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into the nasal fossa, was mistaken for a polypus, and operated on by Richter.

Prognosis. When the hernial tumor contains a very large portion of brain, death alone can be expected. When the tumor is small, the patient may reach adult age, though that is far from probable.

Treatment. The leading plans have been ligature-incision or excision -puncture-compression.

A. Ligature.-There have been three recorded cases and three deaths. It is to be hoped there will be no more of either.

B. Incision and Excision. Mr. Wells has collected the particulars of nine cases in which this disease has been treated by incision or excision, in seven of which the operation was followed by death. The most speedily successful case is that, related by Held, of a woman, nineteen years of age, who had a tumor the size of a rennet-apple to the left of the frontal suture. It yielded a little on pressure, and appeared to contain a fluid. He took it for meliceris, and determined to remove it; but, after incising the skin, he recognised an opening in the cranium below the fontanelle, and found that the tumor passed through this opening. It was covered by a membrane, which appeared to contain liquid. He incised this membrane, when two ounces of a yellowish fluid escaped, and the tumor collapsed; and he perceived pulsation and a portion of brain. Dry dressing was immediately applied, and gentle pressure employed, until the brain was reduced. The opening afterwards completely closed. The woman perfectly recovered, and afterwards had several children. Mr. Wells remarks, that the compression employed would, in all probability, have been equally beneficial if employed alone, and certainly, if conjoined with puncture. Incision appears to be equally unnecessary, useless, and dangerous.

c. Puncture.-Mr. Wells relates the particulars of six cases in which this was performed. Of these patients four died; in one the result was not ascertained; and Mr. Adam's single case is the only instance of cure —and this, it will be seen, was imperfect. It would appear, therefore, that though puncture may be less dangerous than incision, it is by no means free from risk; for it is extremely probable that many of the patients whose cases have just been detailed, would have lived much longer if the disease had been left to nature. The successful case of Mr. Adams' is the following:

Puncture was performed seven times with a needle, and once with a lancet; and on this occasion alone did the operation itself seem to be followed with any fever or unusual restlessness in the infant. Pressure was once applied by means of plaster and bandage; but convulsions came on, and the pressure was never repeated. After repeated punctures, the quantity of fluid became so trifling that the operation was no longer necessary; but the solid part of the tumor, formed of the brain itself, was not diminished. The treatment" kept the disease from progressing until

the child arrived at that state of development when the brain and its membranes became less disposed to watery secretions, and the powers of the constitution enabled the infant to provide a stronger skin, capable of sustaining the weight of the hernia.

Mr. Wells sums up :-The only circumstance under which our present experience can lead us to expect benefit from puncture, are probably when the sac is so much distended that its rupture or ulceration is almost certain. This occurrence is proved to have been fatal in so many instances, that it would be far better to anticipate it by puncture; thereby evacuating the fluid more gradually, and rendering the healing of the opening in the sac far more probable. This result is facilitated by making the punctures in those parts of the sac least affected by the effects of distention. Mr. Wells has not been able to discover more than two successful recorded cases.

The first is the case of M. Salleneuve, which was related to the French Royal Academy of Surgery. The patient was a child, who was born with a tumor on the posterior and lateral part of the head,-soft; disappearing on compression; occupying the situation where the parietal, occipital, and temporal bones approximate each other; passing through an opening an inch and a half in diameter; and regularly pulsating. A piece of sheet-lead, pierced with holes, by which it could be fastened to the cap, was applied so as to make a moderate degree of permanent compression upon the tumor. It gradually diminished in volume, ossification proceeded, and the lamdoid suture was eventually perfectly closed. A case was also treated in a similar manner by Callisen. He does not give the details, but refers to it in the following terms : "Sic parvas hernias cere bri curari, ac hiatum osseum denique occludi posse, aliorum et propria experientia evicit." But he agrees, that when of a larger size, scarcely anything can be done beyond applying some contrivance to shield the protruded parts from injury.

