sufficiently strong to maintain it in the erect position. The eyes were prominent, directed downwards, and constantly rolling from side to side; and, to add to the disfigurement, there was divergent strabismus. The pupils were rather dilated. Such had been the state of the child for the last few weeks; but of late the head had enlarged so rapidly, and the little sense or power of perception which the child possessed had become more dim, while at the same time the nutrition of the other parts seemed almost at a stand-still. Under these circumstances, so hazardous to the existence of the child, no other course was open than a resort to the trocar. After some difficulty the scruples of the mother were overcome, and her consent obtained. A very fine trocar and canula were introduced into the coronal suture, about an inch or so from the middle line, in order to avoid the longitudinal sinus, and eight ounces of clear, pale fluid drawn off.

It escaped with a slight saltatory motion, being influenced, I presume, by the movements of the brain, or by the cries that the puncture evoked. The effects of the removal of the pressure were immediate and decided. While the fluid was flowing the child gave a louder cry than it had ever before uttered, and showed other signs of being more lively. The eyes receded somewhat from their former prominent position, and assumed a more natural direction; the rolling ceased; the strabismus became less marked. The bones of the cranium collapsed, their serrated margins being distinctly visible. More might have been drawn off, but it was not thought advisable to do so. The child bore the operation remarkably well, no convulsions ensuing. Strips of plaster were then applied in a circular manner round the head, to compensate for the pressure of the withdrawn fluid.

The child was brought to the hospital four days afterwards. The mother stated that the child had appeared much relieved, and had been more cheerful and lively for the first two days, but on the third it had been very restless and feverish, and from that time it had relapsed into the same drowsy condition. The head, on the removal of the strapping, appeared very tense, and to have acquired almost the same dimensions. The surface of the head was hot. Mr. Lawrence repeated the puncture, but in a different situation, selecting the posterior part, as the fluid gravitated in that direction. Ten ounces were let out. A little hemorrhage followed the perforation, and the child became rather blanched. I thought I observed a few slight, transient, convulsive movements of the face, and a clenching of the hands. No compression was employed this time, merely cold applied, and hyd. c. cretâ, gr. iij, ordered to be taken every night. The child was again brought on Tuesday last, four days after the second puncture. The head had not enlarged to the same extent as before. The child had not been so drowsy, but, on the contrary, more restless. Its appearance was much more animated. Dose of hyd. c. cretâ increased.

Another ten days elapsed before the child was again brought to the hospital. The mother stated that during that time the child had continued to improve in health, and had shown more animation. The head continued about the same size as before. Not having seen or heard of the child for more than three weeks, I proceeded to inquire at the mother's residence, but unfortunately the family had left a few days before, and the landlord was unable to inform me where they had moved to. I learned, however, from him that the baby had died about ten days back, apparently from innutrition; that the head had not, in his opinion, increased in size, and that it had no convulsions.

ART. 28.—New Researches on the General Paralysis of the Insane. By M. LINAS. (New York Journal of Medicine, March, 1858.)

The following quotation is taken from an excellent report by Dr. BrownSéquard on the recent advances of the medical sciences in France:

"This affection, which has been, for the first time, well described by some French physicians, among whom particularly Bayle and Calmeil, has lately been the object of a very remarkable inaugural dissertation by M. Linas. One of the principal questions examined by this young physician concerns the nature of this disease. Is it the effect of an inflammation of the encephalon or

of its membranes, as Bayle, Delaye, Calmeil, Parchappe, and others admitted, or is it a purely nervous affection of the brain, as Lélut and others have maintained?

