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PRAISE FOR WAREHOUSE MANAGEMENT THIRD
EDITION

‘There are few people in the world with Gwynne Richards’ specialist knowledge and experience. Aligned to
the rapid pace of change in today’s logistics industry, his latest edition of Warehouse Management is an
invaluable tool for understanding best practice in this vitally important business. Seasoned practitioners as well
as the young talent needed by the industry will find this a great source of reference and learning.’ Peter Ward,
Chief Executive, United Kingdom Warehousing Association

‘Warehouse Management, third edition, is an essential “one-stop shop” for both experienced practitioners and
those who want to fully understand the fundamentals of how to manage a business storage facility. This is a
technical topic, yet the book is accessible, with industry terms clearly explained and examples of best practice
provided. Warehouse Management is a must-read for everyone in the supply chain and logistics industries,
business students and those who want to understand more about how to operate a warehouse.’ Phil Wood,
Order to Cash Manager – Northern Europe, Mondelēz International

‘This third edition of Warehouse Management is very welcome and provides great insight into all aspects of the
subject. I know from my work with Gwynne Richards at The University of Warwick that his students
appreciate the book as a source of reference during their studies. It is an invaluable addition to the bookshelves
of students and experienced practitioners alike.’ David James, Director, Subsidiary Management, KNAPP
AG

‘Comprehensive! Warehouse Management is an excellent resource for anyone with warehouse and distribution
responsibilities. This book provides readers with a deep understanding of the principles of warehouse
management and opportunities to improve efficiencies.’ Michael Mikitka, Warehousing Education and
Research Council (WERC)

‘A great resource for students and practitioners. Whether at university or as part of continuing professional
development, Gwynne Richards’ third edition provides timely updates that warehousing and operations
professionals need to know to stay ahead.’ Kevin Richardson, Chief Executive, The Chartered Institute of
Logistics and Transport (CILT) UK

2
Third Edition

Warehouse Management
A complete guide to improving efficiency and
minimizing costs in the modern warehouse

Gwynne Richards

3
Publisher’s note
Every possible effort has been made to ensure that the information contained in this book is accurate
at the time of going to press, and the publisher and authors cannot accept responsibility for any errors
or omissions, however caused. No responsibility for loss or damage occasioned to any person acting, or
refraining from action, as a result of the material in this publication can be accepted by the editor, the
publisher or any of the authors.

First published in Great Britain and the United States in 2011 by Kogan Page Limited
Second edition published in 2014
Third edition published in 2018

Apart from any fair dealing for the purposes of research or private study, or criticism or review, as
permitted under the Copyright, Designs and Patents Act 1988, this publication may only be reproduced,
stored or transmitted, in any form or by any means, with the prior permission in writing of the
publishers, or in the case of reprographic reproduction in accordance with the terms and licences issued
by the CLA. Enquiries concerning reproduction outside these terms should be sent to the publishers at
the undermentioned addresses:

2nd Floor, 45 Gee Street

London EC1V 3RS
United Kingdom
www.koganpage.com

c/o Martin P Hill Consulting

122 W 27th St, 10th Floor
New York NY 10001
USA

4737/23 Ansari Road

Daryaganj
New Delhi 110002
India

© Gwynne Richards, 2011, 2014, 2018

The right of Gwynne Richards to be identified as the author of this work and the right of each
commissioned author of this work to be identified as the author of their contribution has been asserted
by them in accordance with the Copyright, Designs and Patents Act 1988.

ISBN 978 0 7494 7977 0

E-ISBN 978 0 7494 7978 7

Typeset by Integra Software Services, Pondicherry

Print production managed by Jellyfish
Printed and bound by CPI Group (UK) Ltd, Croydon CR0 4YY

4
CONTENTS

Cover
Title Page
Copyright
Contents
List of Figures
List of Tables
Acknowledgements

Introduction

01 The role of the warehouse

Introduction
Types of warehouse operation
Why do we hold stock?
Warehouse location
Number of warehouses
Supply chain trends affecting warehouses
The growth of e-fulfilment and its effect on the warehouse
Specialized warehousing
Summary and conclusion

02 Role of the warehouse manager

Introduction
Warehouse trade-offs
The warehouse manager’s challenges
Lean warehousing
People management
People challenges
Attracting and retaining warehouse employees
An ageing and constantly changing workforce
Operating hours
Training
Warehouse audit
Quality systems
Summary and conclusion

03 Warehouse processes: receiving and put-away

Introduction
Receiving
Pre-receipt
In-handling
Preparation
Offloading
Cross docking
Recording
Quality control

5
 Put-away
Summary and conclusion

04 Warehouse processes: pick preparation

Introduction
Preparation
Warehouse pick area layout
Summary and conclusion

05 Picking strategies and equipment

Introduction
Picker to goods
Goods to picker
Types of automated picking
Examples of automated picking systems
Handling equipment
Storage equipment
Summary and conclusion

06 Order-picking methods

Introduction
Paper pick lists
Pick by label
Pick by voice
Barcode scanning
Radio frequency identification
Pick by light/pick to light
Put to light
Vision pick
Comparisons
Cost of errors
Deciding on type of picking system and equipment
Summary and conclusion

07 Warehouse processes from replenishment to despatch and beyond

Introduction
Replenishment
Value-adding services
Indirect activities
Stock management
Stock or inventory counting
Cycle counting or perpetual inventory counts
The count itself
Security
Returns processing
Despatch
Documentation
Role of the driver
Summary and conclusion

6
08 Warehouse management systems

Introduction
Why does a company need a WMS?
Choosing a WMS
The process
Selecting the right WMS
What to look for in a system
Selecting a partner
Before the final decision
Implementation
Software as a service
Cloud computing
Summary and conclusion

09 Warehouse layout

Introduction
Data collection and analysis
Space calculations
Aisle width
Other space
Warehouse layout examples
Finding additional space
Summary and conclusion

10 Storage and handling equipment

Introduction
Storage equipment
Storage options
Shuttle technology with a difference
Very high bay warehouses
Other storage media
Warehouse handling equipment
Vertical and horizontal movement
Automated storage and retrieval systems (AS/RS)
Specialized equipment
Recent technical advances
Summary and conclusion

11 Resourcing a warehouse

Introduction
Processing activities
Other factors
Modelling automation
Summary and conclusion

12 Warehouse costs

Introduction
Types of costs
Return on investment (ROI)

7
 Traditional versus activity-based costing systems
Charging for shared-user warehouse services
Logistics charging methods
Hybrid
Summary and conclusion

13 Performance management

Introduction
Why do we need to measure?
What should we be measuring?
How to choose the right performance measures
Traditional productivity measures
New performance metrics
Hard and soft measures
Integrated performance models
Benchmarking
Balanced scorecard
Summary and conclusion

14 Outsourcing

Introduction
The outsourcing decision
Core activity/core competence
Cost reduction, cost visibility and economies of scale
Improvement in customer service
Management skills and innovation
Capital investment reduction
Flexibility
Role of third-party contractors
Preparing to outsource
Choosing the right partner
The transition
Managing a third-party relationship
Why contracts fail
The future of outsourcing
Summary and conclusion

15 Health and safety

Introduction
Risk assessments
Layout and design
Fire safety
Slips and trips
Manual handling
Working at height
Vehicles
Forklift trucks
Warehouse equipment legislation
First aid
Insuring against liability
Summary and conclusion

