61

(such as Birkett’s) uncontrollable in character, but moderatein amount.

I cannot help, as we pass, drawing your attention to the factof the obliteration of a large bronchial tube on the immediateconfines of a large cavity. It is not sufficiently known, or atleast acknowledged, that such a condition is, though rare, notexcessively so. The importance of the observation arises fromthe fact, that if, under certain conditions of the pulmonarytissue, an adjoining bronchus be obliterated, the strongestproof is supposed to be obtained, that the conditions in ques-tion depend on the cicatrization of a cavity. Now it is clearthat as such closure may be effected at the very brink of acapacious excavation, it is illogical to attacli weight to itsoccurrence as a sign of cicatrization.

Birkett expired in the twenty-second month after his cere-bral seizure. What was the state of the encephalon Note firstthe condition of the pupils-" rather dilated, and as nearly aspossible equal in size;" the right (that of the paralyzed side)having been, from first to last, during life, notably the largerof the two.The most striking appearance in the brain was certainly the

diminished bulk of the left hemisphere; coupled with thepeculiar state of the membranes, it represented veryaccu-rately the condition common in aged insane persons, who diein a state of general paralysis. But in a case like the presentsuch appearances have all the interest of novelty. Let usendeavour to interpret them. In the first place, starting withthe postulate that Birkett’s original disease was softening,what are the appearances which ordinary experience wouldhave led us to expect ? Why, if the convolutions were its seat,we should have looked for yellow coriaceous patches on thesurface, or losses of substance by ulceration; if the central parts,we might have expected excavation, simple or reticulated,with or without adjoining yellow discoloration, and diminishedsize (centrally) of the affected hemisphere. Now none of thesethings existed; and it is matter of certainty that no change oftexture exhibited itself in the deep-seated parts of the brain.But the opacity of the substance of the convolutions, theirpeculiar crumbly and granular look, their deficient consistenceand indistinctness of texture, and their atrophous state, allappear to me conditions explicable only by a previous processof softening. No other morbid action with which we are ac-quainted at the present day seems of a kind to plausiblyexplain them. And what reason is there to suppose that allsequences produced by softening have yet been described bysystematic writers ? It is certain, too, that the time necessaryfor the production of the secondary appearances they havedescribed is absolutely unestablished, and in all probabilitywidely differs in different cases. Who has yet studied theinfluence which the condition of distant organs, and of the eco-nomy at large, may exercise on the series of changes commonlyarising in softened brain ? Is it in the least degree unsound toimagine, that the state of Birkett’s lungs, and the failure ofthe nutritive functions in general entailed thereby, may havemodified the character of the secondary processes in thecerebral substance ? Far from this, we may affirm that somesuch modification must have been thus exercised. If, in ordi-nary cases, closeness of texture and induration of con-

volutions may be seen, why expect them here, wheneven the intestines were transparent from emaciation ?Is it not more reasonable to suppose, that in a case like

this, brain once softened should continue loose in tex-

ture, and undergo, as it did here, emaciation or atrophy ?Besides, when a portion of brain, which has once undergonesoftening, presents itself after a greater or less lapse of time,with the signs of induration within the area it fills, think youit is the nervous substance itself that has become hardened ?Most unquestionably I believe not; no evidence has ever yetbeen adduced to show that the fibrous or vesicular textures ofthe brain are capable of regaining an amount of consistencethey had once been deprived of. When any portion of brainappears hardened, this, in reality, depends on changes arisingin exudation-matter, or in liquor sanguinis, effused and infil-trated amid its substance. Now in the case of Birkett, wemay safely infer that blood-infiltration had not occurred; hadit done so, we should have detected its reliquiae and imprintin yellow-buff discoloration of the affected parts. And asregards exudation-matter, (supposing it to have been thrownout,) that it should have been deficient in plastic force, andthe faculty of maintaining itself permanently in the form ofinduration-matter, is precisely what might have been expectedin an individual of the low vital energies of the patient.The atrophy seemed very distinctly limited to the convolu-

