6
341 sartoritis muscle spread out to a most uncom- mon breadth, in the case of a tumour in the thigh. The rectus muscle also does it in a most extraordinary manner, and we make ample allowances for it. You must not suppose, if you go on tapping at the side of the linea alba, that that will be sufficient. What I tell you is a fact, which I am sure you will all see and feel at once, that the rectus muscle yields in a particular manner. All parts don’t yield in the same manner: you don’t see fat peoples’ parts yielding in this way ; you have seen Punch’s belly pretty fat, I am inclined to think ; and what is it that yields there Why, the muscles are kept in,,but the front of the belly yields, so that Punch could lay his belly on the I table. And, therefore, I cannot tell you exactly where you are to tap at the side ; but, I say, make ample allowance for the yielding of the rectus muscle. Linea sentilitnaris (Mr. Abernethy de- scribed this). Well, what is the linea semi- lunaris’! What is it but the three sinews appearing together without muscles inter- vening on the outside of the rectus’! Now the rectus muscle going down, reaches the lower end of the symphysis pubis, and the outer edge gradually tucks in ; so that it is the tucking in, as I have called it, which occasions this semilunar sweep, in the white appearance. Semilunar it ought not to be called; it is but one horn, one half moon, or horn. There are, sometimes, ventral herniæ sometimes, from great exertion, those sinewy chords are rent, and, at the gap made in them, the bowels come out. There was one woman brought into the Hospital, who, from the straining of parturition, tore both her linea alba and linea semilunaris ; the bowels came out en musse, as the French- man said. I never saw such a thing in my life ; an immense quantity of her bowels. She got sent to this Hospital; where the plague she came from, nobody could tell, and it was not till after a great deal of la- bour and attention that we got a great por- tibn of her gut back through the linea alba. When that part was restored, some one put his fingers into another gap, and so the whole was reduced. Of course bandages were applied ; and it ’was a case that could not be expected to have been got well in a sudden ; but the woman did get well, and she went out of the Hospital, as she thought, pretty comfortable. 11’ell, so much for the importance of these parts; and what I have said with re- gard to ventral hernia, is only said for this reason : to show how every fact of anatomy ought to be attended to, because they are applicable to every step in surgery. LECTURES ON THE Diseases of the Nervous System, BY DR, CLUTTERBUCK, B LECTURE IV. On the Varieties of Inflammation uf the Brain. I AM now to treat of the various forms of encephalitis, or inflammation of the brain, both acute and chronic; these we shall find to include a great number of diseases to which different names have been given, but which are all of the same general nature, however different in their external charac- ters. I shall first present you with a theo- retical outline of the subject without regard to names ; for these have in general served little other purpose than to render the matter more obscure. Inflammation of the brain is to be studied like that of any other organ ; taking care not to give undue importance to symptoms merely, but to look always to the disease itself, out of which the symptoms arise. This is the more necessary here, because the attention of practitioners has been generally otherwise directed ; the names employed to designate brain affections, having ’a reference for the most part to symptoms only ; at the same time that these have been made the chief object of attention in practice. Thus, if a patient is suffering acute pain, without any obvious topical inflammation ; or is affected with con- vulsive action of muscles ; or watchful or de- lirious; or is the subject of any anomalous affection; he is supposed to labour under nervous irritation, as it is called; and stimulants and opiates are probably prescribed, with little if any reference to the primary cause of such affections, and which is frequently an inflammatory state of some part of the encephalurt. Now, ds in the case of other organs, in- flammation of the brain may affect its mem- branes or coverings merely ; or it may be seated in the cerebral substance : and it can- not be doubted, that the symptoms will dif- :’ fer in the two cases. The membranes, not being essential _to the performance of the ! functions, will give rise, when inflamed, to but few and simple, symptoms; as in the ; analogous case of pleurisy: while, if the substance of the brain be the seat of the disease, it will be seen principally in the di-

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341

sartoritis muscle spread out to a most uncom-mon breadth, in the case of a tumour in thethigh. The rectus muscle also does it in amost extraordinary manner, and we makeample allowances for it. You must notsuppose, if you go on tapping at the side ofthe linea alba, that that will be sufficient.What I tell you is a fact, which I am sureyou will all see and feel at once, that therectus muscle yields in a particular manner.All parts don’t yield in the same manner:you don’t see fat peoples’ parts yielding inthis way ; you have seen Punch’s belly prettyfat, I am inclined to think ; and what is itthat yields there Why, the muscles arekept in,,but the front of the belly yields,so that Punch could lay his belly on the Itable. And, therefore, I cannot tell youexactly where you are to tap at the side ;but, I say, make ample allowance for theyielding of the rectus muscle.