8
16 The warehouse and the environment

Introduction
Legislation and other pressures
Warehouse energy usage
Energy production
The environment and waste
Packaging
Pallets
Stretchwrap
Cartons
Labelling
Product waste
Waste disposal
Hazardous waste
Forklift trucks
Equipment disposal
Summary and conclusion

17 The warehouse of the future

Introduction
Context
Views of the future: the landscape
Views of the future: the warehouse
Other advances
Summary and conclusion

Appendix 1: Warehouse audit checklists

Appendix 2: Barcodes
Bibliography
Websites of companies that have contributed to this book and other useful websites
Glossary of terms and abbreviations
Index
Backcover

9
List of Figures

FIGURE 1.1 Warehousing in the supply chain

FIGURE 1.2 Seasonality: chocolate

FIGURE 1.3 Seasonality: apparel and equipment

FIGURE 1.4 Apex Corporation’s ACTYLUS™ Smart Bin System

FIGURE 1.5 Warehouse costs globally (courtesy of DTZ)

FIGURE 1.6 Factors determining the location of a warehouse

FIGURE 1.7 Bendi articulated truck for use in a refrigerated environment

FIGURE 1.8 Sorter bag system (courtesy of Knapp)

FIGURE 1.9 Classification and labelling of hazardous products

FIGURE 2.1 Warehouse trade-offs

FIGURE 2.2 Daily picked volumes UK retailer

FIGURE 2.3 Warehouse challenges (adapted from Dematic Corporation 2009)

FIGURE 2.4 Shadow boards courtesy of Fabufacture

FIGURE 2.5 5S methodology in the warehouse (adapted from and courtesy of Cerasis Ltd)

FIGURE 3.1 Warehouse activities as a percentage of total cost

FIGURE 3.2 Warehouse processes

FIGURE 3.3 Push Pull image

FIGURE 3.4 Onpallet.com TiHi calculation

FIGURE 3.5 Example of incorrectly sized cartons

FIGURE 3.6 Retail operation goods in planned v actual graph

FIGURE 3.7 Automated unloading (courtesy of Joloda)

FIGURE 3.8 Boom conveyor unloading cartons (courtesy of Best Conveyors)

FIGURE 3.9 Robotic palletizer (courtesy of Bastian Solutions)

FIGURE 3.10 Robotic unloading of container with boom conveyor (courtesy of Bastian Solutions)

FIGURE 3.11 Example of cross docking

FIGURE 4.1 Picking interrelationships

FIGURE 4.2 Pareto’s Law or the 80/20 rule (courtesy of Vanderlande)

10
FIGURE 4.3 Pareto analysis of orders and SKU

FIGURE 4.4 ABC analysis: quantity and frequency of sales (courtesy of ABC

FIGURE 4.5 ABC analysis: product value and frequency of sales

FIGURE 4.6 Benefits of ABC analysis (courtesy of Cirrus Logistics)

FIGURE 4.7 FMCG manufacturer: order analysis

FIGURE 4.8 Product cube picked and despatched per month

FIGURE 4.9 Basic warehouse layout based on ABC classification

FIGURE 4.10 Rack and shelf layout (adapted from J P van den Berg, 2011 and reproduced by kind
premission)

FIGURE 4.11 Alternative rack layout with racks at right angles to the main aisle

FIGURE 4.12 Rack tunnel (courtesy of Nene Storage Equipment Ltd)

FIGURE 5.1 Picking strategies and equipment

FIGURE 5.2 Cluster pick cart (courtesy of Inther)

FIGURE 5.3 Mini-load system (courtesy of Vanderlande)

FIGURE 5.4 Cimcorp 3D Shuttle

FIGURE 5.5 Autostore robot

FIGURE 5.6 Ergonomic workstation (courtesy of Dematic)

FIGURE 5.7 Highly automated solutions (courtesy of System Logistics)

FIGURE 5.8 Robot picking (courtesy of SSI Schäfer)

FIGURE 5.9 Kiva robotic system

FIGURE 5.10 Eiratech eirabot system (courtesy of Eiratech)

FIGURE 5.11 Low-level order picker (courtesy of Toyota)

FIGURE 5.12 Tow tractor (courtesy of Crown)

FIGURE 5.13 High-level order picker (courtesy of Toyota)

FIGURE 5.14 Autocruiser from SSI Schäfer

FIGURE 5.15 Conveyor systems (courtesy of Dematic Corporation)

FIGURE 5.16 Carton flow rack (courtesy of Knapp)

FIGURE 5.17 Typical shelving area for fashion items (courtesy of Joe Fogg)

FIGURE 5.18 Static shelving versus carton flow (courtesy of Cisco Eagle)

FIGURE 5.19 Storage drawers

11
FIGURE 5.20 Filing drawers

FIGURE 5.21 Mobile shelving

FIGURE 5.22 Horizontal carousel

FIGURE 5.23 Vertical carousel (courtesy of Kardex)

FIGURE 5.24 Kardex Remstar LR 35

FIGURE 5.25 (Part 1) Pick module selection matrix (courtesy of OPS Design)

FIGURE 5.25 (Part 2) Pick module selection matrix (courtesy of OPS Design)

FIGURE 6.1 Benefits of voice picking (courtesy of ARC Advisory Group)

FIGURE 6.2 Why voice outperforms scanning

FIGURE 6.3 Laser-guided AGV with voice (courtesy of Toyota)

FIGURE 6.4 One-dimensional and two-dimensional barcodes

FIGURE 6.5 Wearable RDT with finger scanner (courtesy of Vanderlande)

FIGURE 6.6 Picking with hand-held barcode scanner (courtesy of LXE)

FIGURE 6.7 Picking with finger scanner (courtesy of LXE)

FIGURE 6.8 Yankee Candle pick to light (courtesy of SSI Schäfer)

FIGURE 6.9 Pick rate comparison for the various pick technologies (Wulfraat 2013)

FIGURE 7.1 The returns cycle (courtesy of University of Huddersfield)

FIGURE 7.2 Outbound work stations (courtesy of Joe Fogg)

FIGURE 7.3 Automatic stretchwrap machines

FIGURE 8.1 Advantages of quality information (used with permission of Tompkins Associates)

FIGURE 9.1 Warehouse 3D drawing (courtesy of Cirrus Logistics)

FIGURE 9.2 Diagram showing the different modules – width, height and length,

FIGURES 9.3 and 9.4 Aisle widths (courtesy of Carson Racking Systems Limited)

FIGURE 9.5 U-flow warehouse (courtesy of University of Huddersfield)

FIGURE 9.6 Through-flow warehouse (courtesy of University of Huddersfield)

FIGURE 9.7 Rail-connected warehouse (courtesy of DHL)

FIGURE 10.1 Pallet storage equipment used in UK warehouses (Baker and Perotti 2008)

FIGURE 10.2 Example of block stacking (courtesy of Howard Tenens)

FIGURE 10.3 Double-deep racking (courtesy of Redirack)

FIGURE 10.4 Narrow aisle racking (courtesy of Constructor Group)

12
FIGURE 10.5 Drive-in racking (courtesy of Howard Tenens)

FIGURE 10.6 Pallet-flow racking (courtesy of Constructor Group)

FIGURE 10.7 Push-back racking (courtesy of Redirack)

FIGURE 10.8 Mobile racking (courtesy of Constructor Group)

FIGURE 10.9 Shuttle racking above despatch bays (courtesy of Toyota)

FIGURE 10.10 Example of satellite racking (courtesy of Toyota)

FIGURE 10.11 ACTIV in action (courtesy of Retrotech)