tions;--might it not have been caused by the presence of theserosity in the anfractuosities, and the contractile influence of

the hardened exudation-matter infiltrating the cellular tissueunderneath the arachnoid ? No; for two reasons. First, thereis no proof that chronic meningitis really exercises such in-fluence; and secondly, (what is even more conclusive,) themorbid state of the meninges existed on both sides, the atrophyof the convolutions on the left only. The meningitis, too, andthe softening, were evidently of different limits. The mem-branes overlapping some of the most diseased convolutions(those of the infero-lateral part of the left hemisphere) weresound. The spaces, which would otherwise have been ren-dered empty by the loss of substance of the convolutions, were’filled by the serosity in the anfractuosities, while the generaldeficiency of bulk of the hemisphere seems to have been madeup for by the fluid occupying the proper cavity of the arach-noid on the convex surface of the brain-a most unusual situa-tion for its accumulation. Under circumstances of this kind,the cranium itself thickens occasionally; but no such changehad taken place here.As far as could be discovered by careful naked-eye exami-

nation of the membranes, no tuberculous deposit had everformed in them. The pia mater in the fissures of Sylvius(one of the favourite localities of tubercle) was perfectlyhealthy, and in the fundus of each of the upper anfractuositiesnothing was perceptible but common induration-matter. Thecase furnished a good illustration of the limitation of diseaseto the pia mater, the arachnoid itself being perfectly freefrom morbid change in its proper substance and on its innersurface; not that I mean that such a state of things is rare, (forthe very reverse is the truth,) but that it is well for us totreasure in our memories one more example of the fallacy ofthe opinion which made the word meningitis synonymous witharachnitis.The convolutions were the main seat of change; and their

vesicular had suffered more seriously than their fibrous sub-stance. So, in the more advanced periods, especially ofBirkett’s malady, the intellect was more deeply affected thanhis motor powers, and vastly more so than his powers of sen-sation. His faculties of attention and memory (the power ofeven adding three to four was lost) were peculiarly impaired;and hence we find a distinct accordance between the func-tional and the anatomical states observed,-at least, such of usas are of the school which contents itself with regarding thevesicular matter of the convolutions as the centre of in-tellectual manifestation, and makes no attempt to connectparticular mental faculties with particular gyri of that matter.The case lends no support to phrenological views. Birkett’svesicular matter was greatly sounder in the region of"number" than in that of " benevolence," and of other facul-ties in nowise impaired. The peculiar condition of speeckwould be, by some persons, referred to the alteration of theanterior lobes; but it is worthy of note that the anterior con-volutions were much less affected than several of the centraland latero-inferior ones of the left side.

Is the implication of sensibility and voluntary motion inBirkett to be referred to the slight alteration of the centresof those faculties (the optic thalamus and corpus striatum)found after death, or to a morbid influence propagated to.those ganglionic bodies, from the diseased vesicular matter ofthe convolutions ? The existing state of knowledge does notpermit us to answer this question satisfactorily; the latternotion is, however, of the two the more in accordance withpositive acquirement on the subject; at least I know of nocases on record in which such slight diminution of consistenceas existed in the optic thalamus and corpus striatum here,hasbeen (if unattended with disease of the convolutions) accom-panied with paralysis.

Hospital Reports.KING’S COLLEGE HOSPITAL.

Reported by HENRY SMITH, Esq., formerly House-surgeon to theHospital.

Excision of the Head of the Femur.ON Saturday last, the 13th instant, Mr. Fergusson performedthe operation of excision of the head of the femur for cariesof the hip-joint. The patient was a little girl, who had beenlabouring under the disease for nearly three years, and whenbrought into the hospital, the condition of the parts was sucha to lead to the supposition that the head of the thigh bonew 1s alone or chiefly affected. It could be felt lying on thed-i sum of the ilium in a carious condition. After a carefulexamination some days before, and there being no contrain-

