the surgeon is called upon to treat. It may prove fatal at different periods of its progress. In some cases, death ensues during the acute stage, in consequence of suppurative meningitis: the patient dies comatose or hemiplegic. On dissection, the dura mater is found detached from the cranium, and bedewed or bathed with pus. The pus is either collected at one spot, or diffused between the meninges. In such cases, pus in large quantity may also be found under the scalp, or between the pericranium and bone.

At other times, the patient sinks, at a late period, from the absorption of purulent matter into the system. The violence of the early stage having passed over, numerous abscesses form under the pericranium, and the pus diffuses itself extensively under this membrane. The openings, either spontaneous or made with the knife, give vent to the pus, and with it are mixed shreds of dead cellular and aponeurotic tissue; and the cranium is found bare at several points. Acute symptoms again make their appearance; the fever of purulent absorption is lighted up; the pus from the wounds becomes vitiated; and the patient dies, with all the symptoms that indicate visceral abscesses.

In a third set of cases, the patient perishes from external hæmorrhage. Some of the considerable branches of the temporal or occipital arteries become ulcerated, and the loss of blood may prove suddenly fatal.

A case of this sort occurred in the ward of Hôtel Dieu, in 1830.

Lastly, the case is sometimes very tedious, and does not prove fatal for a long period after the subsidence of the acute symptoms.

The outer table of the skull, having been deprived of its nutritious envelope, dies, and Nature attempts to throw off the dead bone; but the strength of the patient generally sinks before this slow process can be effected. Sometimes, indeed, we meet with a fortunate exception to this remark. The following is a rare example of this nature.

A young man was admitted into the Hôtel Dieu, with a small wound on the head. He was seized with diffuse inflammation of the scalp. The acute symptoms having subsided under a most active antiphlogistic treatment (venesection and the use of large doses of tartar-emetic,) suppuration set in: incisions were made at different points to discharge the matter and the sloughing shreds of cellular membrane. The whole of the external table (toute le table externe) of the cranium became necrosed (!) It was necessary from time to time to make numerous incisions to extract the different portions of detached bone. After six months of this travail eliminatoire,' the patient was discharged cured.

Dupuytren found that the different sequelæ, when put together, equalled in extent the whole convex surface of the cranium. (!)

The treatment of this formidable affection-diffuse inflammation of the scalpis well understood in the present day, although the surgeon is often disappointed of success. In general it is necessary to adopt vigorous antiphlogistic measures at first. The use of the tartar-emetic, as recommended by Dessault, ought never to be neglected. But constitutional remedies alone will not do. One or more free incisions through the entire thickness of the scalp, and fairly down to the bone, must be practised.

When suppuration is established, Larrey advises that the wounds be dressed with compresses wetted with camphorated vinegar.-Bulletin de Therapeutique.

ENCYSTED TUMORS-SEROUS, ATHEROMATOUS AND MELICERIC-TREATED BY INCISION AND INJECTIONS.

Case 1. A young child, who had long been troubled with an impetiginous eruption on the scalp, had a soft movable tumor, as big as a walnut, situated in front of the larynx. It had been as large as a hen's egg, before it was lanced. The

contents were a limpid serosity mixed with a little blood. Eight days after the incision, the cyst had refilled, and it was again punctured.

An attack of erysipelas then came on, and, for a fortnight, an oozing of pus took place from the wound. When the erysipelas subsided, all the loose cellular tissue in front of the neck became infiltrated, so as to form un poche volumineuse.' Several acupunctures were made; but the sac, in two days after it was emptied, was found to be more filled than ever.