FIGURE 10.12 Quinn Glass warehouse (courtesy of Stöcklin Logistik)

FIGURE 10.13 Warehouse capacity graph: euro pallets (courtesy of Constructor Group)

FIGURE 10.14 Warehouse capacity graph: UK pallets (courtesy of Constructor Group)

FIGURE 10.15 Two-dimensional decision tree (courtesy of Insight Holdings)

FIGURE 10.16 Cantilever racking (courtesy of Locators)

FIGURE 10.17 Mezzanine floors at Arvato (© Joe Fogg, 2016)

FIGURE 10.18 Automated guided vehicle (courtesy of Dematic)

FIGURE 10.19 Internal view of computerized forklift truck (courtesy of Atlet)

FIGURE 10.20 Pallet stacker (courtesy of Locators)

FIGURE 10.21 Aisle width calculation, CBT

FIGURE 10.22 Reach truck aisle width calculation

FIGURE 10.23 Mini Bendi (courtesy of Bendi)

FIGURE 10.24 Reach truck (courtesy of Atlet)

FIGURE 10.25 Articulated forklift truck (courtesy of Locators)

FIGURE 10.26 The Translift SpaceMate

FIGURE 10.27 Combilift sideloader (courtesy of Locators)

FIGURE 10.28 Linde AGV picking truck

FIGURE 10.29 Crane system for AS/RS (courtesy of Stöcklin Logistik)

FIGURE 10.30 Articulated forklift truck with sideloading attachment (courtesy of Bendi)

FIGURE 10.31 Toyota hybrid truck (courtesy of Toyota)

FIGURE 10.32 Doosan Concept Forklift Truck (courtesy of Doosan: www.doosanflt.com)

FIGURE 11.1 Put-away time illustration

FIGURE 11.2 Growth factors influencing work rates

13
FIGURE 11.3 Screenshot of a labour management system courtesy of WCS

FIGURE 11.4 Resource planning program (courtesy of Wincanton)

FIGURE 11.5 Demand variability

FIGURE 11.6 Daily activity profile

FIGURE 11.7 Weighted hours

FIGURE 12.1 Simple warehouse cost tree

FIGURE 12.2 Breakdown of the cost of ownership – FLT (courtesy of Toyota)

FIGURE 13.1 Retailer and third-party KPIs (courtesy of Steve Whyman)

FIGURE 13.2 Cost of service improvement (courtesy of Rushton, Croucher and Baker 2010)

FIGURE 13.3 The balanced scorecard (Kaplan and Norton 1996)

FIGURE 14.1 The outsourcing decision (McIvor 2000)

FIGURE 14.2 Outsourcing decision matrix (Vitasek 2010)

FIGURE 14.3 Outsourcing logistics process (courtesy of FT Group Sourcing 2009)

FIGURE 14.4 Outsourced relationships (courtesy of Steve Whyman)

FIGURE 14.5 Why outsourced relationships fail (courtesy of Eye for Transport)

FIGURE 14.6 Where do LSPs come up short?

FIGURE 14.7 Performance pyramid (Vitasek 2010)

FIGURE 14.8 From confrontation to collaboration (Vitasek 2010)

FIGURE 14.9 The five rules

FIGURE 15.1 Main causes of injuries in the warehouse (www.HSE.gov.uk)

FIGURE 15.2 The accident pyramid (adapted from Bird and Germain 1996)

FIGURE 15.3 Partial rack collapse (courtesy of Nene)

FIGURE 15.4 Sprinkler system (courtesy of Joe Fogg)

FIGURE 16.1 Warehouse energy usage (courtesy of UKWA 2010 and the CTP)

FIGURE 16.2 Energy-saving warehouse (courtesy of Chalmor and Ritrama)

FIGURE 16.3 Solar panels on warehouse roof (courtesy of Miniclipper)

14
List of Tables

TABLE 1.1 Comparison between many and fewer warehouses

TABLE 1.2 Retail e-commerce sales

TABLE 2.1 Warehouse shift patterns (adapted from Ackerman 2000)

TABLE 3.1 Pallet dimensions (ISO)

TABLE 3.2 Excel spreadsheet denoting delivery truck booking times by door

TABLE 3.3 Inbound product quantity checklist

TABLE 3.4 Goods received non-compliance report

TABLE 4.1 Best in class: picking (WERC)

TABLE 4.2 ABC comparison

TABLE 4.3 ABC analysis using Excel

TABLE 4.4 Product popularity by order frequency

TABLE 4.5 Example of product slotting tool (courtesy of John Bartholdi, www.warehouse-science.com)

TABLE 4.6 Order analysis: FMCG manufacturer

TABLE 4.7 Example of pick-face analysis

TABLE 5.1 Shelf storage versus carton flow storage (courtesy of Cisco Eagle)

TABLE 5.2 Comparison chart - order pick strategies

TABLE 6.1 Pick method comparison (adapted from CILT Warehouse Management course)

TABLE 6.2 Pick system advantages and disadvantages

TABLE 6.3 Cost and accuracy comparison of the various pick technologies (Wulfraat (2013))

TABLE 7.1 Stock classification

TABLE 9.1 Storage space calculation

TABLE 9.2 Storage method options

TABLE 10.1 Choosing a warehouse racking system

TABLE 10.2 Comparison chart for MHE (courtesy of Locators)

TABLE 12.1 Warehouse cost structure

TABLE 12.2 Overhead contribution

TABLE 12.3 Main warehouse activities and cost drivers (adapted from Griful-Miquela 2001)

15
TABLE 12.4 Example ABC model

TABLE 12.5 Pallet storage charge calculations

TABLE 12.6 In-handling cost per pallet

TABLE 13.1 Manual record of work

TABLE 13.2 Department metrics (courtesy of Vitasek 2010)

TABLE 13.3 Stock cover calculations

TABLE 13.4 Integrated performance model (adapted from and printed with permission of Tompkins
Associates 1998)

TABLE 13.5 Mondelez benchmarking model

TABLE 13.6 Internai benchmarking (courtesy of Wlncanton)

TABLE 13.7 WERC performance metrics (2016 and 2017) (courtesy of WERC)

TABLE 14.1 Sourcing considerations

TABLE 14.2 Outsourcing decision matrix (adapted from and used with permission of Tompkins Associates
1998)

TABLE 15.1 Example risk assessment partly completed for the warehouse

TABLE 16.1 Potential warehouse energy savings

16
concepts such as just in time (JIT), efficient consumer response (ECR) and quick response (QR), companies
are continually looking to minimize the amount of stock held and speed up throughput. The use of tools such
as postponement – where products are finalized in the warehouse, not at the manufacturing location – are
becoming commonplace.
We have gone from a ‘push’ to a ‘pull’ supply chain over recent years. In fact, the phrase ‘supply chain’ can
be a bit of a misnomer; rather, it should be called a demand chain, with consumers holding sway.
In the past, manufacturers produced goods and passed them onto the retailers, expecting them to sell as
many of their products as possible. The manufacturers operated a large number of local warehouses and
delivered product direct to store.
This situation changed in the 1980s when retailers took significant control of their supply chains and began
to build national and regional distribution centres. This changed the face of warehousing with a move towards
larger, multi-temperature sites owned by the retailers and in many situations operated by third-party logistics
companies.
These sites continue to grow, with Tesco recently building a 1.2 million square foot warehouse at Teesport
in the United Kingdom and Target in the United States operating a 3.4 million square foot import warehouse
and distribution centre in Rialto, California. The location of these warehouses is also part of a movement
towards port-centric logistics.
Budget supermarket retailer Lidl plans to operate a warehouse at London Gateway, the United Kingdom’s
newest port complex. The siting of warehouses close to ports is not confined to seaports; we are also seeing a
growth in logistics centres in and around airports.