62

dication in the general condition of the patient, who waa com-pletely crippled, Mr. Fergusson determined to perform theoperation in the manner he has before adopted in the sametheatre. He made a longitudinal incision, about four inchesin length, over the end of the femur, and another at right anglesto this, and then cleared the tissues well away from thebone, so as to ensure a proper application of the saw. Thesection was made considerably below the trochanter major,and the head of the bone, which was found to be in a com-pletely carious condition, was removed, together with that pro-cess, in a few minutes. Happily there was no caries of the coty-loid cavity; but a considerable deposit of new bone existedin that situation. After the operation Mr. Fergusson tookthe opportunity of making some remarks upon the case, andupon the propriety of performing this operation in certaininstances. He was aware that some apparently strong objec-tions had been made against the operation, chiefly in conse-quence of the supposition that in disease of the hip-joint thepelvis was involved to the same extent as the head of thefemur. He was willing to admit that in the majority of casesthe disease involved the acetabulum; but cases were occasion-ally met with where the caries were entirely or chiefly limitedto the femoral side of the joint; moreover, in those caseswhere the disease had attacked the pelvic side of the joint, adeposit of new bone takes place and fills up the cotyloidcavity, as in the case under notice, and thus a partialcure is effected. It is in such cases as these that he deems itproper for the surgeon to have recourse to this operation; asit is by no means probable that the carious head of the femurwould separate without his aid ; and if there should be foundto exist any disease of the acetabulum, the surgeon has it inhis power to take away, by proper instruments, the cariousportions of bone, in the same manner as portions of the sca-pula may be removed in the like operation on the head ofthe humerus. He had every reason to hope that the pa-tient just operated on would do well ; and he should takean early opportunity of calling the attention of the stu-dents and others interested more fully to the subject.

HYDROPATHY AND ITS EVILS.REPORT OF A CASE.

BY C. B. GARRETT, ESQ., Surgeon, Thames Ditton.FIVE children, of a respectable family in my neighbourhood,were attacked last month with scarlatina; all progressed welltill Friday, Nov. 3rd, when one, a boy, through incautious ex-posure to wet and cold, was seized with inflammation of themeninges. I saw him shortly after its commencement, in theevening, and adopted the proper therapeutic measures. Thepain and screams of the boy increased during the night, and atthe suggestion of an alarmed relative, who had been under thistreatment, the hydropathic doctor was sent for early en themorning of the 4th. Wet sheets, towels, and bandages werelavishly applied; cold water lavements, cold water for food,and (toujours perdrix !) nothing but cold water for food, drink,or raiment.On my arrival I met this gentleman: "Sir," said I, "how do

you expect your treatment to act ?" " Derivatively," replied

he; " cold water promotes absorption, attracts the morbidaction to the skin, and instantly relieves the brain. The wetrollers round the loins act powerfully on the kidneys, and thelavements clear out the bowels. Taking nothing but coldwater starves out the disease. Sir," continued he, smashall your bottles; you will adopt hydropathy in a week, and asplendid water-cure practice you will make." 11 I wish youcould get rid of a toothach for me," said I, experiencing atwinge at that moment. " Sit with your feet wrapped incloths of cold water for half an hour, and I will guaranteethat you lose your toothach."To proceed: my visits now ceasing to be professional, I con-

tinued them occasionally, out of curiosity. On the evening ofthe 4th, pain most acute; epileptic attacks frequent; pulsefeeble &c. On the 5th, pains diminished; pupils dilated;pulse slow and feeble; coma, insensibility, and great prostra-tion of strength. The treatment went on till the morning ofthe 10th, when on the visit of the learned hydropathist, heshook his head and pronounced the boy in articulo mortis, puton his hat, and left the house.My attendance was again requested. I found the little pa-

tient in a positive pond of water and wet clothes, bed and allsoaked. He was perfectly unconscious of all around him, moan-ing and crying " Ma ! ma! ma!" unconscious of his mother’s pre-sence ; the symptoms previously enumerated being, if possible,aggravated. The excretions were passed involuntarily, and

he had not even swallowed water for twenty-eight hours!pulse almost imperceptible, and in every respect all but dead.A dry bed, dry clothes, warm milk-and-water, tonics, &c., soon

revived him; a genial warmth pervaded the system, the pupilsregained their natural calibre, consciousness returned, andwith it a serenity and happiness of countenance, which tooplainly evidenced the advantage of the change, and his luckyescape from this amphibious incarceration. On the llth, heconversed cheerfully with those around him, took pleasure inhis toys, and ate with much goût a mutton-chop for his dinner,He is now quite recovered.