Our author concludes that when an encephalocele is not very large, and is reducible without producing evidence of cerebral compression, the displaced parts should be returned, and pressure applied by means of a plate of ivory, silver, or lead, maintained by a bandage. Ivory is preferable to a metallic support, as it is not so good a conductor of caloric, and therefore less capable of transmitting variations of temperature to the brain. If reduction be impossible, and pressure causes no pain or dulness,— compression may be still applicable to prevent further enlargement. Lastly, if the tumor cannot be returned, nor pressure supported, all we can do is to adopt some mechanical contrivance, varied according to the form and situation of the tumor, to protect the brain from external injury, and from cold. It may be advisible to combine puncture with compres、 sion under the circumstances before stated.

A well executed article.

ENDOSTEITES.

For an account of this, we are indebted to Professor Walshe. This gentleman has coined the word Endosteum, as representative of the medullary

membrane of voice, and Endosteitis signifies its inflammation. To this, we suppose, there can be no further objection than lies to the multiplication of names.

The author's account of the pathological condition of the inflamed membrane is succinct. Increased vascularity, he says, forms, as elsewhere, an important feature in the anatomical condition of the inflamed endosteum; the injection is commonly extremely minute, so much so, that in some instances the medulla appears of a uniform florid or livid red colour. It is not very unusual to find blood extravasated in points or patches, and small hæmatomata are sometimes seen. The stage of exudation takes place with extreme rapidity. The medulla and meshes of the endosteum become infiltrated with liquid fibrinous matter, which at first causes softening of the infiltrated tissue; it nevertheless possesses the plastic property in so high a degree, that it almost immediately becomes concrete, increases the dimensions and firmness of the medulla, and causes thickening of the membrane itself. This is best seen in cases of endosteitis following amputation, where the medulla protrudes in the form of a small rounded deep red coloured mass on the surface of the stump, to such extent sometimes, as to require removal with the knife. When, as may be the case, the surgeon is obliged to repeat this little operation, in consequence of re-production of the removed part, the protruding mass at length ceases altogether to contain adipose matter, and is wholly com. posed of solidified fibrine. The contents of the cells of the cancellated structure, if the inflammation spread to them, undergo similar fibrinous infiltration.

This stage may be brief, and that of suppuration succeed. Pus may accumulate in minute spots, which by increasing and running into each other form abscesses of some size (a size of course always proportional to the space in which suppuration occurs); or a greater or less extent of the tissue may be infiltrated with that fluid.

to the cancellated texture.

Sphacelus is a not unfrequent termination. stratrum of the shaft follows.

The infiltration extends

Necrosis of the internal

Endosteitis may be acute or chronic. Examples of chronic endosteitis are those cases of abscess of the central cavity, and more especially of the articular heads of the bones, of which not a few examples are now upon record. A rarer appearance in the chronic state is induration and thickening, with grey or dirty-red discolouration of the medulla, attended with shrivelling of its substance. This shrivelling of tissue manifestly depends upon the slow contraction, co-advancing with the organization of the fibrine exuded during the acute stages. And, in all probability, the grey discolouration (depending immediately upon impaired freedom of the circulatory movements) the induration and reduced size of the endosteum and medulla, all of them so clearly traceable to the contractile power of the fibrine, are not the most important phenomena due to it. Dr. Walshe conjectures that the contraction in question may so far obstruct the motion of the blood in the vessels as nearly or totally to arrest the circulation in the adjoining bony layers. Even the occurrence of rupture of the delicate communications between the membrane and the bone appears to be in this manner not impossible. Now if either of these states is produced, ne

crosis of the bony layers referred to must be the result. The correctness of this idea remains to be determined.

Chronic, even more commonly than acute, endosteitis leads to changes in the bony structure characteristic of inflammatory action. It plays a leading part in the central or articular caries. Endosteitis, too, is among the causes of the purulent impregnation of the blood accompanied by metastatic abscesses in the viscera, the lungs and liver especially, which prove among the most frequent causes of death in operations requiring division of bony structure. In injuries of the head, this inflammation affecting the diploe, holds the same relation to the purulent collections in the liver. That these secondary purulent accumulations are the result of suppuration in the endosteum, is firmly established by the fact, that in some such cases no other tissue in the body is the seat of primary suppurative inflammation. Probably the veins of the membrane are implicated.