CASE STUDY Tradeport Hong Kong

Background
Established in 2001, Tradeport Hong Kong is the only regional distribution centre located at Hong Kong
International Airport (HKIA), which is the world’s busiest cargo airport. Serving 100+ airlines collectively
flying direct to over 190 destinations worldwide, including 40 cities in Mainland China, HKIA handled over
4.5 million tons of air freight during 2016.
The Tradeport operation is a premium-grade logistics centre comprising 300,000 sq ft of space from where
they provide customers with logistics solutions, including vendor-managed inventory, kitting, pick and pack
services.
With its unique on-airport location and highly secure TAPA (Class A)-certified facility, Tradeport
provides logistics services for products that are time-critical, fast-moving and valuable – for example
electronics, luxury items and industrial parts.
Strategically located at the heart of the Pearl River Delta region of southern China, Tradeport’s hinterland
embraces a population of 100 million people, increasingly inter-connected by high-speed rail, road and bridge
infrastructure networks.

The challenge
Tradeport’s initial discussions (back in 2004) with Eurocopter Asia (now Airbus Helicopters Asia) identified a
need to provide a storage-and-service solution for critical spare parts and emergency handling service for over
1,500 helicopters operating in the Asia Pacific region. The spare parts portfolio consists of 16,000 stock
keeping units (SKUs) with inventory replenished on a weekly basis via consolidated air freight shipments from
France and Germany. The geographic territory to be serviced from the Hong Kong hub includes 30 countries
reaching from North Asia down to Australasia and across the Pacific Ocean.
According to Even Lam, Tradeport’s Chief Operating Officer:

the demands were very challenging, including extremely high requirements for speed of response and
service levels. The emergency response element for Aircraft on Ground (AOG) scenarios requires parts

28
 being picked and packed, ready for despatch on the next flight out, within a maximum of just two hours
from the phone call requesting support; with the service available around-the-clock, 24/7/365, including on
public holidays.

The solution
Tradeport worked with the customer on developing solutions for the challenging service requirements. It was
clear that taking a pro-active, collaborative approach to tackling the issues would be critical to achieving a
successful outcome.
Due to the 24/7/365 service requirements, Tradeport management engaged closely with all key members of
the front-line operations team throughout the solution development process, in order to finalize a solution
that would work for all stakeholders in the project.
Successful employee engagement resulted in a creative solution for staff involved in the call-out roster,
including targeted changes to remuneration and company provision of mobile equipment, together with
training from the customer.

The benefits
During the past decade, the scope of the programme has developed and grown in line with the customer’s
business needs. The Tradeport spare parts operation is now internationally recognized as providing some of
the best service levels across the entire network of Airbus Helicopters.
Tradeport’s Chief Executive Officer, Kenneth Bell adds:

Engaging the key stakeholders from the outset – including our staff, who ultimately have to deliver on these
high service standards, day-in and day-out – was a fundamental step in empowering the whole team with
the confidence to make it happen.

The trend towards outsourcing Western production eastwards has resulted in companies having to hold
higher levels of finished goods stock than previously. This is to cover the extended lead time between
production and final delivery.
Containers from Shanghai to the United Kingdom, for example, can take upwards of 31 days, not including
clearance at the port of entry.

VIDEO 1.1 Samsung Television Supply Chain (https://youtu.be/KCFLJcF6LFQ)

Video 1.1 shows a Samsung television being moved between a UK port and a customer. Note the role of
warehouses in this operation including at the store.
The recent elections in the United States and Europe and the United Kingdom’s planned exit from the
European Union potentially point towards anti-globalization and a more protectionist approach with the
opportunity to bring production closer to the point of consumption. This could well have an impact in the
future as we see unparalleled uncertainty within today’s supply chains.

29
Another random document with
no related content on Scribd:
It is fair, however, to assume that there must be a capacity for
serious results in the vibratory jar, as the discoverable lesions in
many well-examined cases have been in themselves insufficient to
kill. The rapidity of recovery of those who get well also bears weight
on this point.

Of nineteen cases of recovery from concussion of the brain of which

I have record, the average stay in hospital was eight days. The
range of stay was from one to twenty-five days. Many of these were
at first profoundly shocked, some of them apparently hopelessly so
when we compared their symptoms with those who died. As they
recovered, however, in so short a time, there surely could not have
been any gross lesion to account for their symptoms. What else,
then, can account for them than vibratory jar? and if this can produce
such severe results within the line of recovery, why cannot the
degree of it be so extended as to involve, for example, the
respiratory centres, and so kill without leaving perceptible sign?

The SYMPTOMS of concussion of the brain range from a mere daze or

stunning to those of deep unconsciousness. There is no paralysis of
the extremities in pure cases. Often the patient is very restless, and
throws his limbs about in all directions. When these are quiet there is
response to irritation and electricity. Loud speaking to him may elicit
some attention, but the answers are mostly incoherent. There is
pallor, often extreme, coldness of surface, and sweating. Vomiting is
usual, and may come on immediately or later, and it continues as
long as there is anything to discharge; sometimes there is retching.
In favorable cases the cessation of vomiting is accompanied by a
slow return to consciousness, which may be preceded by delirium.
This return is never sudden, and the method of it serves to
distinguish the case from that of some forms of epilepsy. The pulse
is generally frequent and feeble, often irregular; in extreme cases it
may be slow and feeble, very rarely, if ever, strong or bounding. After
reaction it becomes more natural, and if recovery follows it will not
show much variation. The temperature is depressed at first. In one
characteristic case it was 98° on the first day, reached 101° on the
third day, and receded to 98½° on the eighth day, when the brain
symptoms disappeared.

There may be retention of urine and sluggishness of the bowels, but

in bad cases coincident with the vomiting there is sometimes
involuntary discharge both of feces and urine. The respiration is
irregular, sometimes almost ceasing, and then returning with great
rapidity.

Much has been said and written about the condition of the pupils in
concussion of the brain. I have made this matter a subject of
observation, and am convinced that the state of the pupils is of no
diagnostic value whatever as to determining the existence of
concussion or compression. Their state is of great value in telling us
that the functions of certain brain-centres are partially or wholly
impaired. The progress of the case will tell us whether the
impairment is due to clot or effusion, congestion or jar.

It is wrong, therefore, to say that the pupils are one way in

compression and another in concussion. It is right to say that in
either case they are sluggish or wholly irresponsive to light. In one
person they may be dilated, in another contracted, and in the same
person the eyes may present marked contrasts.

In the light of modern physiology this is what might be expected. The

condition of the pupils is dependent on that part of their nerve-
connections which is involved in the injury, and also upon the
method of that involvement. Clinical experience, I think, amply
sustains this view.

The reaction from what may be called pure concussion is generally

slow. The patient is apt to be dazed for some time, although the
pulse and temperature may be normal. When there is a rebound with
fever, and florid complexion, and suddenly or gradually another but
deeper unconsciousness supervenes, it is almost certain that
positive lesion took place at the time of injury, and that the reaction
has brought with it great congestion if not extravasation.
Now, really, compression to be followed by inflammation is the
condition demanding attention.

