cavity of the cranium, by breaking through the orbital process of the frontal bone, going through the anterior part of the brain, and then passing upwards about as far as the coronal suture, making a distinct track throughout its course upon the surface of the brain. In this instance there was no one symptom during the fortnight the patient lived that could have led one to suppose that any injury whatever had happened to the brain." (p. 523.)

(2) As in wound of the dura mater much danger is to be dreaded from the extension of the inflammation to and throughout the serous arachnoid membrane by which it is lined, the younger CLINE advised that a puncture should be forthwith made through the arachnoid and pia mater into the surface of the brain, for the purpose of exciting afmore active and immediate inflammation, by which the general serous cavity might at once be shut off from the wound that he thus hoped to circumscribe. I once saw him adopt this practice, but the patient died; the injury he had received, upon examination after death, showing itself to have been beyond remedy. ASTLEY COOPER also recommended this treatment, but without acknowledging at whose suggestion.-J. F. S.]

400. When good suppuration takes place, a nourishing diet and constantly dry dressings are advisable. If the suppuration be bad and thin, if fresh symptoms of inflammation arise, there is probably some splinter, which it must be attempted to remove; or the pus may not flow freely, in which case it may be necessary to enlarge the opening in the bone by trepanning. If an abscess form in the brain, it must be opened with a lancet (1). If the patient be weak, the suppuration bad, or the wound itself gangrenous, strengthening remedies must be used, especially bark, and it must be bound up with astringent remedies, as lime water, decoction of bark or of elm bark, with tincture of myrrh, with digestive salves and the like. If a portion of the brain be entirely spoiled, it must be taken away. Loose pieces of bone must be carefully withdrawn. The dressings should be changed each time as quickly as possible, so that the wound be not long exposed to the air; care must also be taken that the air surrounding the patient should not be foul. [(1) If there be any sufficient guide to the situation of the abscess, I do not see any objection to making a cut through the brain to it; but to ascertain this is always very difficult and generally impossible, as it by no means follows that the abscess is immediately opposite the part where the blow has been received. The case which GUTHRIE quotes from LA PEYRONIE (a) appears to be merely a simple circumscribed collection of pus beneath the dura mater, which, as its quantity increased, enlarged its cavity at the expense of the brain, so that it was presumed to have attained the size of a hen's egg, and to have descended to the corpus callosum. It was immediately emptied by puncturing the dura mater.

DUPUYTREN's case (b) is, however, an abscess in the substance of the brain. A young man was wounded on the head with a knife; the wound healed, leaving only a little pain, which occasionally came on about the scar. Some years after he was brought to the Hôtel-Dieu, in a state of stupefaction, with which he had been suddenly seized. An incision through the scar exposed the point of the knife sticking in the bone, the removal of which gave no relief. The trephine was also applied without benefit. The paralysis continuing on the side opposite to that on which the wound had been received, it was determined to open the dura mater, and plunge a knife into the brain, which evacuated a large quantity of pus. The paralysis ceased that night; he recovered his speech, became sensible, and entirely though gradually recovered.]

401. Foreign bodies often remain in the brain with different consequences. Sometimes they do not give rise to the slightest symptom through the whole of life; sometimes merely pain is produced when the head is placed in a certain position; sometimes they cause cramps, and epileptic fits; often sudden coma, convulsions, and death.

[Numerous examples are given of foreign bodies lodged in the substance of the brain, and producing symptoms of less or greater severity; but in the greater number it will be found, that after a few months they die either suddenly, or from some inflamma(a) Sur la partie du Cerveau où l'Ame exerce ses fonctions; in Hist. de l'Acad. des Sciences, 1744, p. 199. (b) Lancette Française, 14th Oct. 1830.

tory attack of the brain. If therefore they remain quiet during life, it may be presumed that they assist in shortening it.

A very remarkable instance is mentioned by LANGLET (a) of a seven-drachm ball remaining for eighteen months in the brain, enveloped in a sort of membranous covering attached to the dura mater, and which contained pus.]

A.-OF INFLAMMATION OF THE BRAIN AND ITS MEMBRANES.

402. Inflammation of the Brain (Encephalitis) may occur in every injury of the head; and its causes are, the operation of external violence, the splintering and indenting of bone, injury of the brain and its membranes, violent separation of the dura mater from the skull, bruising of the diploë, collections of matter under the tendinous aponeurosis, and so on. Inflammation arises either soon or later after the injury, and is severe, quick in its course, or slow. Its appearances are various, according as the inflammation proceeds from the dura mater or from the brain itself, and as it passes from one structure to the other. Its usual termination, when it does not disperse, is suppuration.