"Already Bayle had opened one hundred corpses of paralytic insane, and Calmeil forty-seven. They had found the meninges of the convexity of the cerebral lobes opaque, injected, hardened, infiltrated with serosity, and offering frequently granulations or false membranes. M. Linas has opened one hundred and fourteen bodies of paralytic insane. In twelve cases he has found the pia mater excessively injected. The cerebral substance was quite full of blood, the gray matter being from an intense red to a dark violet. In twenty-eight cases, besides the preceding alterations, there were adhesions between the convolutions and the meninges. In seventy-four cases, the meninges were infiltrated, opaque, and as tough as a fibrous membrane; the cortical substance of the brain, sometimes violet, sometimes yellowish, according to the degree of the paralysis, always softened, less thick than in normal brains; the white substance injected, and sometimes infiltrated; the convolutions meagre, and the whole mass of the brain more or less atrophied.

"In thirteen cases, besides the preceding alterations, there was one or many small circumscribed places where the encephalitis had been more violent than elsewhere. In eight cases there were also effusions of blood.

"From these facts it results positively that the paralysis of the insane depends upon a chronic inflammation of the brain and its meninges. Whether the disease begins in the membranes, as Bayle had said, or in the brain itself, as M. Calmeil maintains, is a question of comparatively little importance. The great point is, that the brain is always inflamed. M. Calmeil has ascertained with the microscope that in doubtful cases, when the brain did not seem to be much altered with the naked eye, there were, nevertheless, all the microscopical appearances of inflammation.

66

M. Linas relates cases to prove that an acute encephalitis may cause the paralysis of the insane.

"As regards the first symptoms of this affection, M. Linas declares that sometimes intellectual disorders first appear, and in other cases muscular paralysis and insanity appear at the same time. It has been said that there was always what is called by the French ambitious delirium. But Parchappe, Trélat, Lasègue, have shown that there are exceptions to this rule, and that, therefore, there is nothing specific or essential in this symptom. M. Linas goes farther, and he calls this opinion a paradox. According to him, the delirium of paralytic insane has sometimes the monomaniac form, sometimes the hypomaniac, and in other cases the maniac; but he acknowledges that ambitious ideas are extremely common."

ART. 29.-On Facial Paralysis as a Sign of Cerebral Hemorrhage. By M.

TROUSSEAU.

(Gaz. des Hopitaux, No. 84, 1857.)

M. Trousseau observes that in facial paralysis properly so called, that in which the seventh pair is alone concerned, the loss of motor power is ordinarily complete and absolute, while when it depends upon cerebral hemorrhage it is never complete. There may be some difficulty in the movements of the mouth, but nothing comparable to that seen in paralysis of the seventh pair; and we never find the paralysis of the orbicularis palpebrarum carried to the same extent. The patient is always enabled to cover a portion of the eyeball, which is not the case in facial paralysis. M. Trousseau, in fact, has never once witnessed paralysis of the seventh pair which was not complete at least at its commencement, nor, on the other hand has he seen a single case of facial paralysis, dependent upon cerebral lesion, and accompanied by general hemiplegia, in which the paralysis of the orbicularis was carried thus far. It is, therefore, a diagnostic sign of importance.

ART. 30.-On the Effect of Galvanism upon the Augmentation of Hearing which may exist in Facial Paralysis. By M. LANDOUZY.

(Gaz. Méd. de Paris, March 13, 1858.)

M. Landouzy was the first to pay particular attention to the condition of the hearing in cases of facial paralysis, and his investigations may help us to decide the important question, whether the brain is or is not affected in these cases. If the hearing is diminished, it may be supposed that there is some actual lesion in the brain or in the auditory nerve; if the hearing is more acute, there is reason to believe that the facial paralysis is dependent on simple paralysis of the facial nerve or of its tympanic branch; if the hearing is unaffected, it is said that the paralysis of the facial nerve does not implicate the tympanic branch.

