round the tumor at this place, measures 3 ft. 5 in., and that a line drawn from its attachment at the great trochanter, and carried round its outer edge all the way, measures 7 ft. 5 in. The tumor is probably steatomatous, but apparently containing matter of every degree of consistence, from the most condensed fat to the softest pappy or lardaceous substance; its surface is traversed in all directions by tortuous vessels, some of a very large size, and there is a great cleft towards the inner and middle part of it, which she ascribes to its striking on the other thigh and knee when she was able to walk. She is now unable to move, and with difficulty turned in bed; she does not complain of much pain, but of great itching, and a sensation as if insects were moving through the tumor; it seems to incommode her most by its bulk and weight. Her general health is now very indifferent; her pulse quick and feeble; she is affected with almost constant dyspnoea; her face sallow: left leg and foot anasarcous; yet her appetite is pretty good, and her bowels regular. The menses finally ceased about a year ago. I have often been solicited by the woman and her friends to remove this tumor (which I conceive cannot weigh less than 100 lbs.) by operation, but always declined, from dread of the event; which dread has been increased by a knowledge of the fate of Hoo Loo, the Chinese, operated upon in Guy's Hospital last Summer. Forres, Aug. 22d, 1832. woman. J. BELL. We perfectly coincede with Mr. Bell, in his repugnance to operating on this poor When we consider the great size of the tumor at its attachment, the large vessels supplying it, the age of the patient, and her state of health, we think the chances of recovery from an operation so very slight, as to preclude any prudent man from employing the knife. It is true that the woman must die, if the tumor be allowed to remain; but when we consider that she has attained the age of 52, and reflect that all unsuccessful operations bring a certain degree of discredit on surgery, and perhaps deter patients from submitting to the knife when they might really be benefited by it, we must again express our decided conviction of the judgment and propriety of Mr. Bell's deter mination. LVI. MR. CRAMPTON ON INFLAMMATION OF THE BRAIN AND ITS MEMBRANES. In the Number of the Dublin Journal for September, were some valuable observations, by Mr. Crampton, upon Injuries of the Head. We had the pleasure of introducing those observations to the notice of our readers, and we feel gratified by observing a continuation of them, in the Number of the same able Journal for November. We trust that this will not be the last, as it has not been the first, occasion for expressing our approbation of the candid manner in which Mr. Crampton lays the results of his extensive and varied experience before the public. Would that the generous example were more widely followed than it is. The subject of Mr. Crampton's present paper is acute inflammation of the brain. The subject is one of equal interest to surgeon and physician, too often one of equal difficulty. Mr. Crampton is one of that practical class of surgeons, who look upon inflammation of the brain as inflammation of the brain, and while they admire the bold and clever generalizations of the French, lament that they cannot find them confirmed by Nature. In other words, Mr. Crampton agrees with those, who acknowledge themselves unable to distinguish with nicety between inflammation of the substance and inflammation of the meninges of the brain. Accordingly, by the term, inflammation of the brain, he implies inflammation of the parts included within the encephalon generally. Premising thus much, we may pass on. Mr. Crampton's object in the present paper, if we rightly understand it, is rather to shew that Nature does not altogether support our current notions, than to establish, by deranged facts, any previously-admitted principle, or to build, on an inductive basis, a new one. We will give an abridgment of Mr. Crampton's cases, and then our readers may judge for themselves. Case 1. Mr. J. Cooper, æt. 17, strong and healthy, indulged more than usual in gymnastic exercises on the 11th March, 1832. On the following day he went to a heated church, and consequently dined out. At midnight he awoke with an excruciating pain in the left eye-ball, and felt as though the eye must burst. Next morning he was seen by a gentleman, who ordered him some purgative medicine. The pain was severe throughout the day, but was relieved in the evening after the operation of the physic. During the night it returned, and next morning he requested the application of leeches. Twelve were applied, but they had scarcely fallen off when the pain became more violent-he raved-imagined that the gymnastic pole was pressing against his back-and sometimes almost screamed with agony. At 6, p. m. he was seen by Mr. Crampton, who found him thus: "He was lying on his right side, his eyes closed, his mouth half open, and his head thrown backwards; his face was deadly