Linea sentilitnaris (Mr. Abernethy de-scribed this). Well, what is the linea semi-lunaris’! What is it but the three sinews

appearing together without muscles inter-vening on the outside of the rectus’! Nowthe rectus muscle going down, reaches thelower end of the symphysis pubis, and theouter edge gradually tucks in ; so that it isthe tucking in, as I have called it, whichoccasions this semilunar sweep, in the white

appearance. Semilunar it ought not to becalled; it is but one horn, one half moon,or horn.There are, sometimes, ventral herniæ

sometimes, from great exertion, those sinewychords are rent, and, at the gap made inthem, the bowels come out. There was onewoman brought into the Hospital, who,from the straining of parturition, tore bothher linea alba and linea semilunaris ; thebowels came out en musse, as the French-man said. I never saw such a thing in mylife ; an immense quantity of her bowels.She got sent to this Hospital; where theplague she came from, nobody could tell,and it was not till after a great deal of la-bour and attention that we got a great por-tibn of her gut back through the linea alba.When that part was restored, some one puthis fingers into another gap, and so thewhole was reduced. Of course bandageswere applied ; and it ’was a case that couldnot be expected to have been got well in asudden ; but the woman did get well, andshe went out of the Hospital, as she thought,pretty comfortable.

11’ell, so much for the importance ofthese parts; and what I have said with re-gard to ventral hernia, is only said for thisreason : to show how every fact of anatomyought to be attended to, because they areapplicable to every step in surgery.

LECTURES

ON THE

Diseases of the Nervous System,BY

DR, CLUTTERBUCK,

B LECTURE IV.

On the Varieties of Inflammation uf the Brain.

I AM now to treat of the various forms ofencephalitis, or inflammation of the brain,both acute and chronic; these we shall findto include a great number of diseases towhich different names have been given,but which are all of the same general nature,however different in their external charac-ters. I shall first present you with a theo-retical outline of the subject without regardto names ; for these have in general served little other purpose than to render thematter more obscure.

Inflammation of the brain is to be studiedlike that of any other organ ; taking carenot to give undue importance to symptomsmerely, but to look always to the diseaseitself, out of which the symptoms arise.This is the more necessary here, becausethe attention of practitioners has beengenerally otherwise directed ; the names

employed to designate brain affections,having ’a reference for the most part to

symptoms only ; at the same time thatthese have been made the chief object ofattention in practice. Thus, if a patient issuffering acute pain, without any obvioustopical inflammation ; or is affected with con-vulsive action of muscles ; or watchful or de-lirious; or is the subject of any anomalousaffection; he is supposed to labour undernervous irritation, as it is called; and stimulantsand opiates are probably prescribed, withlittle if any reference to the primary causeof such affections, and which is frequentlyan inflammatory state of some part of theencephalurt.Now, ds in the case of other organs, in-

flammation of the brain may affect its mem-branes or coverings merely ; or it may beseated in the cerebral substance : and it can-not be doubted, that the symptoms will dif-

:’ fer in the two cases. The membranes, notbeing essential _to the performance of the

! functions, will give rise, when inflamed, tobut few and simple, symptoms; as in the; analogous case of pleurisy: while, if thesubstance of the brain be the seat of thedisease, it will be seen principally in the di-

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turbed state of its functions. It is not often violence of the disease, and the dispositionto be expected, however, that the disease of the system to be influenced by it.will be so exclusively confined to either the Inflammation of the cerebral substancemembranes, or the cerebral substance, as not to will differ, according to its extent, and thespread in some degree to the other. Ac- particular seat it occupies. Now, as the

cordingly, in actual practice, we commonly brain is a very diversified structure, consist-meet with mixed cases, the membranes and ing of many parts, each differing from thecerebral substance being affected at the same rest in structure and in function; and as eachtime; as the symptoms will generally de is liable to inflammation singly, or in com-note. The subject, however, will be best bination with others, it is plain that there isunderstood, by considering them apart. room for great diversity in the character of

