to force the latter into extreme adduction or abduction, the external malleolus is subject to powerful pressure. In the first instance that of abduction, by the outer surface of the calcaneum, and in the second that of adduction by the outer surface of both the astragalus and OS calcis; in which position the applied force often ruptures the internal lateral ligament, and the fracture may take place in either of the two ways cited.

Given, therefore, a recent injury of the ankle joint, the question arises, is the injury a dislocation, a sprain, or a fracture? Dislocation being accompanied by displacement, and by a change in the relationship of the bony prominences, may be readily excluded. The two remaining injuries have, however, many symptoms in common, viz., pain, disability, swelling, discoloration. If the ligaments are torn, as is the case in severe sprains, preternatural mobility must be added to this list. Indeed, the unnatural mobility of a severely sprained ankle is frequently much more apparent than is the case when a fracture of either the external malleolus or the distal end of the tibia occurs. Furthermore, infusion into the sheaths of the tendons may impart a kind of false crepitus, which makes itself apparent on passive motion and which may readily be mistaken for the real. Yet, withal, it is more probable that the incautious and hasty observer will mistake a fracture for a sprain rather than the reverse. It has been my fortune not infrequently to meet fractures of a week or ten days' standing which have been treated as sprains. These were, generally speaking, fractures in which the injury was brought about with but little violence and which primarily caused little or no disability. In cases of this sort a comparison of the symptoms may not be amiss.

Sprain. In any age, but mostly in the young or the aged. Pain, most severe. Indeed, we may say that the pain of a tadly twisted ankle is one of the most severe to which the human organism is subject. Swelling more extensive. The discoloration coming on at an earlier period. It is to be especially noted that it is the external lateral ligament which is injured, and often it can be felt

as having given way, or its absence may be noted. On the other hand, fractures of this bone most often occur between the ages of thirty and forty, almost never under fifteen. Malgaigne, whose broad experience is summed up in his classical treatise on fracture, states that he has never seen a fracture of the ankle joint in a person under fifteen or over sixty.

The pain of sprain is of the character best described as sickening. This increases by motion. The disability is extreme and instantaneous; as has been said, the swelling comes with marked rapidity. An almost pathognomonic symptom of sprain is "foot drop," which never occurs in fracture, and which is otherwise only observed in palsies. This is due to the rapid exudation which fills the joint capsule.

The injury in case of fracture is most often received when the foot is in abduction; that is, the inner surface of the foot is the pivotal surface or fulcrum. This fact accounts for the rupture of the internal lateral ligament by overstretching, as well as for the broken end of the fibula. It is to be noted that the broken end of the lower fragment is forced inward toward the tibia. In cases of sprain, which our patient so frequently describes as a "turn of the foot," we are familiar with the fact that the foot has turned in such a manner that the weight of the body is received upon the external edge, just the opposite of the manner in which fractures are usually acquired.

I might cite the fact that Malgaigne states that he has never seen the displacement above described in cases of fracture produced while the foot was in abduction. This certainly is controverted by the experience of American surgeons.

Indications for Treatment.-Having determined the character of the injury the question of paramount importance from the standpoint of the patient is, in what manner shall we treat it? The indications for treatment are three. (1) To control the inflammation, (2) to secure the absorption of transudation, and (3) to restore function. Two methods of treating sprains have been in vogue from time immemorial. One might be described as the "heroic," the other as the "rest" cure. In my personal experience

the most satisfactory method of treatment has been as follows: To place the sprained member as quickly as possible after the injury has been received into a solution of hot brine, allowing it to remain there from three to five minutes, then to plunge it immediately into a cold solution of bicarbonate of soda, alternating between these two solutions as long as the patience and perseverance of the patient will permit. The difference in the specific gravity of the solutions, the stimulating action of the alternating heat and cold, markedly and rapidly reduce the swelling by causing absorption of the exudate; they also markedly influence the pain, relieving it more quickly than anodynes. After a rest this treatment should be repeated. About twenty-four to thirty-six hours usually suffices to bring the member into such state that it can be readily and satisfactorily examined without great inconvenience to the patient. If doubt has existed as to the nature of the injury, a correct diagnosis may now be made, with the full assurance that absolutely no harm has resulted from the delay.

The swelling having been satisfactorily reduced, an elastic bandage made from flannel may be smoothly, snugly and comparatively tightly applied. This further reduces the swelling, and, by immobilizing the joints adds much to the comfort of the patient. The second element in the treatment is massage, which may usually be applied about the third day.

A word of caution is necessary with regard to too protracted fixation, as frequently disability, even anchylosis, may result therefrom. If our injury on the other hand proves to be a fracture, all of the indications are best met by the careful application of a plaster cast, which may be applied as well by the practitioner in the remote districts, as by his city brother.