pale, (the leech-holes were still bleeding,) the breathing not hurried, but he moaned almost incessantly, like one who is suffering in his sleep. Sometimes he cried out with a voice of agony, 'Oh dear, oh dear, what shall I do?' and then muttered indistinctly. When roused, however, he was perfectly rational, but was impatient of being questioned; sometimes, when spoken to, tossing himself to the far side of the bed, and hiding his head in the bed-clothes. On being questioned, he said, 'the pain had left his eye, and had settled in the back of the neck,' where the slightest pressure seemed to cause severe pain. In short, his whole aspect and manner was that of a person who had received a severe blow or fall on the head, and who was beginning to awake from the deep coma of concussion. The pulse was 84, soft and regular while he remained at rest, but it rose to 120 when he moved, or was raised in the bed, establishing another remarkable resemblance in the symptoms to those attendant on concussion: skin hot and moist. Bowels had been moved three times; urine natural. Twenty ounces of blood were ordered to be taken from the back of the neck by cupping; two grains of calomel every hour; a cold lotion to the shaved scalp." Next morning, at 9 a. m. Mr. Colles was added to the consultation. He was much the same, but had some appearance of collapse. He had raved much during the night and was much more comatose, but he could be roused when s ken to loudly, and then conversed rationally though reluctantly. Pulse 100, soft, regular, more frequent on motion-hearing obviously impaired-his mother thought he was blind-pupils fixed, of medium size. Forty leeches to the forehead and temples—blisters to the nucha. P. c. cal. et pulv. Dov. At 6, p.m. deep coma-perspiration-pulse 140, small. At 10, p.m. respirations 70 in the minute and stertorous frothy mucus flowing from the mouthradial pulse extinct. At 9, a. m. of the fol lowing morning, 80 hours from the commencement of the pain in the eye, he died. On "Inspection 22 hours after death. raising the dura mater, the whole surface of the hemispheres appeared of a pale greenish colour, in consequence of the effusion of a thick green-coloured pus beneath the arachnoid: that membrane preserved its normal structure and transparency, but the pia mater was highly vascular, and its surface flocculent; the more fluid purulent matter was intermixed with portions of a greenish matter of some consistence, which might be called adventitious membrane: this substance chiefly followed the course of the sulci which separate the convolutions, dipping between them to the depth of half an inch. The chief seats of the purulent effusion were the inferior surface of the anterior lobes of the cerebrum, the whole of the base of the brain and the cerebellum, but especially the pons and medulla oblongata. On squeezing the pituitary gland, two or three drops of perulent matter escaped through the cut extremity of the infundibulum; the brain itself was of a natural colour and consistence, but appeared to me more vascular than the healthy state; there were about two ounces of limpid fluid in the ventricles; the choroid plexus was unusually pale." Mr. Crampton thinks the following circumstances most worthy of notice. "1st.-The absence of 'delirium ferox,' convulsions, or paralysis, either spasmodic or atonic symptoms, which are described by nosologists as essentially characterizing inflammation of the brain, or its membranes. 2nd. The resemblance with the whole assemblage of symptoms presents to those which are usually thought to denote concussion of the brain, from external violence." We bow to the authority of Mr. Crampton, and yet we would fain persuade ourselves that the assemblage of symptoms, as recorded, does differ in some important respects from those thought to denote concussion. In this case there was excruciating pain in the head, only obscured by ob. scured sensibility-on the second day there was raving and delirium, the patient imagining himself pressed and injured by what was not near him-and the skin was hot. On the third day still delirium-coma-impaired hearing-probable blindness-fixed pupils. In the evening deep coma and stertor, with the pulse 140. On the following morning death. We have not seen a tithe of the cases which Mr. Crampton must have witnessed, but certainly we have seen no case of mere concussion like this, nor, so far as we can judge, do the ordinary descriptions of concussion tally with it. Such symptoms after concussion indeed, we have seen, and have seen them prove fatal; but they marked inflammation of the brain, and such has been found on dissection. In the present instance we cannot but express our surprise as well as our regret, that so little should have been done by the gentleman in attendance previously to Mr. Crampton. It is surely not good practice to allow most intense and fixed pain in any part of the head to remain hour after hour without a recurrence to local or general depletion. Case 2. Mark Moore, æt. 10, an intelligent and delicate