On The Pathology and Treatment Of Cerebral Disease
98 Art. Y.?. No. V. :Author: Robert Hunter Semple, M.D., Fellow of the Royal College of Physicians of Loudon.
In treating in a previous paper on the Inflammatory Diseases of the Brain I adverted to the difficulty which exists in the present day of defining the exact meaning of the term “inflammatory,” the earlier definitions of the word being now inadequate to express the idea intended to be conveyed. In former days, inflammation was a word easily and generally understood, and the symptoms of inflammation were pretty well recognised ; but at the present time many maladies, or assemblages of symptoms, although apparently inflammatory, are no longer regarded in that light, and, on the other hand, many structural changes of organs and tissues are now by some authorities regarded as inflammatory in their origin, although the well-known and hitherto recognised features of inflammation are absent, My meaning will be readily understood by con- trasting a typical inflammation, as it was formerly regarded, with certain other morbid conditions which are now admitted by some recent writers into the same category. In the con- junctiva, for instance, the capillary vessels are often seen to be enlarged and distended with blood, and at the same time the eye is exceedingly hot and painful; after a time, according to circumstances, either the swollen vessels are disgorged of their blood and the membrane resumes its usual transparency, or the disease advances in intensity, and pus is thrown out over the con- junctival surface, or, when the iris is attacked, lymph is seen to be effused, the colour of the organ is changed, and the pupillary aperture is altered and obstructed. In such a case as this, there are all the features of the old-fashioned typical inflammation, namely, the congestion of the capillaries, and the subjective and objective phenomena of heat, swelling, redness, and pain ; and, moreover, there are all the typical terminations of inflammation ?namely, resolution, or the return of the parts to their normal condition ; suppuration, or the effusion of pus upon the mucous surfaces; and effusion of lymph, which occurs in certain membranous structures.
Oil the other hand, such diseases as cirrhosis of the liver and tubercular consumption are now regarded by some writers as forms of inflammation, and many specious arguments are adduced in favour of this view. In the first-named disease, it is assumed that the hypertrophy of the fibrous structure of the liver is due to an inflammatory process; and in the second, it is now supposed that the tubercular deposition in the lungs is the result of a pre-existing inflammation of the pulmonary substance or the air-tubes, or, in other words, that pulmonary phthisis is only a sequel or accompaniment of bronchitis, pneu- monia, or pleurisy. Again, there are many diseases which, at former times and in other countries, were considered as varieties of inflammation,’but which are now, in this country at least, no longer regarded in that light; as, for instance, typhoid or enteric fever, which, from its presenting ulcerations on the mucous membrane of the lower parts of the small intestine, was once classed as a special inflammation, and was called gastro-enterite by Broussais.
Even the same medical author has at one time regarded a malady as inflammatory which at a subsequent period he has excluded from that category, as Bretonneau, for instance, who applied the word Diphtherite or Diphtheritis to the malady which he himself subsequently called Diphtheria, the change being due to the fact that liis opinions as to the inflammatory nature of the affection had undergone a change in the interval. For such reasons, and many others, it is obviously a matter of great difficulty to fix the limits which separate ” inflammation ” from any other morbid process; and the difficulty is the greater in the present day when, by the labours of modern pathologists, a multitude of morbid actions and processes have been detected which tend to alter the structure of organs and tissues, but which it is impossible to range under any one comprehensive title.
Such being the general difficulty hanging over the definition ?f inflammation, the inquiry into the distinction between the inflammatory and non-inflammatory affections of the brain is further beset with special difficulties arising from the nature ?f the organ Concerned, and from the mystery which has ever shrouded and still shrouds the connexion between the material conformation of the intra-cranial mass and the manifestations to which its operations give rise. In its healthy state, this con- geries of blood-vessels, membranes, and nervous ganglia and fibres?this chemical compound of water, albumen, and phos- Phuretted fats and earthy salts,?presides over and directs an infinitude of subordinate agents in the bodily economy, and is moreover the medium of expressing the faculties, the emotions, the passions, the sympathies, the joys and the sorrows, the sum of all of which constitutes the mind of man. In its morbid conditions how varied are the phenomena this organ presents, how contradictory are the results observed ! Sometimes the most serious and extensive lesions of its substance are unat- tended with proportionate disturbance of the bodily or the mental manifestations; at other times, lesions apparently slight induce the most formidable and even fatal consequences; and very often the organ suffers as a whole, in its functional rela- tions, from irritation of remote regions or parts, although under- going itself no structural change whatever.