DIAGNOSIS.—The history of the case and the symptoms as detailed

will enable us to reach a conclusion in most cases as to the
existence of concussion of the brain. There are some conditions,
however, from which it is to be carefully distinguished. These are
simple fracture, with or without depression, compression from any
cause, drunkenness, and epilepsy.

There may be such profound shock with fracture that at first

concussion symptoms mask those of the lesion, or even keep them
for a time completely in abeyance. The head bruises are often very
deceptive to the touch in the search for fracture.

I am in the habit of directing students to feel their own scalps, in

order that they may appreciate the fact that the touch gives no
sensation whatever of the natural thickness of the cranial covering. It
seems as though something like a piece of thin parchment only
intervenes between the fingers and the bone. The fact is, the scalp
varies from an eighth to a quarter of an inch thick, differing in
different places, and where muscles, as the temporal, for example,
are beneath it, the bone is much deeper. The importance of this
observation lies in the fact that a pulpefied bruised mass of scalp will
cause the edges of its healthy surrounding part to feel almost
precisely like bone around the borders of a depressed fracture. The
accompanying general symptoms will mostly not be in accord with
this condition, but in some cases the deception is so complete that it
is very difficult to persuade those not familiar with the fact that a
fracture does not exist, and to induce them to refrain from rash
proceedings.

One case I can call to mind where the opinion of the attending
physician was only changed by the ultimate favorable result, which
left no sign of permanent injury of any kind. These cases are
particularly apt to occur with children.
I remember also another source of deception. A boy was severely
injured by a blow upon the forehead. Concussion was marked. There
was a lacerated wound reaching to the edge of the orbit; fractured
bone could be felt, and at first sight what appeared to be brain-
matter was oozing from the wound. A hasty unfavorable prognosis
was given to the parents. On closer examination it was found that
the fracture was of the external wall of the frontal sinus, and the
supposed brain-matter was the delicate fat-lobules of the orbit. The
patient recovered rapidly.

There is a marked distinction between the ordinary symptoms of

concussion and those of compression, whether from depressed
fracture or effusion, as of blood in apoplexy. Here there are flushed,
often swollen, countenance, stertorous breathing, slow and it may be
strong pulse, deep or absolute insensibility, and fixed pupils. The
injury, if there is one, is mostly palpable and explanatory. If it is
concealed, the other symptoms point to the true nature of the case.

The diagnosis from drunkenness is not always easy, although deep

intoxication is more apt to be accompanied with compression than
with concussion signs. Drunkards often have bruises on their heads
caused by falls, and some of them are pale and sick after debauch.
The smell of liquor is not always reliable, for it is so common after
accident for friends to administer stimulants before the patient is
seen by a medical man that he might be easily misled into too hasty
a judgment. The general appearance of the old stager is well known,
but in cases where there is the least doubt the patient, whether in
hospital or in private, should be kept a sufficient time under
observation for the effects of drink to pass off. Then it will be seen
whether this has masked a more serious condition. Too hasty
conclusions in this matter have led to most unpleasant occurrences.
These are well known in police administration and to hospital men.

The convulsions of the epileptic, the foaming mouth, and the quick
return to partial or complete consciousness will generally serve to
distinguish the case from one of concussion, but at times there are
those who require also to be kept under observation for some hours,
and even a day or more, in order to come to a correct conclusion.

The PROGNOSIS in concussion is generally favorable, but if complete

unconsciousness is present it is doubtful as to the individual so long
as this lasts, for, as before intimated, the cases which recover may
present as marked symptoms at first as those which prove fatal.

Recovery is mostly complete, but not suddenly so. The after-effects

in any case may prove serious.

There is, however, an unwarranted tendency to attribute any defect

in character, and even criminal lapses, to a blow upon the head,
especially should the history or marks of one be discovered as
having occurred at any time, no matter how long, previous to the
inquiry.

The blow may be the cause of subsequent epilepsy, chronic

inflammations, and insanity or imbecility. These cases have,
however, an almost continuous history of trouble from the date of the
injury, the manifestations varying in severity from time to time as
pathological changes go on or as exciting causes develop them.

TREATMENT.—Absolute simple rest in bed is all that is necessary in

mild cases of concussion. The patient should be well watched for
any symptoms which might supervene and show that the injury was
more severe than at first supposed. On the other hand, serious
symptoms may be present without indicating any great gravity in the
case. Children, for example, often have convulsions from the
slightest cause. I have attended them when these set in immediately
after the injury, but in a day or two there was entire recovery.

The more serious cases equally require rest, but also something
more. To bring about reaction from shock, sinapisms to the
extremities, to the nape of the neck, and over the stomach should be
used. Hot-water bags should be placed along the sides of the body
and limbs. Alcoholic stimulants must be sparingly used, if at all: they
are rarely necessary. The stomach will often reject them unless in
minute doses. If too much is absorbed, unpleasant consequences to
the brain may follow. In extreme cases hypodermic injections of
brandy or ether may be administered. Ammonia, camphor, and other
diffusible stimulants may be useful, either externally or internally.

If the reaction is regular, with gradual restoration to consciousness

and no noticeable rise in temperature, nothing further is required but
a continuance of the rest and the use of cooling drinks and spare
diet. The bowels and bladder must be attended to; the catheter may
have to be used.

Restlessness, with or without delirium, is not unusual, but it generally

subsides under full doses of bromide of potassium.

When reaction is followed by high fever, and especially when there is

with it a passing on into secondary unconsciousness independent of
true sleep, we have almost surely internal compression from
congestion, effusion of serum, or hemorrhage to deal with. Now,
blood may be taken generally or locally with great benefit. Cups,
both dry and wet, to the temples and back of the neck are very
useful. Leeching also is an efficient method of depletion. Ice in bags
or towels, or cold water, should be applied to the head. Hot water,
say about 120° to 130°, to the head is often of great service and very
soothing.

The choice between cold and hot water is to be determined by the

effects produced. Sometimes surprisingly good results come from
alternating their use. Hot mustard foot-baths may be given in bed
while the patient is kept lying on his back with the limbs flexed.

The result only in these severe cases will determine whether the
symptoms were due to great congestion or to extravasation, possibly
with brain lesion. Complete recovery takes place in the first
condition. In the latter a fatal termination is much more probable, and
if there is recovery it is apt to be only partial, and the patient may be
the victim of nervous troubles more or less pronounced throughout a
long life.
 Concussion of the Spine.

John G. Johnson of New York is authority for the statement that

English railways paid in five years two million two hundred thousand
pounds, or eleven million of dollars, as damages awarded by juries
in cases of concussion of the spine. The statement appears almost
incredible, but the facts are ample to sustain it.

It also illustrates the powerful influence of one great authority

(Erichsen) better than anything I know of in the history of the medical
profession. After this celebrated surgeon's lectures and work on
concussion of the spine, etc. were published, dating back to 1866,
the great body of medical men received them as the standard and
guide in all such cases. They were a godsend to plaintiffs and
prosecuting attorneys, and the defendant had a poor chance with
juries when the possible miseries of any one who claimed
compensation for injury to the spine was pathetically pictured to
them.

That the defendants have suffered injustice in a great number of

cases I think there can be no doubt. Is it any wonder, therefore, that
a reaction has occurred of late, and that the views formerly held by
professional men have been subjected to sharp criticism founded
upon a much more scientific and practical knowledge of the subject
at issue?

As in all reactions, extreme views have been reached by certain

observers, and there are those who seem to hold that concussion of
the spine cannot occur. By spine here is meant the spinal cord or
marrow.