boy was attacked while travelling in Wales, with intense pain in the head, accompanied by vomiting and somnolency. Mr. Crampton saw him fifteen hours after the commencement of the attack. "He lay on his side, with his head thrown back and his eyes half closed; the face flushed but without a circumscribed patch of red on the cheek; he moaned almost incessantly, sometimes shrieked, started up on his seat, looked about wildly, and then tossed himself to the opposite side of the bed. Pulse 120; skin hot, but moist; tongue white in the middle and bright red at the edges; stomach irritable; bowels constipated." "It appeared to me that I had to deal with an acute inflammation of the brain, and I took my measures accordingly. I opened on the instant the jugular vein, and took away at least twelve ounces of blood; twenty leeches were applied to the forehead, and an iced lotion to the shaved head; two grains of calomel and one of Dover's powder every two hours; iced barley-water for nourishment. The symptoms were completely relieved for six hours, but returned at the expiration of that period, with increased violence. The bleeding was repeated at midnight, and leeches were applied in relays, twenty at a time, so as to keep up a continued flow of blood from the skin of the head. The inflammatory symptoms, accompanied with delirium, recurred five successive times, at the intervals of 6, 5, 10, 11, and 14 hours; the bleeding was repeated on each of these occasions, and on the eve of the fourth day the system was brought fully under the influence of mercury. The recovery was rapid and complete. The patient is now, after an interval of eighteen years, in the enjoyment of perfect health. I had the advantage of Doctor Cheyne's valuable assistance in the treatment of this important case, after the second day." Here was a case really similar in many respects to the preceding, and, beyond question, one of cerebral inflammation. It would puzzle us to point out much resemb. lance between the features of such a case and those of concussion. Mr. Crampton acted promptly and boldly, and the result displays in a striking manner the beneficial consequences of early and judicious vigour in the treatment of these dangerous forms of disease. In Mr. Crampton's preceding communication he related the case of Fagan, a pipemaker, which case we detailed in the last number of this Journal, at page 512 et seq. Circumstances worthy of record have since occurred, and Mr. Crampton resumes his report in the present paper. In order that our readers may understand Mr. C. we will recapitulate a few of the previous particulars of the case, referring our readers for the details to our last number. The man was wounded in the head with a dragoon's sword, for dragoons, in Ireland, appear to take great liberties. The skull was fractured, the membranes wounded, and the brain protruded. On the eight day he was attacked with convulsions followed by stupor. A portion of the bone was removed by Hey's saw. he convulsions gradually passed away, but fungus cerebri appeared on the 10th day. In 24 days this had disappeared, and in 11 days after this the wound was healed. In a fortnight more Fagan was discharged and resumed his employment. He was unable to remember the names of things. At this point the last report ended. After this man was discharged, he led a very irregular life, suffering after each debauch from severe pain in the head. On the 22d of August (he was discharged on the 15th May) he nearly lost all power in the right arm and hand, and the right side of the face was paralyzed. On the 24th he was re-admitted. "The following statement is abridged from the hospital journal: John Fagan readmitted August 24th, complaining of severe pain in the state of the original wound; and although his head pain is not constant, the paroxysms recur several times in an hour, and last for two or three minutes; vomits occasionally; vion indistinct; pupils dilated, and very sluggis; strength and sensibibility of the right arm and leg much diminished; pulse 100, soft and easily compressible; tongue clean; bowels free; memory very defective, particularly with respect to names and recent events; but the defect is not confined to the faculty of memory, as, with few exceptions, he cannot repeat proper nomes, but miscals almost every thing; although he can perfectly describe the use of it, he calls, for instance, a watch, a gate; a book, a pipe, &c.; a pipe is the word he pronounces most frequently; it is remarkable, however, that the moment he employs a wrong word he is conscious of his mistake, and is most anxious to correct it. The cicatrix of the wound, which is six inches long, and half an inch broad, is raised, particularly at its centre, above the level of the scalp; it is of a purplish red colour, tense, and shining, very painful to the touch; and at the centre, which is the softest and most prominent part, there is a strong pulsation, obviously synchronous with the radial pulse. 