its diseases, each of which will be markedThe first division, then, of encephalitis, by its appropriate symptoms. Thus, either

will be into the membranous, and the paren- of the senses may be impaired or obliterated;chymatous. The former, when it does not as in gutta serena, or in deafness; the conse-spread into the substance of the brain, is quence of disease situated at the origin ofsufficiently simple in its characters, and, in the nerves of sight and hearing. Or theall essential respects, analogous with pleu- muscular power may be lost or impaired, to arisy and peritonitis. This it is which lays the greater or less degree ; as in palsy. Or thefoundation for hydrocephalus or dropsy of the mental powers may be disturbed, without anybrain, one of its most frequent consequences, disorder in the other functions of the brain;at least, in infants; and under this title, as is observed in many cases of insanity orthe subject of membranous inflammation of mental derangement. In other cases, fromthe brain will be fully considered hereafter, more extensive disease in the brain, differentThe second, or parenchymatous inflammation functions may be affected at once; as inwill be characterised by an imperfect or dis- epilepsy, where the voluntary power is vio.ordered state of the sensorialfunctions; ac- lently exerted, while sensation and intel-

companied, in many cases, with disorder in lect are obliterated for the time; andother parts of the system, according to their apoplexy, in which all the smorialfunctioitsdependence upon, or disposition to be in- are at once suspended. To these, I mightfluenced by, the brain. The signs or symp- add a host of anomalous affections, that baffletoms are to be- looked for, therefore, in the all attempts to describe them, and which arefirst place, in the state of the different or- commonly called nervous, a term that everygans of sense, in that of the voluntary power, body uses, but no one can define. All theseand in that of the mind or intellectualfunc- you will readily understand, if you have ations; and, secondly, in the state of the previous knowledge of the physiology of thegeneral system, but especially of the stomach, brain, or nervous system, but which are other.(a part nearly as much under the influence wise unintelligible.of the brain, as the organs of sense.) Nor Inflammation of the brain, frequentlymust it be forgotten, in the consideration of leaves behind it alterations of structure,this subject, that from the confined state of which, according to their degree and extent,the organ, as I have before observed to you, may impair or destroy the functions of thean expansion or swelling of one part, or part, and that permanently: as when palsyeven any unusual fulness or distension of or fatuity followsfever, as they-often do ; orthe blood-vessels, whether general or par. when mania, or permanent insanity, succeedstial, will occasion pressure upon other parts, to phrenitis, as is likewise frequently theso as to impair their functions, if not wholly case. Sometimes the change of structuresuspend them. Thus in apoplexy, arising is so slight, as to be compatible with a tole-from extravasation, the effused blood, by rable performance of functions, under ordi-the pressure it makes in all directions, has nary circumstances : but when any freshthe effect of suspending for a time all the cause of excitement is applied to the brain,sensorial functions. Hence it is, also, that, the functions become disordered in a highin extensive inflammations of the brain, it degree. And thus may be explained theoften happens that, though the....functions recurrence of the paroxysms of epilepsy, mallia,are at first excited and actively disturbed, and other periodical affections of the brain.they come at length to be oppressed and Another division of inflammation of theimpeded, in consequence of arterial ful- brain is into the acute and c/troitc, or febrile,ness, and which, in very violent cases, and non-febrile, where the difference is

may take place from the commencement, or founded on the degree of the disease, ratherat a very early stage of the disease ; as is than its extent.

°

seen in some instances, both of phrenitis and Of the acute orfebrile inflammations of the’ of ordinary fever. But where the disease is brain, that termed phrenitis by authors, may

partial and limited in extent, the functions be regarded as the simplest instance; be-may suffer individually, with or without cause, in general, one of the sensorial fiwc-general febrile excitement, according to the tions only is disturbed, namely, the mental;

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although, as in the casp of membranous in- by pressure simply, destroy their func-flammation, the disease may spread into the tions.

surrounding parts, so as to render the symp- From what I have now said, you willtoms more varied and complicated. easily see that it must be difficult, if not im-

