We shall quote but one more case from this second volume of our author, as we find our limits will not permit us to extend our analysis much farther. At Case 18. "M. Remy, 60 years of age, had been long affected with gout in the feet, which were quite deformed by its ravages. In working at some theatrical decorations in the beginning of September, 1818, he fell into the orchestra, which, for an instant deprived him of sense, but he soon became collected, and only complained of a slight pain in his side, which went off in a few days. He took to his work, and the accident was forgotten. In a fortnight afterwards, however, it was remarked that Remy was confused in his ideas-that his memory was affected that he was drowsy-and that his speech was embarrassed. Five or six leeches were applied to the neck. The patient was obliged to take to his bed the right arm became paralytic, and, from time to time, agitated by convulsive movements the left hand was frequently applied to his head, or employed in floccitation. The friends of the patient having omitted to mention the fall to the physician in attendance, the patient was treated as having an idiopathic fever, till the 9th or 10th day, when M. Lallemand happened to see him for the first time, and, on inquiry, learnt the true history of the case. this time the patient fell into so long and profound a syncope, that he was supposed to be dead by many of the by-standers. On recruiting, the right arm and fingers were bent so rigidly as not to be, overcome; yet the member and that side were insensible to the touch-the eye-lids were closed-the eyes reversed, divergent, and insensible to the light-hearing, and the intellectual functions in general, quite suspended-whole body covered with a cold and viscid perspiration-breathing difficult, quick, and stertorous-pulse imperceptible at the wrist, and scarcely to be felt in the carotids. In this desperate state the man appeared to have but a short time to live. The blisters and sinapisms had produced but little effect on the skin, and were unlikely to rekindle the dying spark. M. Lallemand, therefore, proposed to the physicians present to pour boiling water on the calves of the legs and thighs, while ice should be applied to the head. This proposal was adopted, but with great reluctance on the part of the physicians, as it was considered cruel to disturb the last moments of a man now moribund. The instant the boiling water touched the skin the patient marle sudden movements throughout the whole body-the left arm became agitatedthe eye-lids opened-the pulse became perceptible at the wrist. In half an hour afterwards the water was applied to the thighs, and the effect was still more remarkable. The face assumed some colour-the pulse rose in force and frequency. The ice was now applied to the head for two hours. The patient seemed to revive, and raising his hand to his head, seemed to attempt removal of the ice. It was taken away whenever the skin of the forehead became cold, and re-applied as soon as it again became hot. In the evening there was considerable reaction, as evinced by the resistance of the Vol. III. No. 11. 3 R pulse and the flushing of the face. Ten leeches were therefore ordered to the neck, and the ice directed to be continued to the head through the night. Next morning things wore a more favourable aspect; but the evening brought an exacerbation of the symptoms. Six leeches to the neck, and ice to the head through the night. On the third day there was some sensibility in the skin of the right arm. Ice to the head in the evening. M. Lallemand, being now obliged to be absent for eight days, was surprized, on his return, to find the patient sitting up and eating. He recovered. The eschars produced by the boiling water were very deep, suppurated profusely, and continued open for fifty days. To this powerful counter-irritation and drain our author attributes the complete recovery of the patient from a state that, at one time, was almost beyond hope." P. 300. After the symptoms and dissections which have been detailed, there is every reason to believe that the case now related would, had it not been for the judicious measures pursued, have exhibited, on dissection, similar appearances to those so often pourtrayed in the course of this article. We are justified therefore in concluding, that the disease under consideration, especially in its earlier stages, is not beyond the resources of our art. We now proceed to the third letter or volume of M. Lallemand's work, in which the subject of unequivocal suppuration, or encysted abscess of the brain is taken up, and illustrated by numerous cases. These cases are, many of them at least, very interesting to the practical physician and surgeon, their value and importance being quite independent of any doctrine for the support of which they may be brought forward. On this account we shall