It has been well remarked, I think by Page, that we do not speak of

concussion of the skull. We always say concussion of the brain. The
use of the term spine has given rise to much confusion, but the
professional man will understand what is meant when so-called
concussion of the spine is under discussion.

The advocates of the rarity or even impossibility of the injury call

attention with much force to the anatomical facts. First, to the
immense strength, pliability, and cushioning of the bony and
ligamentous encasement or column; then to the ample calibre of the
canal in which the nervous cord is suspended, and to the pliant
structures intervening between its inner walls and the cord itself.
From without inward, in the canal, we have fat, watery connective
tissue, and the plexus of spinal vessels; then comes the dura mater,
loosely investing the cord and unattached to the bone, not forming
here, as in the skull, the internal periosteum. Within the dura mater is
the arachnoid, its visceral layer separated by a wide interval from the
viscus or cord, which interval contains the cerebro-spinal fluid; then
the pia mater or vascular membrane, which closely invests the cord.

Besides these structures there is the ligamentum denticulatum

passing from the dense pia mater to the parietes of the canal and
supporting the cord and roots of the nerves in the most efficient way
—pliable enough to yield and break the force of vibrations, and
strong enough to sustain.

Thus we see that the cord is much more securely protected from the
effects of external violence than the brain, and we can understand
that there is reason for the doubt of the sceptics as to the frequency
of the injury described as concussion of the spine.

Clinical observation is, I think, of far greater value in determining

questions of the kind than any theory, however strongly supported by
anatomical facts. Does transient concussion of the spine occur as
transient concussion of the brain occurs? Page, if I understand him,
says not. In his work on Injuries of the Spine and Spinal Cord
(London, 1883), in criticising a well-known case as to the claim of
persistent paraplegia without discoverable lesion, he says: “We
italicize the word persistent, for simple concussion of the brain may
give rise to a transient unconsciousness, and, if the analogy holds
good, concussion of the spine should per se produce a transient
paraplegia. We know of no case, nor can we discover the history of
any case, where this has happened.”

I italicise the last sentence. In 1881 a boy came under my care who
was shot in the back three inches to the right of the third or fourth
dorsal vertebra. He at once had characteristic symptoms in the legs
of being wounded in the spine in such a way as to affect the cord
somehow. There was partial paraplegia, with pains in both limbs.
Under rest these symptoms soon disappeared. In a few days I made
a deep incision and removed some clothing and fragments of bone,
and then from the depths of the spinal gutter I took a large conical
ball which was resting against the bony bridge of a vertebra. The boy
recovered rapidly. I saw him some months afterward perfectly well.

Surely, this was a case of spinal shock or concussion with transient

paraplegia, and the cause of it could have been nothing else than
the impact of the ball against the column, producing vibratory jar
sufficient to affect the cord. The immediate symptoms and the rapid
and complete recovery are, in my opinion, inconsistent with any
theory of congestion or pronounced lesion of the medulla.

Here is another case of transient paraplegia also occurring in 1881,

and, to my mind, still more significant: A man fell from a height of
about twenty feet and landed directly on his feet. He was
immediately paraplegic. On examination no injury to the spinal
column could be detected, but there was fracture of both calcanea.
The spinal symptoms were thoroughly marked. Besides the paralysis
of the limbs there was loss of control of the bladder and bowels, and
the other accessories in such cases. But all went on to recovery. Pari
passu with the fractures the spinal symptoms improved. It is not
necessary here to give further details, but simply to state that in four
months, the time required being chiefly due to the fractures, the
patient was discharged able to walk and well in every other respect.

If this is not a case of transient paraplegia owing to spinal shock or

concussion, I am willing to admit that I do not know the requirements
of the critics when they ask for such cases. I think that it is no matter
how the blow or shock to the column is received, whether direct or
indirect, so that it is shown that the medulla is influenced within the
line of recovery, without having suffered fairly presumable lesion.

President Garfield surely suffered from transient spinal shock

produced immediately by impact of the bullet upon the column. The
symptoms soon passed off, and at the post-mortem the cord was
healthy in every respect. The differences between his case and the
others I have mentioned were those of degree only, his concussion
not being severe enough to cause paraplegia.

Spinal concussion or shock from railway collisions does not differ

from forms of the same injury received in other ways. It is absurd,
therefore, to give a peculiar pathological history to so-called railway
spine. That the injury occurs, I have no doubt; that the medulla is
seriously affected in the vast majority of cases, I have very great
doubt.

I cannot now, after thirty years of hospital and private practice, call to
mind a single case of concussion of the spine arising from other
accidents than on railways which has had the terrible after-history
that is so often attributed to them; and I have seen in that time many
cases of spinal injuries of all kinds.

There is another fact of personal experience. I have examined many

cases of claimed irreparable or serious injury to the spine in private,
both for plaintiff and defendant, in impending suits, but I cannot
remember a single application of a patient for admission to the
hospital to be treated for the after-effects of concussion of the spine,
the original injury having been received in a railway collision.

As all sorts of people ride on railways, it is strange that the numerous

recipients of concussions of the spine are pecuniarily independent of
hospitals. One old fraud I do remember who fell from a street-car
and claimed lasting injury to the upper part of the spine and the
head, and adequate compensation for it in court. I was not called as
a witness at the trial, and the plaintiff recovered very heavy
damages. These were afterward reduced to a much smaller amount
when it was discovered what I knew about the case.
Other structures of the spine besides the medulla are much more
subjected to injury than it is, and their consequences often mislead
both patient and doctor, especially the former.

The ligaments and muscles are exposed to contusions, strains,

ruptures, and twists which are wrongly attributed to concussion.
From these injuries and from so-called concussions the patient
recovers rapidly or slowly according to their extent. If damages are
looked for from a corporation, he is in a state of what may be called
expectant pecuniosity, and shows no amendment until the question
is settled. Otherwise, he gets well, as those do who are injured but
have no expectations.

There is a striking want of confirmation by post-mortem examination

of the terrible effects which are said to follow concussion of the
spine.

In fact, the records of such examinations are so few, notwithstanding

the immense number of those who have claimed to have the injury
that the sceptics are somewhat justified in attributing the few cases
which have shown great pathological changes in the cord and its
membranes to the coincidence of disease, as myelitis or syphilis, or
to much graver injuries than concussion.

I have reported a case in full in the Medical News and Abstract

(Philada., Nov., 1881) which illustrates how coincidence might easily
play its part in a supposed concussion. This feature of it is not
alluded to in that paper. A gentleman began to complain of pain
posteriorly at the root of the neck. Paralytic symptoms gradually
developed. It is unnecessary to repeat the details here, but the
history was a most dreadful one, and precisely that of the few
serious ones described in the works on concussion. Within a year
the patient died. The autopsy revealed a meningitis and softening
and destruction of the cord to the extent of two and a half inches of
its brachial enlargement. There was no other disease. Now, this
patient frequently travelled on railways, and if he had been subjected
to the slightest accidental shock it would have been received on all
sides as the cause of the disease. There was, however, no such
history, nor was anything ever known to account for the fact that a
man in otherwise perfect health should have two and a half inches of
his spinal cord as it were spontaneously destroyed.

I will state in passing that this case did not confirm the views of
Johnson and others as to there not being any severe pain on
pressure in myelitis. It showed also that clinical observation is not
always in accord with plausible anatomical facts or reasoning.