But the particular causes of endosteitis, and its distinctive symptoms, are not so clear as its pathological characters. Nor is it likely that we shall ever be much better able to distinguish in the living body an affection, which cannot long remain insulated, and must usually be, at the best, but the initiative of others. Fortunately, this inability is of little practical importance.

EPISTAXIS.

In treating of this Mr. Spencer Wells, the author of the article, describes an apparatus of M. Martin St. Ange for plugging the nares.

It consists of a straight tube, four inches in length, widened into the form of a cone at the extremity, which is not to be engaged in the nose, and terminating at the other by a small perforated nipple. The widened extremity has two rings like a catheter, and a small cock at the distance of five lines. Beyond this a slide plays, which may be tightened at plea. sure by a screw. For the extent of an inch from the other extremity, circular grooves are made, and a small bladder, formed of the cœcum of a sheep, is fixed on the grooved extremity by a firm ligature. To be still more sure that the bladder may not be thrown off from the tube, it is connected by a thread with one of the rings at the handle. The bladder, being softened and folded around the tube, is introduced towards the pharynx, and filled with air or water by injection, which is retained by turning the cock. Slight traction is then employed to draw the small balloon closely against the posterior aperture of the nares. A piece of linen is placed in the orifice of the nares, on to which the screw is to be advanced, and the instrument fixed by its pressure. The whole apparatus can be withdrawn at will by opening the cock, when the bladder, more or less empty, brings forwards the clots contained in the nose.

We should apprehend that, to be efficient, this instrument would make inconvenient pressure on the anterior aperture of the nares. This perhaps might be obviated by an oval plate applied against the aperture and em. bracing the instrument. But the common means of plugging usually answer very well, and tools ought not to be unnecessarily introduced into the surgical chest.

ERYSIPELAS

Is a subject which will always interest both the surgeon and physician. It is treated by Mr. Donellan. We shall advert to some parts of the article.

Influence of Seasons.-There sometimes exists at certain seasons, and even during a course of years, a peculiar condition of the atmosphere, wholly inappreciable by any physical means of investigation, which dis. poses so completely to erysipelas, that the slightest exciting cause, the smallest abrasion or most superficial excitation of the skin, almost infallibly determines the development of the affection. Sometimes this influence is such that there is no need of even an exicting cause, and the disease assumes a real epidemic character. It is, then, impossible not to admit the existence of an erysipelatous constitution of the atmosphere. Tozzi speaks of an aggravated form of epidemic erysipelas that prevailed at Naples during the Autumn and Winter of the year 1700. A similiar epidemic raged at Toulouse in 1716, which, from the mortality it caused, was compared to the plague. Bromfield mentions an epidemic erysipelas of the head that lasted two years, in which the antiphlogistic treatment was generally attended with fatal results, and bark and cordials were most serviceable. During the epidemic that prevailed in Paris in the year 1828, Dupuytren was reduced to the necessity of postponing all operations that were not urgent to perform, and in the lunatic asylum at Charenton all external revulsions, which constitute the basis of the treatment of mental alienation, were obliged to be suspended.

Contagiousness?-Mr. Donellan would almost seem to think erysipelas contagious in England but not in France. A whimsical notion. We fancy that it is contagious in all parts of the world when the circumstances favouring contagion are present, and not contagious when they are absent. If the person who is exposed is predisposed and there are concentrated effluvia and imperfect ventilation, we apprehend that there would soon be evidence of contagion on either side of the channel.

Superior liability of the Female Sex?-Women are more subject to it than men; but not, however, in the proportion of four to one, as Frank found it in the Institute of Pavia, when out of twenty erysipelatous patients sixteen were women. Out of twenty patients affected with erysipelas received into Professor Chomel's clinical wards at La Charité, thirteen were women. In 630 cases of erysipelas, distributed by the Bureau Central to the various hospitals of Paris during the years 1830 and 1331, there were 326 females. In 43 cases of erysipelas observed by Louis, 25 were

women.

Precursory Affection of the Lymphatic Glands.-Though general premonitory symptoms usually usher in erysipelas, sometimes there are none to arrest attention. At others, a painful tumefaction of the lymphatic ganglia appears. This tumefaction always manifests itself in the ganglia appertaining to the parts upon which the eruption is to take place, in the No. 87.

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