Idiopathic fever is another, and by far the possible, in the present state of our know-most frequent, of the acute inflammations of ledge, to arrange the diseases of the brainthe brain ; in which, judging from the more upon strict anatomical principles, that is,general disturbance of all the functions at according to the parts particularly affected.the same time (though unequally- and in Instead of this, the arrangement usuallydifferent degrees,) it may be presumed that adopted is founded upon the functions thatthe disease extends pretty generally through- are observed to be disturbed ; whether it beout the organ. Of this form of inflamma- that of sensation, of voluntary motion, or of mind.tion of the brain, namely, idiopathic fever, According to this principle, the following.the varieties are extremely numerous, de- order might be adopted.pending upon the degree and duration of 1. Diseases of sensation, or affections of thethe disease, the habit of the patient, the different senses not arising from any de-treatment pursued, the season, climate, and fect in the organ itself, but originating inpeculiar nature of the exciting cause ; and, the brain. To these affections, different

lastly, upon its complication with other dis- names have been given, according to theeases. And thus you will easily be made particular sense that is vitiated or lost; suchto understand the inflammatory, the mild, and as amaurosis, dysecoea, anosmia, aghotstia,the malignant forms of fever, as well as ancesthesia, with many others, for which Iothers; and which are less to be considered would refer you to the writings of the noso-as distinct species of the disease, than as va- logists.rieties merely; likewise the different specific 2. Diseases of the voluntary power; includ-fevers, all of which differ essentially from ing spasm, convulsion, paralysis, trenaor, and

comnwn or simple fever, as well as from one the like..another. 3. Diseases of the mental function; as mania,The chronic or non-febrile inflammations of melancholia, and hypochondriasis, with all their

the brain, are still more numerous than the varieties. **

acute ; embracing the comata, the vesaniœ, In some cases, the functions are dis-and many of the spasmi of Dr. Cullen and turbed singly ; as in the case of gutta serena,other nosologists. The arrangement of these, where sensation only is lost ; in paralysis,for the purposes of practice, is a matter of where muscular motion is destroyed ; and inno small difficulty. If we knew the pre., mania, where the mind alone is disordered.cise uses of every part of the brain, we In other cases, two or more of the functionsshould be able, by merely attending to the are affected at the same time, though insymptoms, to assign the actual seat of dis- different ways : as in epilepsy, where theease, or the particular portion of the organ muscular power is exerted in a violent man-affected. But this can only be done to a ner, while sensation and intellect are lost : and

very limited extent. It seems to be ascer- in apoplexy again, where all the sensorialtained, both by direct experiment, and by functions are at once -abolished.the effects of disease and injury, that the Various, however, as are the affectionshemispheres are more especially connected of the brain in regard to their external signswith the mental functions ; and that certain or characters, their pathology is not difficult;parts towards the basis of the brain, and while their treatment is, for the most part,the medulla oblongata, are devoted to the very simple. Most or all of them originatesenses and voluntary power; while the cere- in disordered arterial action, and that mostly6eMMm appears to govern the movements of of an inflammatory kind ; or at least arethe heart, and the muscles of respiration. consequences of this. The general line of

But we are still ignorant of the particular practice, therefore, is sufficiently obvious,uses of the greater number of parts. If you and will be particularised as we proceed.found a person complaining of loss of sight The different diseases of the brain, might, Ior of hearing, where no disease existed in think, be exhibited with advantage in athe external organs of these senses, you tabular form, by which the whole might bewould have no difficulty in concluding that comprehended at;a single glance. Some-these parts of the brain where the optic or thing of this kind it is my intention to pre-auditory nerves originate, were, from some sent you with hereafter. At present, wecause, rendered incapable of performing go on to speak of the diseases individually,their functions. Still, these parts might according to the plan chalked out; taking,not be either of them the actual seat of the as our first subject, inflammation of thedisease, but might be influenced by it in a membranes of the brain, or, (as from its fre-secondary way only. An inflammatory tu- quent termination it is called) hydrocephalus,mour, for example, being formed any where though this is by no means a necessary orin the neighbourhood of those nerves, might, constant result.

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Of Hydrocephalus, or Membranous Inflamma-mation of the Brain.

Hydrocephalus, or a preternatural accumu-lation of aqueous fluid within the skull, isgo generally and obviously a mere conse-quence of inflammation of the membranesof the brain, that I have no hesitation inconsidering them as identical, or rather ascause and effect. This is in exact analogy alsowith dropsical effusion into the other cavi-ties of the body, and which, in most cases,can be traced to inflammation of the serousmembranes as their immediate cause. Dropsyof the Brain, no doubt, sometimes comes oninsensibly, and is even connate in some in-stances, so that it is difficult, at all times,to connect it with inflammation. These,however, are not conclusive objections ;and, at all events, are only exceptions tothe general rule.

