. to suppress cerebral compression by re moving the clots, and also to prevent or overcome infection of the attacked por tion of brain by drainage. The cranium.
it is suggested, should be trephined over the fissure of Sylvius.
The dura mater, having. been exposed by- an orifice from 3 to 4 centimetres in diameter, should be incised, and the brain punctured by an exploratory needle in the direction of the internal capsule. If a luemorrhagic focus be dis covered, it should be exposed by incision of the cerebral substance and the ca,vity be freely laid open and drained by gauze. This operation will, it is stated, often remain simply an exploratory one, and in many cases—itS, for instance, those of abundant effusion and ventricular and bulbar luemorrhages—such treatment, the author acknowledges, will be quite useless. In certain cases, however, life may be saved by exposure of the region of hremorrhage, and the mode of inter vention proposed by the author is held to be free from risk. Lambotte (Ann. et Bull. de la Soc. de Ale.d. d'Anvers, July-August, 1902).
For the hemiplegic after the condi tion has settled down into the chronic stage our resources are sadly limited. Strychnine or its congeners internally, sometimes electricity locally to the mus cles, and care of the general health com prise all that is rational in customary procedure.
Recently a German writer has done good service by calling attention to the importance, in these cases, of doing everything to bring activity again into the patient's impaired nerve-tracts. He shows that by rousing these persons, lift ing them—when not too feeble—into a sitting position, getting them once more interested in life; further, by ex ercising actively and sernipassively the paretic muscles, we can save the patient from the further degeneration that so often ensues and may even effect great gain. To the value of this principle I can heartily subscribe. Ere beginning this plan, however, we must wait until the danger of immediate relapse is past, —say, usually until the end of the first week or ten days.