abridge as many of them as our limits will allow. Case 19. (From Ducrot's Essay on Cephalitis, 1812.) "M. A. about 60 years of age, had a portion of the left frontal bone de-. pressed by a violent blow of a stone, by which blood was lost, but which did not deprive him of the power of returning to his house. On the following day he had pulsative cephalalgia, some affection of the memory, inability to move the tongue freely, feeble pulse, depression of energy. Yet his answers were correct. An emetic. Third day, deglutition difficult, thirst, heat of skin, frequency of pulse. Fourth day, drowsiness, but still answers coherently. A blister to the nape of the neck. Fifth day-soporose-loss of speech, but appeared to understand what was said-involuntary discharge of urine. Sixth day, sopor still more profound-other symptoms the same. Seventh day, same state. Eighth day, delirium, insensibility, convulsive movements in his limbs and body, with distortion of the mouth and eyes, renewed every quarter of an hour. In the intervals the breathing was difficult and stertorous, with fixed eyes and gaping mouth. Ninth day, the convulsions ceased at midnight, the sopor diminished, and sensibility returned-but the memory and judgment were affected-incipient paralysis of the left arm and leg. Tenth day, complete paralysis of the said members, with slight rigidity and pain when they were moved by the by-standers aspect idiotic-answers vague-optical illusions—a convulsion during the night. Eleventh day, entire loss of sense, and of voice-general immobility-coma-breathing high and difficult-died in the evening. "Dissection. Two inches in extent of the frontal bone was depressed about two lines below its proper level. The arachnoid covering the whole convexity of the brain was thickened, whitish, and lined, on its inner surface, by a layer of albuminous matter. At the basis of the right middle lobe of the brain there was a portion of cerebral substance reddened and evidently inflamed." 327. Ducrot, who relates this case, very clearly shews the connexion of the symptoms with the post mortem appearances, but seems not to entertain the least doubt about the propriety of the practice adopted-namely, the Hippocratic treatment of inflammation of the brain and its coverings by-what? --a careful record of its progress, without insulting the omnipotence of Nature by interfering with her ways and means; a precious practice truly! Here M. Lallemand extracts several cases from MORGAGNI of abscess in the brain, and softening of its substance; but these we shall pass over, as Morgagni's work will soon be in an English dress, that will render it of easy access to the profession at large. The following case, which occurred at the Hotel Dieu, illustrates the effects of the pathemata on the cerebral functions and structure. Case 20. "Juctant, a man about 55 years of age, of small stature, but plethoric constitution, having lost a sum of money constituting his whole property, fell into a state of melancholy, which was succeeded by severe head-aches, profuse perspirations, and fever, accompanied with evening exacerbations. In about a fortnight after this, it was noticed that he was delirious-that he talked incessantly, and always of his pecuniary losses. In five days more, the left arm was observed to be paralytic-and this paralysis had continued three days, when he entered the Hotel Dieu, on the 13th January, 1821. His face was then red; the pulse strong, but not frequent; the right arm agitated by convulsive movements-the members of the left side devoid of sensation and motion, the forearm being bent on the arm;-constant muttering to himself. Venesection-lavement-diluents. Next day same state. Venesection repeated more copiously. Fourth day from entrance into hospital, great depression-mouth drawn to the right side-insensible-canet speak. Sinapisms, purgative lavements. Sixth day, pupils dilated-stertorous respiration-died at nine o'clock. "Dissection. Difficulty in separating the cranium from the dura mater, and much blood effused from the torn vessels. Arachnoid and pia mater exceedingly injected. In the middle of the right hemisphere a purulent depôt was discovered, containing about two spoonfuls of a yellowish green pus-parietes of the depôt converted into a rotten and soft substance, forming a contrast with the rest of the hemisphere-ventricles contained a small quantity of serosityno other alteration in the brain or other organ." 