M. Landouzy considers that the exaltation of hearing in facial paralysis, depending upon simple paralysis of the facial nerve, depends upon paralysis of the m. internus mallei, and he relates a case in which the exalted hearing became natural during the passage of the galvanic current through the ear, and exalted again when the circuit was broken. In this case it is supposed, first of all, that the membrana tympani is relaxed by the paralysis of the m. mallei internus, that the sonorous vibrations are more marked in consequence, and that this is the reason why the hearing is rendered more acute; and in the next place, it is concluded that the effect of this current is to throw the paralyzed muscle into a state of contraction, to stretch the membrana tympani, and in that way to render the hearing less acute by diminishing the sonorous vibration transmitted to the brain.

It is, however, somewhat questionable whether this explanation is altogether satisfactory.

ART. 31.-The Esthesiometer. By Dr. SIEVEKING, Physician to St. Mary's

Hospital.

(Medico-Chir. Review, Jan., 1858.)

This little instrument has been contrived and employed by Dr. Sieveking for the purpose of aiding in the diagnosis of certain forms of nervous diseases. Its employment is based upon the principle that the capability of distinguishing the distance between two points at different parts of the body varies with the tactile sensibility of the respective regions. This power, in health, follows the general law of symmetry governing the body; hence, where in morbid conditions the tactile insensibility of one side is impaired, we have a means of determining the relative extent of the impairment by ascertaining at what distance the individual can feel two distinct impressions from two sharp points, slightly pressed upon the skin. The absolute impairment of tactile sensibility may be ascertained by comparing a given result with the tables of Professor Weber, which are contained in most handbooks of physiology.* Thus, if a person in health is able to recognize as two distinct impressions at the tips of his fingers, points one-tenth of an inch apart, it follows that if we find him unable on one or both hands to distinguish more than four-tenths, there must be a serious impediment to the reception or conduction of tactile impressions. The nature of the impediment must of course be determined by other evidence. It is manifest that by applying an instrument to measure the tactile sensibility of different parts involved in a paralytic affection, we secure a more trustworthy standard to judge of its extent and character than if we trust to the patient's description of his sensations, or the ruder modes of pinching and pricking ordinarily employed.

There are three main classes of circumstances in which the Esthesiometer, of which the annexed wood-cut gives a reduced illustration, has been found useful. 1. In actual paralysis, to determine the amount and extent of sensational impairment.

* Müller's Elements of Physiology, translated by Dr. Baly, vol. i. p. 701.

2. As a means of diagnosis between actual paralysis of sensation and mere subjective anesthesia, in which the tactile powers are unaltered.

3. As a means of determining the progress of a given case of paralysis for better or for worse.

It would be superfluous to give illustrations of each of the three classes of cases in which the æsthesiometer may afford us assistance. The first and third speak for themselves; to obviate the possibility of a misunderstanding of the second, an instance is subjoined which will serve as an illustration :

E. M'M., æt. 52, suffered for six months before the first consultation from numbness and formication of the left hand, with severe nocturnal pains along the tips of the fingers and at their metacarpal ends; the patient rarely had pain in the thumb, and none in the palm of the hand. There was frequent vertigo. To determine the character of the numbness, the aesthesiometer was applied, and the patient was found to distinguish one-tenth of an inch equally well at the tips of the middle and third fingers of both hands; the instrument aided in the determination of the diagnosis by showing that the numbness was purely subjective, and not the result of a true paralytic affection.

The instrument is one of very simple construction, being essentially what is known to mechanics as a beam compass. It consists of a rod of bell-metal, four inches in height, graduated into inches and tenths of an inch. At one end is a fixed steel point; another steel point is made to slide upon the beam, and can be fixed at any distance from the first, by a screw which works at the top of the slide. The experimenter notes down the smallest interval at which the person experimented upon is able to recognize two impressions when the points are gently and simultaneously pressed upon any given part. Certain precautions are necessary here, as in all other experiments, in order to insure trustworthy pursuits.

It is important that the patient should not know what is expected of him; therefore it is well not to inform him of the object with which the instrument is applied. At whatever part it is used, it is easy to prevent the points from being seen, so that the eye may not aid in the determination of the tactile impression. It is equally necessary to make the two points impinge upon the surface at the same time, in order to prevent the production of two successive impressions, which would necessarily alter the value of the result.*

ART. 32.-The Pathology of Convulsions, with especial reference to those of Children. By Dr. REYNOLDS, Assistant Physician to the Westminster Hospital.