26th. Yesterday had severe paroysms of pain, accompanied with grinding of the teeth and contortions of the features, and succeeded by complete insensibility, which lasted for five or six minutes, during which time the pulse fell to 50 in a minute. Twenty leeches were applied round the cicatrix, a blister to the nape of the neck, and a cold lotion to the head; purgative pills. 27th. No return of paroxysms; pain relieved. 28th. Several paroxysms of convulsion, followed by stupor; cicatrix more tense and red, but the fluid which it covers disappears on pressure, and returns when the pressure is removed; pulse 72, and regular; tongue foul; bowels open. Continued to improve; paroxysms becoming less frequent until the 4th of September, when he had violent vomiting followed by convulsion, after which he remained insensible for several hours; pupils dilated; pulse 54; respiration natural; a small opening was made into the prom inent part of the cicatrix, and two drachms of healthy pus were discharged; the pulse immediately rose to 68; he sat up in the bed, answered questions rationally, and said he was quite free from pain. 7th. Continued free from pain or convulsion; the little opening is healed, and the tumour is as large as before; a larger opening was made into it, and a small quantity (about half a drachm) of bloody serum was discharged. experiments, if they may be so called, were performed in the presence of Dr. Marsh, and a great number of the pupils of the hospital." On these cases Mr. Crampton makes the following remarks. "Considered separately, these cases possess but slight claims to attention, either on the ground of their singularity or of their furnishing any new views with respect to the pathology or treatment, of diseases and injuries of the brain. It appears to me, however, that when viewed in connexion with one another, they acquire some degree of importance. By placing a case of acute inflammation of the brain arising from external violence, and therefore probably complicated with some other organic lesion, beside a case of acute inflammation, arising idiopathically, we are the better able to compare the symptoms of each with the other, and separate those which are the proper signs of inflammation from those which belong either to concussion or compression of the brain. Oct. 9th. Has had no pain or convulsion since the 4th of September, when the abscess was opened; he appears in perfect bodily health, with the exception of some remaining weakness in the right arm and hand, and some slight confusion of vision; the cicatrix is perfectly on a level with the head, and there is no sensible pulsation in the seat of the former abscess; the mental phenomena are as before described, and are most remarkable; he speaks correctly, and even fluently; describes his sensations with great clearness, but avoids all proper names, In the instance of Fagan, (for example,) he says, (for example,) 'I have a great the symptoms in the early part of the case, weakness and numbness here,' (pointing to though less acute, were of the same charachis shoulder,) and along here,' (drawing ter as those which occurred in the case of his finger along the arm to the palm of the Mr. Cowper; we had in both violent pain hand; but no pain.' When I sit up sud- of the head, great nervous irritability, foldenly I don't see rightly; but I soon see as lowed by stupor, and that peculiar kind of well as ever.' He counted 5 on his fingers; delirium in which the patient seems like one but could not say the word 'finger,' though talking in their sleep, from which, however, he made many attempts to do so. He called they can be roused into perfect, though tranhis thumb, 'friend.' When desired to say sient rationality. In both the pulse was 'stir-about,' he said, and invariably says, quick, and the skin hot. In the case of 'buttermilk;' but was immediately consci- Mr. Cowper, the inflammation terminated ous of his error, and said, 'I know that's in the effusion of purulent matter, generally on not the name of it.' Sometimes (as in the the surface of the brain, and of serous fluid last instance) one could trace the associa- into the ventricles, and this was attended tion of ideas through which he was led to with blindness, deafness, and derangement the misnomer: stirabout and buttermilk of the functions of life generally; but there being associated in the mind of every man were neither convulsions nor paralysis. In of his class in this country; but in the the case of Fagan, the inflammation termigreater number of instances, no such asso- nated in circumscribed abscess on the surface, ciation could be traced; but this should or within the substance of the brain, and excite no surprise, as the disturbing cause, then appeared the symptoms which denote which was of sufficient force to dissociate irritation and compression of that organ: the idea of the name from the thing, would, namely, convulsion, followed by stupor, parnaturally enough, be sufficient to disturb the alysis of the side opposite to that on which faculty of association." Generally, these the injury has been inflicted, destruction or |