When M. Magistel saw the patient first, the swelling was as large as an ostrich's egg, and extended over all the fore part of the neck, He made an incision of about an inch in length, and discharged two glassfuls of a serous fluid, mixed with flakes of albumen and striæ of blood. For the following two days, an oozing of a similar fluid continued: the lips of the wound were kept apart by pieces of lint. On the third day, M. M. injected some warm 'vin aromatique miellé' into the sac, and kept compresses, wet with the same, on the swelling, by means of a bandage passed round the neck. The sac became somewhat painful and inflamed, and the patient was feverish for the next twenty-four hours. When these symptoms subsided, the injection was repeated daily for about a week. The lips of the wound were touched occasionally with the nitrate of silver. The cure was complete in about a month from the date of M. M.'s first visit.

Case 2. A gentleman, advanced in life, had been annoyed for twenty years with a tumor, seemingly a fatty one, situated in front of the neck. It was of the size of a small egg.

In a

During the last six months, it had become much softer, and the skin over it was thin and purplish. M. M. opened it freely by a vertical incision. A grumous cheesy-looking pus was discharged. The parietes of the cyst were of a reddish colour, and exhibited numerous minute projections, like mucous follicles. From these there oozed out a liquid, similar to the contents of the sac. day or two, M. M. had recourse to an injection, consisting of decoction of cinchona; and compresses, wet with the same, were applied over the surface of the swelling, the lips of the wound being prevented from closing. This mode of treatment was continued for a fortnight. The wound then healed, and the cure was completed in about a month.

Case 3. An eminent physician had, for a number of years, a small wen on the left temple. It began to increase in size and to become soft; and when M. M. saw it, it was as large as a hen's egg. Most of his surgical friends advised him to have it excised; but, professional-like, he did not approve of this summary mode of treatment. He consented, however, that M. M. should lay it freely open. The contents were un pus melicerique." The injections, which were first used, consisted of eau miellée," and afterwards of decoction of cinchona. On the fourth day, M. M. extracted with the forceps a tough, whitish, fibrinous membrane, which was no doubt a portion of the cyst. The wound required to be occasionally touched with the nitrate of silver. In three weeks from the time of the operation, the cure was complete.-Gazette Medicale.

In reference to these cases, we have only to remark that, when the sac of an encysted tumor can easily be removed, the surgeon should always do so. It is useful, however, to know that the cure may frequently be effected by the free incision of the swelling, and the evacuation of its contents; for, in some instances, the sac adheres with great firmness to the surrounding integuments, and is not readily dissected from them.-(Rev.)

CASE OF ILEUS, IN WHICH GASTROTOMY WAS PERFORMED.-DEATH.

Annette Rondot-25 years of age, stout and healthy, with the exception of occasional bilious attacks, which were always accompanied with most severe colic in the epigastrium-was in the month of March last seized, after one of her usual ailments, with acute pain in the right iliac region. This was attended with diarrhoea. Three days subsequently, a large hard swelling made its appearance in the suffering part. For two months the diarrhoea continued, with only occasional remissions, and alternating every now and then with fits of vomiting. The symptoms seemed to be always aggravated soon after eating, and also whenever the bowels were constipated. In the second week of May, she was admitted into the Hospital Cochin at Paris. The swelling, occupying the ileo-cæcal region, was firm and hard, but not very sensitive on pressure. Leeches were applied freely both to the swelling itself and also to the anus, but without any decided benefit. An obstinate constipation now came on; and this was accompanied with vomiting at first of bilious, and subsequently of distinctly fæcal, matters. Fortunately, after all other means had failed, a pill of croton oil succeeded in acting upon the bowels: the symptoms, which had been very alarming, were quickly mitigated, and the swelling considerably subsided.

But the relief was only temporary; for, on the following week, the constipation, fæcal vomiting, hiccup, &c. returned; and these symptoms now resisted the use of croton oil, as well as of every other remedy that could be devised.

The state of the patient became so alarming, that M. Monod, one of the surgeons of the hospital, recommended that the operation of gastrotomy should be immediately performed.