While the X-ray machine facilitates the diagnosis, it is not essential, as a careful consideration of the anatomical points will invariably satisfy us as to the nature of the injury in this well-marked joint. 1818 North Charles Street.

[Written for the MEDICAL BRIEF.] Cerebro-Spinal Meningitis.

BY HENRY N. READ, M. D., Professor of Diseases of Children in the Long Island College Hospital; Attending Physician to the Long Island College Hos pital; Attending Physician to Sheltering Arms Nursery; Member of the Kings County Society, Pathological Society, Pediatric Society, Physicians' Mutual Aid Association, etc. Brooklyn, N. Y.

In view of the fact that a large number of cases of cerebro-spinal meningitis have appeared recently, a few words relative to the diagnosis and treatment of this disease will be of special interest.

This cerebro-spinal variety of meningitis is due to the diplococcus intracellularis. Practically, there are but two kinds of meningitis, tubercular and non-tubercular, and the prognosis is largely gov. erned by the classification of the disease. If tubercular, the disease is, as a rule, hopeless. If non-tubercular, prognosis is less fatal, but is still very grave.

The prognosis is better in the cerebrospinal variety than in that due to pneumococcus, trauma, or any of the mixed infections, including the streptococcus.

Diagnosis.-Diagnosis of the cerebrospinal variety of meningitis is readily made. When the disease prevails epidemically and is accompanied with an erup. tion from which the old name of "spotted fever" took its origin, the mortality is very high. Cases occurring sporadically are usually apt to be much milder in char. acter. In any event, it is a dangerous and long-continued disease, marked by a protracted convalescence, and the sequelæ may leave marks which will last through life.

The fever, as a rule, is not very high, seldom rising beyond 103° or 103° F. The meninges of the cord are most prominently affected, and give rise to symptoms referable to lesions of the nerves coming off from the upper part of the cord, namely, retraction of the head, severe pains at the base of the brain, etc.

Treatment. The treatment, unfortu nately, does not present any very marked features by which we can hope to cure the disease and is confined mainly to the alleviation of the symptoms and supporting the strength of the patient.

Usually it is well to keep the temperature within bounds by cold sponging, and

it is also necessary, in my opinion, to administer remedies for the relief of the pain, and to control the intense nervous excitement.

As the disease usually lasts a long time it is necessary to conserve the strengtn of the patient as much as possible. I have been in the habit of giving both opium and chloral hydrate, and in goodsized doses, for the relief of pain, the production of sleep and the guarding against convulsive seizures.

Laxatives and careful regulation of the bowels are required. Sometimes counterirritation to the back of the neck will give great relief.

In children it is necessary that they should be put to bed, in a cool, dark room, all light and noise shut out, and excitement sedulously avoided.

The strength must be supported with nutritious and easily-digested food, such as juice of meat, milk properly prepared, eggs, and stimulants used with care.

After the second week, if the fever is reduced to 102° F., and the convalescence seems to be sure, I have found of benefit the administration of Brown-Sequard's mixed treatment of the iodides and bromides, which are used in epilepsy. This to be continued for two or three weeks, or until constitutional symptoms have disappeared.

This disease usually follows a long and severe winter with dampness, and rigid weather conditions; the general vitality of the patient seems to be impaired after such season has passed.

Spinal puncture has not proved of any benefit in my hands, as regards treatment, though enabling us to clear up a doubtful diagnosis.

Recovery seldom takes place in less than six weeks, and may require a much longer time.

228 Clinton Street.

[Written for the MEDICAL BRIEF.] Cough Following Colds.

BY ROBERT C. KENNER, A. M., M. D.,
Louisville, Ky.

On page 432, May issue, I had an article on this subject, and wish to have the dose of the second prescription read a tablespoonful instead of a teaspoonful.

[Written for the MEDICAL BRIEF.] Views on the Abdominal Brain.

BY BYRON ROBINSON, B. S., M. D., Chicago, Ill.

Every Organ Has Its Rhythm.

In this short communication I wish to present some views on the abdominal brain, both practical and theoretical, with two drawings from nature illustrating its dimension, location, contour and distribution.