403. Acute Inflammation of the Dura Mater (Meningitis traumatica acuta) appears most commonly from the third to the fifth day; the patient complains of severe, oppressive head-ache, which spreads from the injured part over the whole head; the warmth of the head is increased, the pulse small, compressed and rather hard; the patient is heavy, difficult to rouse, his ideas become unconnected, quiet delirium comes on; and lastly, when the inflammation proceeds to suppuration, the patient falls into a continued state of stupefaction from which he cannot be easily roused: convulsions come on, continued shivering, irregular pulse, the pupils are wide and fixed, the breathing snoring and slow; the sphincters are paralysed and the patient dies. On dissection the dura mater is found reddened, covered with exudation, separated from the inside of the skull, pus between it and the bone, and at this part the dura mater often gangrenous.

404. Chronic Inflammation of the Dura Mater, which in injuries commences only after a long space of time, often after seven or fourteen days, often after a month, begins with headache, with mental and bodily depression, heaviness, unsteady walk, gastric symptoms, quick pulse, and in its further course a circumscribed painful swelling of the coverings of the skull commonly arises at the place of the injury, or if there be a wound it becomes pale, and secretes a thin sanious fluid, which sticks fast to the bandages. The pericranium separates around the wound, and the inflammation soon runs into exudation of a yellowish ichorous purulent fluid, which collects either between the skull and the dura mater, or between the latter and the surface of the brain. (par. 386.)

[ASTLEY COOPER mentions the case of a woman who had this chronic inflammation of the dura mater, which terminated in suppuration and caries of the bone above it. She had fallen upon her forehead against a chest of drawers, which produced a small wound and great contusion: but she got well, excepting some pain and a sense of weight in the head, which continued to increase, became very severe, and at the end of eight months she was attacked with epilepsy. She had then a purulent discharge from the nose and ears, which relieved her; but it ceased after three days, and she was as bad as ever. This occurred again and again. But she got worse, lost her appetite, had very distressing pain in the head, especially at the part where the blow had been received, which was increased by pressure. She slept but little, became very irritable, and was often convulsed on the slightest disturbance. At last she was quite comatose, and

(a) Bulletin de la Faculté de Médecine, No. 19.-1812.

then BIRCH of St. Thomas's, whose patient she was, cut through the scalp, but did not observe any disease in the pericranium or bone. The discharge from the wound at first afforded some relief; but it became fetid, the pericranium separated, the bone was carious, and an aperture in it allowed the passage of pus at every pulsation of the brain. A trephine was therefore applied to render its escape more ready; and, on the removal of the bone, the dura mater was found inflamed and gangrenous. She died next day, about nineteen months after the accident. (p. 326-28.)

I have seen several cases of this chronic inflammation, which is always a very serious disease, and very difficult of control; often indeed entirely unmanageable. The patient goes on slowly from bad to worse, sometimes with intervals of improvement, sometimes without, and will frequently live in a state of constant suffering for many months.-J. F. S.]

405. Acute Inflammation of the Brain (Encephalitis acuta traumatica) begins immediately after the injury, with severe, constant, increasing pain in the head, uneasiness, sleeplessness; the eyes are red, intolerant of light, the pupils contracted, countenance red, the carotids beat actively, the head is hot, the pulse full, hard, and vibrating. Contractions of the muscles of the face, and of the whole body, and severe violent delirium ensue. If the inflammation do not subside, it may be fatal by its severity, by the gorging of the brain with blood, and paralysing of the brain thereby; or it goes on to suppuration; symptoms of pressure on the brain, constant sleepiness, but often broken by delirium, and all the above-described symptoms (par. 403) come on, and death ensues. On dissection, the brain is found full of blood, its medullary part reddened, and, when cut through, a quantity of bloody points, and even extravasated blood; collections of pus may also be noticed at various parts on the surface of the brain, or in its substance.

406. Chronic Inflammation of the Brain (Encephalitis chronica traumatica) frequently comes on very late; its symptoms are commonly deceptive, and, at the first, easily overlooked; often showing intermission or remission. Bodily and mental depression, continued headache, febrile shiverings, and the like occur for a shorter or longer time; and with the passing of the inflammation into suppuration, the disturbance of the brain becomes greater, or symptoms of compression come on. Examination after death shows either a defined or diffused collection of pus in the substance, or on the surface, of the brain (1).