Amidst a host of difficulties by which the pathology of the brain is surrounded, there are perhaps a few truths which may be regarded as established data for the guidance of the prac- titioner of medicine. In the first place, there can be very little doubt that the central parts of the brain, or those which underlie the convolutions, have very little share in producing the morbid manifestations which usually indicate cerebral disease. This statement is abundantly borne out by the records of military surgery, which show that large portions of the cerebral matter have been removed without danger to life, and without precluding the chance of the brain being eventually restored to health. The clinical history of brain-diseases and the records of post-mortem examinations are no less conclusive on this point, for, as many besides myself have shown, the most extensive disease of the medullary structure, or the presence of abscesses or tumours in the central mass, has been found quite compatible with the maintenance of life and even the enjoy- ment of health.
In the next place, it is proved that when the seat of disease lies in the track of some of the nervous threads passing to the various organs and limbs, sometimes the functions of special sense will be impaired, sometimes the limbs will be paralysed or thrown into convulsions, sometimes pain will be expe- rienced in remote parts, or sensation will be impaired or abolished altogether.
A third fact, pretty well established, is that the peri- phery or circumference of the brain is exquisitely sensitive, and that injuries or diseases of this portion are attended with the most serious consequences. Hence, the inflammation of the membranes of the brain, especially of the arachnoid membrane and the pia mater, is one of the most fatal maladies known in the practice of medicine, and will be discussed in some of its bearings in the ensuing pages of this paper.
The question of local lesions of the brain, and of the con- nexion of these with special manifestations of morbid action, mental or bodily, is now occupying some of the most acute intellects among physiologists and pathologists, but is too exten- sive for detailed consideration in the present paper. It may be mentioned, however, en passant, that the points at issue on this subject at present are whether the brain always acts as a whole, being sensitive to any injury of any part of its substance, or whether certain definite manifestations in some of the limbs or in certain groups of muscles distinctly correspond to the injury or disease of circumscribed portions of the cerebral structure. The direct experiments of Hitzig and Fritsch in Germany, of Ferrier in our own country, and of Albertoni in Italy, tend to prove the connexion between local irritation and definite morbid manifestations ; and the clinical observa- tions of Hughlings Jackson point in the same direction. On the other hand, it is well known that the great majority of facts at present known merely show that injuries of the brain are usually attended or followed by general morbid manifes- tations, and Dr Brown-Sequard, whose authority on such questions is very great, now maintains that the brain, whatever may be the injury or in whatever part of the organ it may be situated, acts as a whole, and not by the separate agency of its individual parts. It is not a little puzzling to the inquirer after truth to follow the lucubrations of this distinguished physiologist, and it is disappointing to find him thus expressing himself in a recent lecture at the College of France : ” I have taken upon me the difficult work to show you that almost everything you have learned, either in the course of your lectures or in books which treat of the actual state of science regarding the doctrines of the physiological and patho- logical actions of the nervous centres, must be thrown overboard as entirely false.”* It is right to add that Dr Brown-Sequard includes his own published doctrines in this sweeping condem- nation.
Recurring to the immediate subject of the present paper? namely, the Inflammatory Diseases of the Brain?I observe in the first place that the word ” inflammation ” is here used by me in its ordinary sense, as characterised by its generally recog- nised symptoms, and as followed by its usual results?namely, the formation of pus, or the effusion of serum or of lymph. It is reasonable to believe, however, although it is very difficult to prove, that inflammation of internal organs may stop short of these last-named results, just as we observe that a visible inflammation of the conjunctiva may terminate in resolution, and without suppuration ; and undoubtedly this is the termi- nation which medical treatment is directed and intended to promote.
However desirable it may be to divide the inflammations of the brain according to the structures which are involved, the distinction in practice is exceedingly difficult, and even the primary division between the inflammation of the substance of the organ (or cerebritis) and that of the membranes (or meningitis) can rarely be clearly established, and during life the diagnosis is always very doubtful. But as a matter of fact, I question very much whether in the present day we can assert that there is such a disease as idiopathic cerebritis. As I mentioned in a previous paper, it is quite evident that the cases formerly described as ” inflammation of the brain were really, in the great majority of instances, nothing more nor less than certain forms or conditions of typhoid or enteric fever, which often begins with symptoms of violent delirium and other indi- cations formerly supposed to denote inflammation of the cerebral mass. It is now known that although this fever is often fatal at a very early period, owing to the virulence of the poison circulating in the system, yet there is no specific inflammation, properly so-called, and the delirium and other symptoms pass away Avhen the fever has run its destined course. The large bleedings and other so-called antiphlogistic measures so freely adopted in former days in such cases must have been useless, if not injurious, and yet a great number of patients recovered, or at any rate escaped, under the treatment. Still there are a few cases, sucli as I have related in the former paper, which, though not strictly idiopathic in their nature, may be regarded as instances of inflammation of the substance of the brain. Such are the cases (though these are far more uncommon than is generally supposed) caused by exposure to a burning sun, especially in tropical climates; the cases where cerebritis arises from severe injuries, as in concussion of the brain, or from disease of the cranial bones ; and those which re- sult from the excessive immediate effects of alcohol. In some of these cases depletory measures, judiciously employed, and at an early stage, appear to be of great service, and many complete recoveries take place. But in the cases now to be mentioned? namely, where the membranes are affected?the danger is much greater and the chances of recovery far less.