Inflammation of the membranes of thebrain has been called by different names ;as meninbitis, in allusion to the meninges orcoverings of the brain : arachnitis is’anothernew-coined appellation given to this disease;upon the supposition, I imagine, that thearachnoid membrane is affected, exclusive ofthe pM mater. This is an assumption, des-titute of all probability. The arachnoid maybe considered, indeed, as an external la-mina of the latter membrane ; and I have

’. never seen it exhibiting the usual marks ofinflammation without observing at the sametime a corresponding state of the pia materitself. The term arachnitis, I consider there-fore, as an innovation neither just nor ne-cessary, and ranking with the modern termiritis; both of them solecisms in language,and useless in regard to practice.To understand inflammation of the mem-

branes of the brain, you must consider theseas serous membranes, the counterpart of thepleura and peritonœum, and others lining thedifferent cavities of the body. The signsof inflammation in these structures, are fewand simple, consisting in little more thanpain and heat in the part, with more or lessof pyrexia or general febrile action, accord-ing to the degree and extent of the inflam-mation, and the susceptibility of the gene-ral vascular system. In itself, this diseasecan hardly be considered as dangerous,though it may lead occasionally to fatal con-sequences. For the inflammation may spreadto the cerebral substance, and, by disturbingits functions in a high degree, immediatelyendanger life. Or it may end in accumu-lation of serum, giving rise thus to hydro-cephalus, or dropsy of the brain, an eventmuch more frequent in infants than inadults, and which is indicated by marks ofoppressed brain, combined, in most cases,

with more or less of those that denote thepresence of inflammation.

Symptoms nf Hydrocephalus.—Employingthis term, as I have just stated, to denoteinflammation of the membranes of the brain,(which is in reality the disease, and of whichthe dropsical effusion is only a consequence,and that not a necessary one), we shouldfirst consider it in its simplest form, that is,without any corresponding affection of thebrain itself. Now there are many suchcases, both in children and in adults ; andin both, the disease is easily recognised. Ishall speak of it chieffy as it regards infants,where it is of most frequent occurrence,and attended with greater danger.The essential signs of the disease are

few, and readily understood. The head ishot, the face flushed, the eyes dull and in.expressive. The arteries in the neck aswell as in the temples, pulsate strongly.The child is restless and fretful, evidentlysuffering pain, which both the countenanceand the hand of the patient refer to thehead as its seat. A febrile state of sys-tem. accompanies the disease, though indifferent degrees. The pulse is accelerated,the skin hot and dry, and the tongue coveredwith a white fur. The appetite is lost,and sometimes there are sickness and vomit-

ing. The bowels are in general constipated,though sometimes the reverse.Now these are all the symptoms that

properly belong to the disease, in the earlystage. They have been often mistaken, andattributed to wrong, causes: such as teetlc-

ing, or worms, or other irritations in the

primœ viz, though seldom with any justfoundation. The disorder has been called,also, the infantile remittent fever; as if itwere a general affection of, the whole sys.tem, instead of a local disease.

Causes.-These, in most cases, are not

perceptible, this inflammation, like others,appearing to come on spontaneously. Theobvious causes are exposure to cold, or injuriesof thehead; such in fact as are common toother diseases. The pain of dentitinn, orworms, or other irritations in the alimentarycanal, may possibly induce it at times; butthese are only to be considered in the lightof causes, -and not as the disease itself, as isoften done ; such causes seem more likelyto irritate and disorder the brain itself, thanits membranes.