Thus, Johnson says: “It is a mistake to suppose that meningitis or

myelitis is accompanied by pain on pressure: the spinal cord is
surrounded by a bony wall thicker than the bones of the skull, and
you might as well press on the head to see if the brain is diseased.”

Now, in this case the pain was simply atrocious and greatly
increased by pressure. To relieve both it and the disease the actual
cautery was applied on both sides of the spinous processes; and
some estimate may be made of the sufferings of the patient, who
would not take ether, when he exclaimed as the hot irons were
burning through his tissues, “Oh, that is better than the pain.”

To sum up, then, I think I have shown that concussion of the spinal
cord proper occurs. I also believe it may occur in a railway collision
just as it occurred in the man who fell twenty feet. Why should not a
traveller sitting in a peculiar position—with his feet, for example,
firmly against a partition or wall of the car—suffer it in a collision.

On the other hand, the great majority of those who after accidents
claim injury to the spinal cord as the cause of their disabilities are
wholly mistaken. The question is of great importance, for upon it
depends the testimony as to whether the patient has sustained
temporary or permanent injury.

Each case must be studied on its own merits. There is no class of

injuries so full of opportunity for the exaggerator or malingerer. The
history of many of them is by no means complimentary to human
honesty. Those interested can study the special works on the
subject: space is not given to detail them in this paper.
The SYMPTOMS and PROGNOSIS of concussion of the spine may be
almost inferred from what has been written above. There are
tinglings, pain, and sometimes cramps in the limbs; there may be
partial or complete paraplegia which is transient in character.
Complete paraplegia is very rare, and when it exists it almost always
indicates a more serious injury than concussion. The case I have
cited is an exceptional one.

The bladder is almost always affected; there is either suppression or

incontinence. The bowels are sluggish for a time. The pulse is mostly
quickened; the temperature does not vary much from the normal.
Priapism, which is so frequently present in wounds involving the
spinal column and cord, is not present in concussion.

I have in the Medical News (Nov., 1881) given my reasons for

believing this symptom to be due to a coincident impression or
laceration of the sympathetic nerve when there is a fracture or other
injury of the vertebra. This view I have been able to sustain by a
case reported in the Medical News (Philada., Feb. 25, 1882).

The PROGNOSIS of concussion of the spine is generally favorable. The

recovery is slow in pronounced cases. Where such terrible
consequences follow as are described in some of the cases which
have been caused by railway collision, there is reason to believe that
the original injury was either too severe to come under the head of
concussion, or that some coincident deterioration was present at the
time of the accident.

The DIAGNOSIS from fractures and dislocations is mostly easy. In

these cases the local and general symptoms are nearly always so
definite as to give no trouble in coming to a conclusion as to their
nature. In obscure cases time will develop the truth.

In the TREATMENT of concussion of the spine the great remedy is rest.

Under this alone the slight cases will rapidly recover. The more
severe ones will require other aids, such as cupping, both wet and
dry, to the spine over and about the chief seat of complaint.
Sinapisms, blisters, and iodine are useful in the order named. Opium
will be borne much better for the relief of pain and restlessness than
in like injuries of the head. The natural functions must be looked
after. Both the catheter and enemata may be required. Great care
must be taken to provide against chafing of the skin and bed-sores.
For this I know of nothing better than repeated sponging with
alcohol, and drying the surface at once by a good rubbing. The
points of pressure should be frequently changed by shifting the
patient.

As soon as the acute symptoms pass away the patient should be

encouraged to rise and use moderate exertion. This, if well borne,
should be increased day by day, for it will be soon found whether the
efforts are injurious or not. All the requirements are present in these
cases to produce chronic hysterical invalids, both male and female. It
is therefore incumbent upon the medical attendant to protect his
patient from discouraging surroundings of any kind. It is also his duty
to so act that while he will be careful to work no injustice, he will at
the same time be on the watch for malingering, for this will often be
practised, especially by those who are among the expectants
already mentioned in this article.

INTRACRANIAL HEMORRHAGE AND

OCCLUSION OF THE CEREBRAL VESSELS,
APOPLEXY, SOFTENING OF THE BRAIN,
CEREBRAL PARALYSIS.
 BY ROBERT T. EDES, M.D.

The various subjects embraced in this article are so closely united to

each other, both in a clinical and in a pathological point of view, that
they must be considered to a certain extent in common. It is of
course more systematic to group them entirely according to the
obvious and final lesion, as hemorrhage, thrombosis, or embolism;
but when it is considered how very closely the symptoms of one
affection may counterfeit those of another—so closely, in fact, that a
diagnosis with absolute certainty is not only difficult, but often
impossible—and also that similar conditions of the vessels may give
rise either to rupture or occlusion, so that not infrequently two sets of
lesions may be found in the same brain, and, finally, that the basis of
prognosis and of the later treatment is not unlike in different lesions,
—we are surely justified in bringing them, at least in the beginning,
under a common head.

Intracranial hemorrhage, and especially cerebral hemorrhage, is the

lesion which more frequently than any other gives rise to the group
of symptoms known as apoplexy, and from this fact has arisen the
frequent incorrect application of the word apoplexy, in a pathological
as well as a clinical sense, to indicate an extravasation of blood, as
in the so-called pulmonary apoplexy, where the anatomical lesion,
being an extensive effusion of blood into the tissues of the lung,
bears an apparent resemblance to the state of the brain often found
in apoplexy primarily and properly so called, the symptoms, however,
being entirely different. This error receives additional support from
the fact that in some injuries to the brain, especially to the base,
pulmonary hemorrhage may secondarily take place. Apoplexy,
however, is not always the result of hemorrhage, but occurs with
many cases of embolism and of thrombosis, and is sometimes, so
far as we can tell, dependent upon neither of these conditions,
recovery in one set of cases taking place so rapidly as to preclude
the supposition of a considerable organic lesion, and in others, which
are fatal, nothing being found beyond an excess of serum or of
vascularity, and sometimes not even that. The first of these
conditions has been called simple apoplexy, but with our present
knowledge its simplicity seems to border closely on ignorance, or at
any rate is not of a character to satisfy the inquiring mind. It is
therefore better to retain the term apoplexy strictly as a convenient
term for a certain set of symptoms, but, whenever possible to
substitute for it an anatomical description of the lesion found post-
mortem or diagnosticated with reasonable probability during life.

The practitioner may very properly, and without laying himself open
to criticism of his diagnostic accuracy, return the cause of death in a
case of sudden death, or where his opportunity for observation has
been limited, or where no post-mortem examination has been held,
as being apoplexy; but in others, where the symptoms were decisive
or a post-mortem has disclosed the exact lesion, the condition of the
cranial contents should be stated. It is also a not uncommon mistake
—or rather piece of carelessness—to speak of small hemorrhages in
the brain as small apoplexies. A small extravasation may give rise to
slight symptoms or next to none, but a real apoplexy can hardly be
small, although it may be short.

The root from which the word apoplexy is derived seems to have
been used by the classic writers in something like its present clinical
signification (Απορληκτος, seized with (apoplexy or) stupor—
Aristophanes; mad—Demosthenes; Αποπλησσομαι, to be struck with
amazement—Sophocles). Morbus attonitus, another of its names,
expresses a somewhat similar idea.

Morgagni was familiar with cerebral hemorrhage, and Bonetus in the

Sepulchretum gives several cases. The allusions of Galen and
Hippocrates supposed to refer to this lesion are not unequivocal,
although the Father of medicine could hardly have helped being
familiar with the symptoms of so striking a form of disease.