(Liverpool Med.-Chir. Review, Jan., 1858.)

The following is an abstract of the contents of this paper:

I. All vital actions are accompanied by, and depend on, physical changes in the living organism.

II. Modifications of vital action depend on modified physical conditions. Some symptoms of disease are modifications of vital actions, and there are two general modes in which they are, or may be, related to the nutrition change:

The instrument may be obtained from Mr. Becker, mathematical instrument maker, 39 Newman Street, Oxford Street.

1. Negative symptoms-i. e., those which consist in the negation of vital properties, such as paralysis, anesthesia, &c.-may depend directly on a "solution of continuity," or some other distinct organic disease; but

2. Positive symptoms-i. e., those which consist in the alteration or excess of vital action-cannot depend directly on such textural condition, but must have for their immediate cause some modification of the minute interstitial processes.

III. Convulsions, being essentially modifications of vital actions, must depend on modifications of physical conditions. Though no "lesion" is discoverable, we are warranted in the conclusion that nutrition is affected.

IV. Convulsions depend on modified nutrition changes in the nervous centres. V. The proximate cause of convulsions is the same in all cases when the convulsions are the same; and the lesions discovered in the nervous centres or elsewhere are not the proximate causes of convulsions, for they differ in locality and kind, and have no constant proportion to the symptom in question.

VI. The proximate cause of convulsions is an abnormal increase in the nutrition changes of the nervous centres-an increase in relation to time or to mobility.

VII. The remote causes are such as induce the abnormal increase. are three general modes in which these causes operate:

There

1. The nervous centres may be involved in a general nutrition change-e. g., as during dentition, at puberty, in Bright's disease, scrofulosis, rickets, &c. 2. The nervous centres may be the seat of special disturbance owing to organic lesion, as tumor, spiculæ of bone, &c.

3. Eccentric irritations may affect their nutrition through afferent nerves. VIII. The diagnosis in convulsions is that of the remote cause, and the first step is to ascertain to which of the above three categories the case belongs. In children, the diagnosis will turn on :

1. The duration of the paroxysm;

2. The frequency of its repetition;
3. Its local or general distribution; and

4. Interparoxysmal symptoms.

The last are of the most value; and the positive or negative character of the symptoms, together with local distribution, afford material assistance in this process.

IX. The treatment of convulsions is guided by the diagnosis, and will consist in the removal or palliation of eccentric irritations, the improvement of general nutrition, and the treatment of local disease.

ART. 33.-Case of Hysteria simulating Hydrophobia. By Dr. M'GUGIN. (lowa Medical Journal, July and Aug., 1857; and North American Med.-Chir. Review,

March, 1858.)

CASE. The patient was a young married female, of extraordinary mental acquirements, and highly impressible. The attack occurred shortly after the death of an infant, her only child. It commenced with pain in the head, without febrile movement. The bowels were constipated, the urine pale, and an attempt at swallowing was undertaken with reluctance and performed with difficulty. Shortly after, she became subject to paroxysms, during which she complained of thirst and demanded water; but on bringing it to her lips violent spasm of the larynx was excited. "When first attempting to drink, the appearance of the water seemed to produce a light shivering, as if of dread, and after some hesitation she would hurriedly, apparently with a feeling of desperation, seize the cup, and with a sudden effort attempt to gulp it down, during which respiration was suspended; and after the effort of swallowing, her conduct resembled that of an individual who had been for a time immersed in water of a low temperature. Then followed a wild expiratory screech. During these fits her countenance manifested the wildest frenzy, and all the muscles of the body seemed tensely contracted." These paroxysms were excited by the unexpected entrance of strangers, a sudden noise, or a current of cold air.