Progress and termination.—Inflammation ofthe membranes of the brain, like others, isoften slight in degree, and terminates quicklyin health. If it be long-continued, thoughslight, it often ends in serous accumulation,which is known or suspected by the marhsof oppressed brain that take place. The

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pulse then loses its frequency, and oftenbecomes preternaturally slow; the pupilsare dilated ; there is torpor of the bowels,and indeed throughout the whole system.The inflammation now frequently declinesor subsides altogether, the heat of head,and of skin, disappearing ; and the tonguebecoming clean. More frequently, how-ever, the continuance of the febrile symp-toms shows the continuance of the inflam-mation, but in very different degrees., Ifthe child is very young, so that the bonesare not firmly united, the head graduallyenlarges in its dimensions, and becomes

misshapen in its figure ; and that so ob-

viously and variously, as not to require beingdescribed. The extent to which the en-

largement goes, is very various. Sooner orlater it generally stops by the bones uniting,the head remaining afterwards through lifepreternaturally large. In this case a quan-tity of fluid remains, without seeming (inmany instances at least) to interfere withthe proper exercise of the sensorial functions,or even with the general health ; exceptthat the bcdy is commonly stunted in its ,,growth. Such subjects are always liableto repeated returns of inflammation in thebrain or its membranes, and which, sooneror later, in many cases, proves fatal. Theventricles are always, I believe, the principalseat of the serous accumulatioa, and theybecome enlarged and distended in conse-

quence. In most cases, though not in all,there is fluid found between the ditra materand the arachnoid membrane ; and in this

case, it makes its way to the basis of thebrain, and down the spinal canal. The en-

largement of the ventricles appears to takeplace from a kind of evolution of the brain,without any material injury to the structure,if we may judge from the perfect way inwhich the functions are sometimes carriedon in these cases. The cerebral substance,in extreme cases of this sort, becomes soattenuated by the expansion as hardly toequal aline in thickness ; which has led tothe mistake of supposing that in such casesthe brain had wholly disappeared.’

Such is the progress, in the milder formsof membranous inflammation of the brain.On many occasions, the disease assumes amore active character, and soon spreads tothe substance of the brain ; as is known bythe great disturbance of functions that en-sues. Then it is, that the restlessness be-comes extreme, irritability both of mindand body is excessive, the expression of thecountenance is altered, and especially thatof the eyes, which are often directed irre-

gularly, with the pupils unequally dilated.The eyelids remain half open, if the child

sleeps ; there is often delirium, as far as

this can be observed in infants the mus-

cles of the hands and feet are in a state ofcontraction ; and frequently general convul-sions take place. The fur on the tonguebecomes thicker, and of a darker colour ;somnolency or stupor follows ; and deathensues. The disease often proves fatal intwo or three days, and, in very young infants,sometimes at the very commencement of theinflammation ; and then commonly with con-vulsions. Sometimes the disease is pro-tracted to two or three weeks before it

proves fatal, depending chiefly upon the

age of the patient. If the disease is thus

protracted, it wears at first merely the ap-pearance of ordinary fever ; which, indeed,it is. A s the disease advances, the brainbegins to be oppressed partly from some de-gree of serous accumulation, partly fromthe arterial excitement and consequent dis-tention : so that there is a mixture of the

symptoms of inflamed, with those of oppressed,brain. In many instances towards the end,a paralytic state of one side of the body isobserved ; while the limbs on the oppositeside, perhaps, are convulsed.

Prognosis.-Tlie danger in all these casesis very great, although many recover ; moreor less perfectly, however, for they are oftenleft paralysed in different degrees ; or withthe mental functions impaired, and some-times nearly lost.

‘ -

When these cases prove fatal in the wayjust mentioned, the appearances observedon dissection aie comparatively slight ; andthe more so, the -sooner the disease has

proved fatal ; because time is not then givenfor any material alteration of structure ; noris the accumulation of fluid at all consider-able. Instead of this, there is observedgreat turgescency of veins on the surface ofthe brain, and also in the medullary substancewhen cut through. The same appearance is

generally observed in the ventricles. Inthose recent cases, also, the arachnoid mem-brane is commonly found thickened andopaque, with serum in the cellular texturethat connects it with the pia mater. Thislatter membrane is often observed to be red-dened by the inflammation; but this ismuch more remarkable with regard to itsunder surface ; as may be seen by strippingit off the brain, and drawing it out from be-tween the convolutions.

Treatment.—The treatment of hydrocepha-lus, or inflammation of the membranes of thebrain/is as simple as that of any other of theserous membranes : and you are to be go-verned in your practice by the same generalrules, which I have so repeatedly pointedout ; namely, by the stage of the disease,the habit and general strength of the pa-tient, and, in some measure also, the vio-lence of the disease. Upon the last point,

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however, (the degree of violence,) some cau-, tion is required. The most fatal cases often

set out with very mild symptoms ; by whichwe are liable to be deceived and thrown offour guard. Considering the great dangerof the disease altogether, and the little

power we have over it when far advanced,it is necessary to be very watchful even ofthe slighter cases ; and it is better, becauses,afer, to be more active than necessary,rather than the reverse.