[(1) It is quite impossible to determine the length of time which abscess in the brain has existed before it produces symptoms, as its only indications are the symptoms of compression, which come on two or three, or three or four days previous to death. The size of the abscess often leads to the belief that it cannot have been formed in the few days during which symptoms have existed; and its situation seems to have material influence on the appearance of the symptoms, proportionate to the importance of the part of the brain immediately compressed. Thus a large abscess may exist in the upper parts of the brain, which probably has occupied some time in its formation, yet symptoms of pressure appear only two or three days before death. Whilst, on the contrary, a smaller, or even a small abscess at the base of the brain, or near the origin of the nerves will produce symptoms, probably at any earlier period, which are more decided and severe. Hence though it is customary to speak of death from abscess in the brain, at various periods after the reception of an injury, it must not be supposed that the abscess has existed during any very considerable portion of that time, though it has probably commenced its formation much before its existence was suspected.

Sometimes the abscess in the brain appears to be sympathetic, with irritation and suppuration of the dura mater; a good example of which is presented by the following CASE under the care of my friend GREEN (a):—A boy, aged twelve years, was admitted into St. Thomas's Hospital, Oct. 26, 1827, having ten weeks previously received a blow on the forehead, followed by abscess, from which several ounces of pus were discharged by puncture; and he recovered. Three weeks before his admission he had an epileptic

(a) Lancet, 1827-28. vol. i. p. 687, 88.

fit, which was followed by incomplete paralysis of the left side. His limbs were shrunk ; his face pale, his eye peculiarly wild, his countenance peevish and anxious. He was restless and irritable, and when spoken to he would only scream out, “my head aches,” putting his hand at the same time to his forehead. The scalp was hot, but the surface generally cool; the pupils especially the right, much dilated; pulse small and 120. He could not move either of the left limbs; the motions were very fetid, and passed involuntarily, as did also the urine. He pointed to what he wanted, rather than asked for it. His head was ordered to be shaved; leeches and cold lotion to be applied. Chalk mixture to check the action of his bowels, and a drachm of mercurial ointment to be rubbed in nightly. The leeches were repeated on the next day. Nov 2.-The pain in the head still severe; but he moves his left side more freely. On the 5th his gums were affected by the mercury; the headache only at intervals, and the heat of the scalp diminished; a blister was put on the occiput. A week after he was capable of retaining both stools and urine, and the powers of motion were improved; but the headache was very severe; the pupils dilated and insensible to light; pulse still quick and small, and the surface quickly cooling when exposed. The mercurial friction was now left off. Another blister was applied in the course of the week, and on the 19th he was ordered dec. cinch. 3jss. acid. mur. mviij. t. d. A puffiness soon after began to appear above the cicatrix, and extended to the left eyelid; and on the 26th distinct fluctuation being felt, a lancet was passed into it, and blood flowed freely, as from opening a vein, without any pus, but after a minute ceased spontaneously. A deeper wound was then made, and about half-an-ounce of cheesy matter escaped. A poultice was applied, and a dose of calomel given. A slight discharge of pus followed, but in three or four days the wound healed. He continued still very irritable; but the headache varied, and when most violent the pupils were dilated. On the 18th Dec. pus was again discharged from the forehead, and also at the left angle of the jaw; the bowels were much relaxed; he gradually sunk and died on the 31st. Examination.-The scalp was found to form the front boundary of the frontal sinuses, their external table being entirely absorbed; but there was little pus. The inner table was almost perforated in many places, and completely in one, but there was not any pus between it and the dura mater, which was vascular, especially over the sinuses. The longitudinal sinus was full of pus, and lined with or ganised lymph; both the lateral, the inferior longitudinal, and inferior petrosal sinuses were also distended with pus; in the right lateral was a hard plug of lymph at the part where it turned to the temporal bone, and the left was filled with lymph to the lacerated hole; the orifices of many of the veins into the longitudinal sinus, and to some distance from it, were filled with pus: the pia mater was loaded with blood. A small abscess was on the surface of the right hemisphere, near to the longitudinal sinus, but not communicating with it. In the left lobe of the cerebellum was a large abscess. There were also abscesses in the lungs, one in the left kidney, and a few small ulcers on the mucous membrane of the ileum and colon.