An incision through the integuments and the layers of the abdominal muscles having been made over the tumor, and the peritoneum cautiously divided, a portion of intestine, which proved to be colon, protruded: this was immediately replaced by the operator, and, inserting his finger into the wound, he drew down gently a loop of the small intestine, which was red and tumefied, and made an opening into it with scissors to the extent of an inch and a half, or so. A quantity of fæcal matter flowed out, and the patient confessed that she found great relief. A ligature was passed through the mesentery of the divided intestine, and retained at the edge of the wound by means of strips of adhesive plaster light dressings were applied, and the patient put to bed.

On the following day, the loop of intestine was found to have retracted inwards; but it was easily found, and was then fixed more securely than before, by means of two sutures. The condition of the patient became rapidly worse, and she died on the evening of this day.

Dissection. On opening the abdominal cavity, some sero-purulent fluid flowed out; the convolutions of the intestines in the pelvis were coated with semiconcrete pus, and were redder than the other portions of the canal. The intestine, which had been opened in the operation, proved to be the ileum, eight or nine inches above the caput coli; a very trifling adhesion had taken place at the seat of the artificial anus. On examining the intestinal canal for the purpose of discovering where the obstruction had been seated, it was found to be at the point of junction of the cæcum with the ascending colon: the contraction of the tube was so considerable, that the point of the little finger could scarcely be passed through it. The cæcum rested posteriorly on an indurated mass of scirrhous-like formation; but the mucous coat of the gut was not injured. The other portions of the intestinal canal exhibited no marks of disease, with the exception of patches, here and there, of redness.—Archives Générales.

Remark. The propriety of resorting to gastrotomy in such cases as the preceding, appears to us to be more than doubtful: "il vaut mieux abandonner à la Providence des malades aussi desesperés.”—Rev.

CASE OF CHRONIC ABSCESS IN THE LEFT ILIAC FOSSA BURSTING INTO THE INTESTINE-CURE. REMARKS ON PELVIC ABSCESSES.

M. Bricheteau, one of the most enlightened physicians of the French metropolis, has reported an example of pelvic abscess, which recently occurred in his practice at the Hospital Necker.

A young woman, of a scrofulous habit of body, had for a length of time been subject to frequent attacks of excruciating pain in the left lower extremity, from the hip downwards; these were believed to be of a neuralgic character. No means, that had been used, had succeeded in procuring for her more than only temporary and occasional relief. When the case appeared almost hopeless, an unexpected cessation of the sufferings took place, immediately after a diarrhoea, which came on spontaneously. It was now found that a considerable quantity of pus, mixed with blood, was discharged with the alvine evacuations. M. Bricheteau, in consequence of this, began to suspect that an abscess might probably have been formed in the left iliac fossa, where a sense of pain and uneasiness had been felt, and had suddenly burst into the colon or rectum; and thus that the pressure upon the crural nerves, to which the neuralgic pain may have been owing, was removed.

The relief to all the symptoms, which had so long distressed the poor patient, was most gratifying: her sleep and appetite returned, the purulent discharge by the anus gradually ceased, and in the course of a few weeks the patient appeared to have quite recovered.

Remarks.-M. Bricheteau is of opinion that there can be little doubt that, the present case was an example of those slow-forming abscesses in the iliac fossamost frequently however the right one-which are almost always accompanied with very obscure and perplexing symptoms at first, and the nature of which is often not discovered until they burst into some portion of the lower gut, and their contents are thus discharged per anum.

The history of such abscesses was first clearly examined by M. Dupuytren, and an excellent account of his researches was published by the late M. Dance in the Repertoire Anatomique of M. Breschet for 1827. The sixth, seventh, and eighth cases, reported in this memoir, are examples of abscesses in the right iliac fossa, which terminated fortunately after the evacuation of their contents by the bowels. In the fourteenth case, the abscess-apparently the result of difficult parturition-was seated in the left iliac fossa: the purulent matter made a way for itself outwardly through the neck of the uterus. In the fifteenth case also, the abscess was on the left side, and the matter had escaped into the bladder and was discharged with the urine. All these five cases did well.