- There are few cases where bloodlettingis not proper ; and when it is so, general Ibloodletting, either from the arrn or, (whichprobably is still better), the jugular vein,is much to be preferred to leeches. Cuppingis a good remedy, though inferior in effectto venesection. There is a great objection to Ithe use of leeches, independent of the uncer-tainty in regard to the,quantity of bloodlost, and the less efficacy of this mode ofdrawing blood ; which is, the great mental iirritation they occasion in infants, and whichis continued often for an hour or two. Thisis particularly injurious in brain affections,

and will often counterbalance any goodeffects they might otherwise produce. The

quantity of blood requisite to be taken, isof course very different in different circum-stances. In an infant of five or six months,previously healthy and strong, three or fourounces may be taken; while, in weaklychildren, an ounce or little more will suf ’fice.

Cold should be applied to the head, wherethis is very hot. If otherwise, it is useful tostimulate the scalp by a weak solution of theta1’tarized antimony, (a scruple to an ounce.)The cantharides cerate may be rubbed behindthe ears; or a mild blistering plaster appliedto the back. A warm fomentation of thehead, from time to time, is also useful,and is not incompatible with the use ofcold water in the intervals.

Frequent mild purgatives are proper ; andwhen the pulse is very rapid, small doses ofthe digitalis seem to do good. After thenecessary evacuations have been made, andin the advanced stages of the disease, wheregreat restlessness is observed, small dosesof opitint are proper ; for instance, one, two,or three drops of the tincture, at intervals offour or six hours, in a child of six months :and so on, in proportion to the age. It isbest to give the opium along with a purgative,such as the infusion of senna.

The utility of calomel, and othei mercurialremedies, has been very much exaggeratedin this disease. In general, they are notrequired, and are often hurtful; as wherethere is great irritability of system, indicat-ed by restlessness and frequency of pulse.These circumstances generally occur in theearly stages of the disease. In the latter

stage, when torpor exists, the pulse beingslow, and the pupils large, mercurials maypossibly be of service. The specific charac.ter, however, which some have given themin this disease, is absurd.When the febrile symptoms have sub.

sided, and marks of. oppregion of brain onlyremain, little is required to be done. It isnot proper to excite the system, either bymercury or any other means, for the pur-pose of producing absorption: for suchmeans will be very likely to reproduce theinflammation, and can do no lasting good inthe way of absorption. As the strength be.comes recruited, by time, and by food takenaccording to the appetite, the balance be.tween exhalation and absorption will be

gradually restored. At all events, you mustnot deceive yourselves, by supposing thatart can accomplish any thing of importancein such circumstances.

Our next subject, Gentlemen, will be

phrenitis, as it is called, or one of the formsof inflammation of the brain itself.

To the EditorTo the Etlito.r of THE LANCET.

SIR,—When candidates pass their ex-amination at the Royal College of Surgeons,I believe they make oath to preserve thehonour and dignity of the profession, &c. ;and if I recollect right, for any egregiousviolations of its decency and decorum, theysubject themselves to be struck from thelist of its Members. Now, if this be the case,what does it not argue for the active surveil-lance and watchfulness of those honourableand upright gentlemen who compose thepresent Court of Examiners. I repeat,ivhat does it not argue, when we see bla-zoned forth in every newspaper, the naiise-ous and disgusting paragraphs of those

quacks in Bouverie Street, Bridge Street,Adelphi, Norfolk Street, &c., styling them-selves Members of the Royal College of &:)’-geons.

Is it not a disgrace to be in any way con-nected with such a body ? The question isan idle one-as the thing is at present con-stituted’, we know that it is, and we alsoknow that there is little hope of reformation.

I am perfectly aware, Mr. Editor, thatwhat I have here complained of, will, (aswe say at school,) long ere it reach Glymplls,be scattered in empty air-but there is

yet another saying, which may apologise forthis intrusion, " Gutta cavat lapidem."

I am, Sir,Your very obedient servant,