Cerebral softening has been recognized since the early part of the
present century, and in some of the cases thirty years ago an
efficient cause, in the form of arterial disease, assigned to it; but the
complete theory of its causation forms a part of the general doctrine
of embolism and thrombosis which was so largely developed and
systematized by Virchow. Andral and Durand-Fardel had apparently
no idea of the exact mechanism of its origin, the latter supposing it to
depend upon inflammation, while Todd mentions a case where
softening giving rise to paralysis depended upon a dissecting
aneurism of the carotid. He seems to have generalized so far as to
say that white softening is atrophic, but the precise way in which this
localized atrophy was usually brought about evidently escaped him.
According to him, the suddenness of the attack was owing to a
gradual disorganization of the brain-substance with few or no
symptoms, and then a sudden rupture of diseased fibres by some
accidental cause or by their having reached the extreme limit of
cohesion.

Intracranial hemorrhage may be situated outside of the dura mater,

separating this membrane from the bones of the skull and producing
more or less compression of the brain. It is usually the result of a
blow, but not necessarily of a fracture of the skull. When a fracture is
present, blood may pass through it from the interior and give rise to
an external extravasation in addition to that which is likely to be the
direct result of the blow upon the skin and subjacent soft parts. The
middle meningeal artery is a frequent source of this hemorrhage.
Hemorrhage in this position will naturally give rise to symptoms of
compression, and, if the fact of the blow be not known or the fracture
manifest, may be mistaken for some of the deeper-seated forms.

Blood may be effused upon the surface of the brain in the so-called
cavity of the arachnoid—that is, outside of the pia mater—or in the
meshes of this membrane, following its course along the sulci. This
also is not infrequently the result of violence either with or without
fracture of the bone. Its source is likely to be found in the veins which
empty into the longitudinal sinus from the surface of the brain.
Rupture of a lateral sinus from a not very severe blow has been the
source of large and fatal hemorrhage.1 Blows upon the head, with or
without fracture of the cranial bones, are likely to cause rupture of
the cerebral substance with hemorrhage, and this may find its way to
the outside and cover more or less of the surface. Such injuries to
the brain, it is important to note, do not necessarily correspond
immediately to the place of the blow or to the external ecchymoses.
Meningeal hemorrhage in this region may, however, be observed
when no injury has been received, or at least when there is neither
history nor external traces of any.
1 Cincinnati Clinic, p. 135, 1874.

The conditions under which it occurs may not vary greatly from those
of the more ordinary intracerebral effusion. In two instances under
the observation of the writer the source of hemorrhage has been a
vessel of small, but not the smallest, calibre (artery), situated near
the fissure of Sylvius, in the lower parietal or temporo-occipital lobe.
In children meningeal hemorrhage is, with only a few exceptions, the
usual lesion of apoplexy. The blood is usually dark and coagulated in
recent cases. Blood found under the membranes where no fracture
has taken place is, however, more likely to have been derived from
the brain-substance and to form part of a cerebral hemorrhage.

Hemorrhagic pachymeningitis, indicated by a layer of fibrin included

between the dura on the one hand and a false membrane on the
other, is met with in connection with meningeal and cerebral
hemorrhages. It is supposed to depend on a small and thin
hemorrhage upon the surface of the brain, which forms, by its irritant
action, a false membrane about itself. It is found usually over the
vertex.

Hemorrhage into the ventricles is nearly always the consequence of

a hemorrhage in the brain-substance breaking through, although it
may in rare cases originate in the vessels of the choroid plexus,
velum interpositum, or meninges. Its source, however, is sometimes
so near the surface as to cause but little laceration of the cerebral
tissue. The blood breaking into any one of the ventricles may be
found in one or all of them (except the fifth), and form quite an
accurate cast of their shape.
The most common form of intracranial hemorrhage, however, which
most nearly concerns us here, and which is generally meant when
sanguineous apoplexy is spoken of, has its principal seat in the brain
itself, which is, of course, more or less lacerated. Such hemorrhages
may vary greatly in size, from a mere red point (punctate or
capillary), of which many may be present at once, to one of many
ounces, filling a large cavity of nearly the length of one hemisphere,
and pushing the torn and compressed brain-substance before it in
every direction. The amount of laceration produced of course varies
greatly; sometimes it seems as if nothing more than a pushing aside
of fibres without rupture had taken place, while at others large
masses of tissue are torn away and mixed up with the blood into a
pulp.

In a recent hemorrhage the clot itself, speaking of those of a size

above the capillary, is usually homogeneous, the brain-substance
surrounding it ragged, œdematous, yellowish or red, and frequently
containing many minute secondary hemorrhages. The rest of the
brain is frequently found anæmic from pressure, the convolutions
flattened, the surface dry, and the section exhibiting a diminished
quantity of blood. In older cases, however, and probably also in
some where atrophy, senile or otherwise, has preceded the
hemorrhage, this condition is not found, and we may have the
convolutions shrunken and the meshes of the pia containing an
excess of serum.

If death does not take place speedily, the clot undergoes

degenerative changes. Its color becomes somewhat lighter,
chocolate color, reddish-yellow, or yellowish-red. A portion is
absorbed, and after a time the cerebral substance in the
neighborhood forms about it a wall of some density, so that finally
nothing is left but a cyst with fluid or semifluid contents, and often
remains of connective tissue. Sometimes the absorption of a clot of
moderate size is so complete that only a firm mass of a reddish or
yellowish-brown color marks the seat of an old hemorrhage. The
brain-substance in the neighborhood may be more or less atrophied,
and a distinct depression may be noted over the position. The
microscope shows in a fresh hemorrhage only broken-down nerve-
tissue and blood and vessels more or less degenerated. In an older
one the blood-corpuscles have disappeared, but masses of pigment
of a dark yellow or a brownish-red remain to show the former
presence of blood. This pigment occurs in the form of rounded
granules or of small rhombic crystals, and has received the name of
hæmatoidin. The light-yellow masses often found along the course of
the cerebral vessels are not evidence of hemorrhage, but of
congestion merely. The so-called inflammation or granulation
corpuscles, which are simply the fattily degenerated cells of the
organ in which they are found, and which usually possess no
distinctive form, being simply round masses of fat-drops, are often
met with in the brain in hemorrhage or softening. It is sometimes
perfectly evident, however, from their form, triangular or pyramidal,
that they are degenerated nerve-cells. The blood-vessels, those just
above the size of capillaries, are usually in a condition of fatty
degeneration, masses of dark granules occupying more or less
densely the line of their walls. A mere deposit of fatty granules inside
the perivascular sheath, but outside of and not involving the walls of
the arteries, may present the appearance of a degeneration of the
walls themselves. This condition may be a consequence of any
lesion involving degeneration of brain-tissue, and in no way a cause.

The intermediate stages of transformation in a hemorrhage are less

frequently found than the recent or old ones, since the patient, if he
does not die within a few days, is likely to live for some weeks or
months.

The changes taking place in the clot itself within the first few days
are not very marked, but the walls of the cavity may become softer
and more deeply colored, at first red and afterward yellow. Blood-
crystals have been detected on the seventeenth day (Virchow). The
following descriptions have been given of clots of different ages:
Eleven days—reddish-yellow softening clot, with brain-tissue stained
for half an inch in depth, and brain rather hard in vicinity. Eighteen
days—cavity with its edges anteriorly and superiorly sharply defined,
with the edges posteriorly ragged and yellowish, filled with a