This, Sir, is a part of the tale only, for the other four chil-dren were all hydropathed. Two had congestion of the brain,and the other two anasarca. The two former recovered, butone of the latter (urine becoming albuminous, bilious vomit-ing and purging) speedily died. The above circumstances Ihave related to you with the most perfect sense of candour andimpartiality, entertaining as I do a deep respect for theopinions of others, however erroneous; and I must say, thatmy hydropathic friend acted throughout with much courtesyand unobtrusiveness, and appeared to attend the case re-

luctantly, and as though pressed against his inclination.i Thames Ditton, Dec. 8, 1848.

REMARKS ON

A CASE OF STRANGULATED HERNIA.BY F. BEVERLEY DIXON, Esq., M.R.C.S., &c., Norwich.

ON Sunday, January 30,1848, I was summoned to WilliamT-, a used-up agricultural labourer, aged seventy-seven,residing at Kirby-Bedon, a village three miles from Norwichcity. My patient I well knew to be subject to double inguinalhernia, and as he was represented to be unable to return theswelling on the left side, which had been " down" since theprevious morning, I immediately visited him, accompanied bymy friend, Mr. John Crook, surgeon, of this city.We found him with an anxious expression of face; vomiting

at intervals; pulse 88; the radial artery (a type of the rest)ossified, and rigid in places; the left division of the scrotumtense, red, and exquisitely tender. After using ice-cold waterto the part to allay sensibility, we proceeded to the taxis,and persevered for half an hour without success, when both ofus considering that further delay with such a hernia and suchsymptoms would be very dangerous, and that an operation wasimperatively necessary, I exposed the sac in the usual way,after tying two small vessels. The hernia was found to be anentero-epiplocele, the proportion of intestine being smallcompared with that of omentum, which latter was of the sizeof a ripe fig, very much congested, and with difficulty returnedto the abdomen, after the division of a very tight stricture.The edges of the incision were united in the usual way, andthe parts kept moist with pieces of lint soaked in warm water;a quarter of a grain of opium was given every eight hours forforty-eight hours, at the end of which time the bowels werereadily relieved of a copious motion by the exhibition of anounce and a half of castor oil. The wound was not disturbeduntil the fifth day, when the sutures and ligatures were re-moved, and union by the first intention found to have takenplace almost entirely. As soon as the cicatrix was sufficientlyconsolidated, my patient was allowed to resume his truss andcustomary habits. Now, I should not have troubled you withthe insertion of so common-place a case as this, were it not formy deviation from the routine laid down bv surgical au-thorities. During my attempts at reduction by taxis I didnot bleed, on account of the advanced age and debility of mypatient. I feared the powerful impression of tobacco on hissystem for the same reasons; and the warm bath could not havebeen employed without great delay, and the risk of sloughingof parts already in an advanced stage of inflammation. Coldand taxis failing were followed by the prompt application ofthe knife. My patient objected to be removed to an ex-cellent hospital, and had he not done so, I should have felt itmy duty to have dissuaded him from so perilous a postpone-meut of the only means of saving his remnant of life. Thereis one point in the after-treatment of this case on which Ishould feel obliged for the opinion of surgeons of greater ex-perience than my own-and that is, the propriety of quietingthe whole system and intestinal tube by small doses of opium(sufficiently large, however, for a sedative effect) for the firstforty-eight hours, instead of exciting by ransacking doses of

purgatives, in our fidgety anxiety for motions. It is, I pre-sume, the constriction and interruption of peristaltic actionwhich cause all danger, and these being effectually removed,why should we re-excite organs already inflamed by deter-