PROCHASKA (a) has also mentioned a similar case of a boy struck on the head by the handle of a winch, whilst drawing water from a well. He received a slight wound, which soon healed; but he suffered much headache, became dull and heavy, and after some weeks was attacked occasionally with convulsions of the whole body, which ceased spontaneously. Rather more than four months after he fell suddenly into the same state, and was brought to the hospital in that condition a week after. Under treatment he began to recover the use of the paralytic hand and foot, and both to see and talk better. After some days, a soft, fluctuating swelling, without pain or redness, appeared on the forehead, where the blow had been received, and, when cut into, a large quantity of black half-coagulated blood was discharged, and the frontal bone felt rough to the finger. At every daily dressing there was a free discharge of similar blood. Soon after he had very severe bleeding from the nose, which relieved the headache; it recurred every day till the fourth, on the morning of which he sunk into a deep sleep, broken only by convulsions, and in the evening he died.

The examination showed the frontal bone rough and porous opposite the swelling; the vessels of the dura mater were loaded with blood, and pressure upon the longitudinal sinus caused the blood to flow through the porous frontal bone, the sinus itself having several openings into the diploë, behind the injured part of the bone through which the blood passed. On the upper part of the left hemisphere the dura mater adhered so firmly to the brain, that they could not be separated without tearing. The cortical part of the brain was here very thin; the convolutions had nearly disappeared; and beneath it was a large oval swelling, hard but fluctuating, over the left ventricle, extending throughout the whole hemisphere, and occupying two-thirds of the transverse extent of the skull, (a) Observationes Pathologicæ, sect. iv. Cas. tert.; in Opera Minora. Vienna, 1800.

so that it thrust the falx much to the right, and compressed the right hemisphere. The cavity of the left ventricle was almost entirely destroyed; the left striated body flattened, and the optic bed, septum lucidum, corpus callosum, and junction of the optic nerves were driven much to the right. The size of the right ventricle was diminished, and it contained little fluid. The medullary substance was very soft around the swelling, so that the latter, which was distinctly encysted, and contained much pus, was readily turned out of it with the finger. In the right hemisphere the medullary matter was very firm.]

407. The symptoms and course of traumatic inflammation of the brain and its membranes may be variously modified, by the simultaneous attack of both brain and membranes, by the occurrence of inflammation in existing pressure of the brain from depressed bone, or by previous concussion

of the brain.

408. The prognosis of inflammation of the brain depends upon the possibility of removing its causes. If the inflammation continue, it runs on to suppuration, and then upon the seat and extent of the collection of pus depends whether it can be removed or not. It is, therefore, the first duty of the Surgeon to examine closely the part of the head on which the external violence has acted, and if splinters, indents, and so on be present, they must be removed according to the rules laid down.

409. The inflammation requires the strictest antiphlogistic treatment, bleeding from the arm, in the jugular vein, leeches to the head, to the neck, of which the bleeding should be kept up for from twelve to twentyfour hours, by the repeated application of the leeches; internally, antiphlo. gistic purgatives, calomel in smart doses (1), and especially the continual application of ice or of SCHMUCKER'S solution, (four ounces of nitrate of potash, two ounces of muriate of ammonia, a pint of vinegar, and ten pints of water,) no remedies being so efficient as cold fomentations to prevent inflammation. They must, therefore, as well as the prophylactic bleedings, be from the first employed in every injury of the head in which inflammation of the brain is to be feared (2).

[(1) In the treatment of inflammation of the brain or its membranes, the principal reliance is to be placed on the use of mercury, till it produces ptyalism; soon after the appearance of which the symptoms begin to be less severe, and therefore the more quickly the constitution can be affected, the more favourable may be the expected results. On this account the calomel should be given in two-grain doses, every eight, six, or even four hours, according to the severity of the symptoms, and even rubbing in mercurial ointment may be also employed twice or thrice a day. So soon as the mercurial fetor of the breath is observed, and the gums begin to separate from the teeth, it will be seen that the constitution is beginning to be laid hold of by the mercury, and then the quantity given or rubbed in must be diminished to that only which is sufficient to keep up the mercurial action.

(2) After free evacuations of blood, which I think are most effectual when local, by cupping on the nape, temples, or behind the ears, a large blister over the whole scalp, or on the nape, if the scalp be wounded, is often extremely beneficial.-J. F. S.]

410. If, with this treatment persisted in with sufficient energy, and for proper length of time, the symptoms of gorging and inflammation of the brain continue undiminished, or rather if they gradually increase, especially when the bared bone shews a grayish colour and change in its texture, trepanning must be had recourse to. In this case it is probable that some cause, as a splinter or extravasated blood, exists within the skull, which keeps up the inflammation, and renders all treatment useless, but may be found out and removed by trepanning.

411. If the symptoms of suppuration have already appeared, the prognosis is very unsatisfactory indeed; there is, however, the simple possibility