356. We have seen cerebral inflammation follow blows on the head at such long intervals that we think practitioners cannot be too much on their guard in such cases. They should watch patients for some months after accidents of this kind. The following case will serve to illustrate the force of the caution. Case 21. "Riom, 17 years of age, had the right parietal bone grazed by a musket shot at the battle of Brienne. He was rendered insensible for a short time, but was dressed in haste and sent on to Paris. He arrived at the Hospital of Invalids on the eighth day of the accident. The wound was nearly cicatrized, but the man was tormented by an acute head-ache, lancinating pains in the cicatrix, and constant drowsiness. The integuments being incised, the trephine was applied, and several fragments of bone and of ball were extracted. He was instantly relieved-the wound soon closedand in three weeks from the operation the patient was discharged from the hospital. In a fortnight after this the head-ache returned, with rigors and fever. Pediluvia and low diet. During the next eight days there was almost constant somnolency, with a sense of formication and numbness of the upper and lower extremities of the left side; embarrassment of speech; slight constriction of the jaws. The patient entered the HOTEL DIEU on the 5th of July, 1813. He could then scarcely hold any thing in his left hand; and was hardly able to walk in consequence of the weakness of the left leg— pulse slow and full. Venesection, purgative lavement, mustard pediluvia. 6th. Complete paralysis of the left side-cicatrix inflamed, tense, and painful, with a pasty feel of the scalp. The integuments were again laid open, the bone exposed, and the trephine again applied. The dura mater was very red, covered with fleshy granulations, and extremely sensible to the slightest touch. It was divided by a crucial incision, and the spinal artery bled profusely. No pus was found under the dura mater. M. Dupuytren suspecting a more deeply seated abscess, plunged his bistoury about an inch into the substance of the brain, and some pus was observed on the blade of the instrument. The bistoury was then plunged a little farther in, and a table spoonful of greyish and somewhat fætid pus followed. The patient was instantly deprived of speeck, and convulsive motions took place in the non-paralysed side. The dressings, in a few minutes, were filled with blood. An instrument was introduced to compress the spinal artery. The convulsions were increased, the pupils be came dilated, the tunicæ conjunctivæ of the eyes greatly injected, the eye-lids became ecchymosed, the same extending to the temples. In the evening the convulsions became less violent; but the pulse was more irregular and embarrassed. Bled from the feet-purgative lavement. At midnight the convulsions ceased, but the man died at one in the morning. "Dissection. A fissure was discovered in the parietal and temporal bones extending to the base of the skull. The dura mater was very red throughout the whole surface of the right hemispherethe arachnoid was equally red, but to a limited extent around the wound. Both membranes on the left side were much less injected than on the right. Around the incision made into the brain by the bistoury, the cerebral substance was softened to the consistence of bouillie, apparently rotten, and exhaling a fetid odour. On this side of the brain no distinction could be observed between the cortical and medullary substance. The focus of the abscess was seated close to the right ventricle, and the cerebral substance surrounding it was in the soft and putrid state above described, which gradually lost itself in the surrounding sound parts. Another and smaller abscess was situated below the former, and exhibited the same appearances." 361. The above case is remarkable, not only for the phenomena, and appearances on dissection, but for the boldness of Dupuytren in plunging his knife an inch into the brain in search of an abscess. It was fortunate for his reputation that an abscess did exit, and that he did happen to strike it! His example, we apprehend, will not often be followed. Our author has seen this puncture of the brain performed five or six times, under the most favourable circumstances, but in all of them without success. "Il ne faut donc pas se faire illusion sur le succès qu'on serait en droit d'en attendre, d'après l'assurance avec laquelle en parlent les auteurs. Quand on a rencontré l'abcès, on se felicite, on croit le malade sauvé; mais on ne tarde pas a voir les symptoms reprendre une nouvelle intensité, et l'on finit par avoir la douleur de le perdre." From Ducrot's Essay on Cephalitis we shall abridge another case resulting from external violence. Case 22. "Louis Motel, 48 years of age, hurt his head against the mantlepiece of a chimney, without experiencing any thing at the time except a slight sense of stunning. In fifteen days afterwards he felt a degree of weakness in the right arm, which gradually increased. The same took place in the lower extremity of the same side. Soon after this the intellectual functions were disturbedpulse feeble and concentrated. On the eighth day (from the commencement of the symptoms, and three weeks from the accident) there was complete paralysis of the right side, accompanied with --- |