For a decade and a half I have investigated and written on the subject of the sympathetic nerve-the abdominal brain and automatic visceral ganglia. During those fifteen years I have published numerous articles and a large edition, my book "Abdominal Brain and Automatic Visceral Ganglia," is out of print. However, periodically some physician has published an article claiming new views; yet I have not read a single article containing the so-called new views that was not published in my investigations. Recently a physician claimed that the solar plexus was the seat of shock, but had never noted a reference to that in literature. This I had discussed repeatedly in my work. Another physician claimed that irritation in the ductus bilis from calculus produced spasm of the intestines. Surely such an effort has been thrashed over for years and is not new. The manifestations of the abdominal brain-anatomic and clinical-entitles it to the dignity of a nervous center-a brain. It receives sensation, reorganizing it and emitting motion. It is a receiver, a reorganizer, an emitter of nerve forces. First, we must consider the abdominal brain, the semilunar ganglia or solar plexus, in the physiology of the sympathetic. This large ganglion receives sensation and emits motion; it is a brain. It is situated (see Figures 1 and 2) at the root of the great visceral artery, i. e., at the foot of the celiac axis. It lies behind the stomach and entwines itself about the aorta and root of the celiac axis and superior mesenteric artery. In short, it is located at the roots of the celiac, renal and superior mesenteric arteries. It supplies all the abdominal viscera. It is a gigantic vaso

motor center for the viscera, as is shown by its location at the roots of celiac, renal and superior mesenteric arteriesthe great abdominal visceral blood way. It is connected with almost every organ in the body, with a supremacy over visceral circulation, with a control over visceral secretion and nutrition, with a reflex influence over the heart that often leads to fainting and may even lead to fatality. It commands visceral peristalsis. No wonder that we may consider the abdominal brain the center of life itself, as the cranial brain is the center of mental and psychical forces.

The abdominal brain, or solar plexus, is composed of the aggregation or coalescence of a large number of ganglia. The abdominal brain is composed of two semilunar ganglia-compact masses of nerve cells, nerve cords and connective tissue. During many dissections I have noted that the right semilunar ganglion is the smaller (see Figures 1 and 2), doubtless because it lies dorsal to the inferior vena cava, and hence has suffered from pressure atrophy. Each of the semilunar ganglia receives the great splanchnic nerve of the corresponding side. The abdominal brain receives the two vagi-cranial nerves. It may be here stated that although the semilunar ganglia are located on the sides, they are practically so intimately associated with the solar plexus that we insist in combining all the names into one, viz., that of the abdominal brain.

All plexuses or strands of nerves are secondary to the abdominal brain. The significance of the abdominal brain in the visceral physiology, i. e., in life, may be compared to that of the sun over the planets. The influence of the sun rules the planets, though they are influenced by other suns and planets (e. g., the cerebro-spinal). The abdominal brain has ganglion cells (brain centers), nerve strands (nerve conductors) and a peripheral nerve apparatus (for collecting sensation), just as the cranial brain possesses all central conducting and peripheral apparatus. The adbominal brain can live without the cranial (shown by living fetuses with no trace of cerebrospinal axis), while the cranial brain and cord can not live without the abdominal

brain. The great sympathetic ganglia, of which the abdominal brain is the ruling potentate, is the center of life itself. So long as the forces of life, assimilation, circulation, respiration and secretion and absorption proceed undisturbed, as in health the abdominal brain remains a silent, steady, but ceaseless worker; but being unbalanced by peripheral or central irritation, it quickly manifests or resents the insult. From the abdominal brain large plexuses with numerous nerve

strands pass to every abdominal viscus, connecting the viscera into a delicately balanced, nicely ordered, exquisitely arranged apparatus for the object of maintaining life. The nerve plexuses or strands are arranged along the highways of nourishment-blood and lymph vessels, vary in size according to the importance of the viscus supplied.

Second, we must consider the automatic visceral ganglia to comprehend the domain of power possessed by the abdominal brain and its clinical manifestation. The automatic visceral ganglia are lodged in the walls of the various visceral tracts and every plexus of each visceral tract leads to the abdominal brain. When the abdominal brain receives a sensation it reorganizes it and emits it on lines of least resistance, which means that the motion travels with greatest facility on the plexus possessing the greatest number of nerve strands. Important visceral tracts, significant to life, possess rich nerve strands and plexuses, as e. g., the tractus intestinalis, genitalis and urinarius. A few common examples of irritation, disease in any one visceral tract, will demonstrate the clinical manifestation on the abdominal brain and the other visceral tracts. It is plain to the anatomist that the abdominal brain with its various nerve plexuses to the visceral tracts are finely and exquisitely balanced. It should be plain to the physiologist, the clinician, that irritation, disturbance, disease in any one visceral tract, will transmit the abnormal force to the abdominal brain, reorganizing it and emitting it, pellmell, disorderly, wildly on all other visceral tracts, causing disorder of secretion, absorption and peristalsis. Take, for example, the tractus genitalis. Menstruation, which should be a normal