We have already stated that these pelvic abscesses are formed more frequently in the right than in the left iliac fossa. Dupuytren accounted for this by the circumstance of the situation of the cæcum on the former side, and the local irritation which may be supposed to be frequently occasioned by the lodgment of hardened fæces in this portion of the intestines. It is also to be noticed that the cæcum is not covered by the peritoneum on its posterior surface, but is attached to the pelvis by loose cellular substance. It is in this loose tissue that suppuration always takes place most readily. On the other hand, the sigmoid flexure of the colon is invested with a peritoneal covering all round: hence, when an abscess is formed on the left side of the pelvis, the matter-not making its escape into the bowel so readily-often works its way downwards, and is discharged either under the crural arch, or perhaps at the inguinal aperture.

Before closing these remarks, we may mention that a case, in almost all respects similar to the one reported by M. Bricheteau, occurred lately to M. Berard : It had been long mistaken for an example of idiopathic coxalgia, and its true

nature was not discovered, until the discharge of purulent matter took place from the rectum.

In addition to the memoir of M. Dance, already referred to, the Leçons Orales of Dupuytren may be consulted with advantage.—Archives Générales.

ON THE MOST FREQUENT CAUSES OF SUDDEN DEATH. By M. Devergie.

It has long been, and still is, a prevalent idea, that by far the most frequent cause of sudden death is apoplexy—that form of it to which the French writers apply the term foudroyante.

The Statistical Report, made each year to the Prefecture of the Police in Paris, usually attributes four-fifths of the sudden deaths in that city to this disease.

M. Devergie having, for several years, had the medical direction of the Morgue, (an establishment to which the bodies of those who have died suddenly are carried,) has had his attention directed in an especial manner to this important point of pathology; and the following abstract of his researches will, therefore, be read with no inconsiderable interest.

He premises, by remarking that it is only in a few cases that the real or material cause of a sudden death can be predicted from the symptoms, which may have preceded and accompanied the fatal event: and, therefore, that unless a dissection of the body is performed, there must always be a greater or less degree of ambiguity.

The immediate cause of sudden death may be situated—as was first well explained by Bichat-either in the brain, or in the heart, or in the lungs. Perhaps, however, in most cases, two of these vital organs are usually affected at the same time. Thus sudden death, from an affection of the brain alone, is of rare occurrence the lungs are, in most cases, simultaneously implicated.

Out of forty instances of sudden death, examined by M. Devergie, in four only was the immediate cause, it would seem, of the catastrophe seated in the brain alone; in three, the brain and spinal-marrow were congested; and in twelve, the lungs and brain had been affected simultaneously.

Sudden deaths, from disease of the lungs alone, are of more frequent occurrence. Out of the forty cases, there were twelve belonging to this category; and if to these we add the other twelve, in which the brain was affected at the same time with the lungs, we see that in twenty-four out of forty cases of sudden death, the lungs were more or less immediately the seat of the fatal mischief. Sudden death from cessation of the heart's action, or syncope, is the most rare form of all: M. Devergie met with three cases only out of forty.

The remaining cases-to complete the number of forty-were examples of hæmorrhage, either from the heart, or large blood-vessels, or from the stomach. From these statements, we may infer that the relative frequency, in respect to the vital organ primarily affected, of sudden death is attributable

1. To the lungs ;

2. To the lungs and brain conjointly;

3. To the brain and spinal marrow conjointly;

4. To the brain alone;

5. To hæmorrhage, whether the blood be discharged outwardly, or be effused into an inward cavity;

6. To the heart.

M. Devergie proceeds to observe that sudden death is very rarely occasioned by local lesion of any of the vital viscera, when this lesion is of very limited extent. Almost always, one of these organs is affected dans tout son ensemble; or two, or all, of them are simultaneously implicated.

He regards the current opinion that apoplexy-that is, a circumscribed cere