In inflammation of the membranes, besides the fact that the disease almost always extends to the cerebral mass itself, there is effusion of pus, or serum, or lymph, from the inflamed sur- faces ; and these effusions, pressing upon the substance of the brain, give rise to the most serious symptoms, and unless they aie lemoved by medical or surgical means they are almost necessarily fatal.
Inflammation of the Dura Mater. Inflammation of the dura mater, as an idiopathic disease, and apart from that of the other cerebral membranes, is very rare, but it is by no means an uncommon circumstance for the dura mater to be inflamed in consequence of injuries to the scalp. It is well known that the cranium is immediately invested with a fibrous membrane called the pericranium, which is the peri- osteum of the skull; and the dura mater, lying between the bony cranium and the arachnoid membrane is, in fact, an internal periosteum. Now, although the pericranium and the dura mater are separated by the cranium, there appears to be a close sympathy or relationship between these two membranes, their anatomical structure being* the same, and a vascular com- munication existing between them through the medium of the cranium. Hence it happens that injuries affecting the external membrane are often followed by disease of the dura mater, and when pus is effused beneath the pericranium a similar effusion occurs between the cranium and the dura mater. A compara- tively slight injury to the outside of the head will thus often be attended with the most serious, or even fatal, consequences ; and I was first impressed with the gravity of such cases when I was a dresser at the hospital to which I was attached. A young woman had received an injury to the head which was by no means apparently of a serious character, and which seemed to doing well under ordinary treatment, when some days after the receipt of the injury the parts became swollen and puffy and the patient became comatose, and died; and after death an effusion of pus was found on the surface of the dura matei. I have seen other such cases since, but the primary injury was of a much more serious character. It is therefore necessaiy to legard all cases of external injury to the head as of great im- portance, considering this anatomical relationship between t le Pericranium and the dura mater.
The early symptoms of inflammation of the dura matei are not, well marked, but those of the effusion of pus 01 lymp 1, which is its consequence, are well known, as they are fiequent y observed in surgical practice, and they result from accidents to the head. They indicate compression of the brain, and are the same in their nature whether they arise from extravasations of blood from natural causes or from external injuries. The patient becomes stupid, sleepy, and lethargic, and falls into the state of what is known as coma, from which he cannot be loused, or only slightly and with very great difficulty; the breathing is heavy and stertorous, the pupils are contracted 01 dilated?sometimes one is contracted and the other dilated ; the pulse is full and strong’ and often slow; the feces are passed involuntarily, and the urine is often retained. When these formidable symptoms are present the chance of recovery is very small.
The present paper being devoted to the inflammatory diseases of the brain and its membranes, the consideration of many other causes of compression of the brain, such as the existence of tumours, the hasmorrhagic effusions of apoplexy, the pressure caused by depressed portions of fractured bone, and many similar conditions, is necessarily omitted. For the same reason, in reference to treatment, the relief afforded by medical or surgical ministrations, in conditions other than those caused by inflammation, is also passed over, and the following- brief remarks on therapeutical management relate in the first place only to cases of inflammation of the dura mater and its consequences.
As an idiopathic disease, I have just remarked that inflam- mation of the dura mater is very rare and is very seldom unaccompanied by disease of the other membranes, and it is perhaps only in the field of surgery (if indeed it exists in that) that such a condition can be recognised. If, however, after the receipt of some injury to the head (and, as has been ob- served, the apparent sliglitness of the injury affords no criterion of the amount of internal lesion) the patient becomes dull, sleepy, and comatose, and exhibits the other symptoms just indicated, the existence of effusion on the surface of the dura mater may be strongly suspected, and remedial measures should be resorted to, although it must be confessed that they are not often of much avail. Cold should be applied to the head, the bowels should be opened by croton oil dropped upon the tongue, perfect rest should be enjoined, and light should be excluded from the patient’s room. The abstraction of blood from the arm may be justifiable with a view of diminishing the amount of that fluid in the brain. But, after all, the only remedial measure which promises relief in such cases, is the removal of the compressing cause, and this can be effected solely by the use of the trephine.
But the difficulties in the way of the successful use of this instrument are various, for, in the first place, the existence of pus or other fluid cannot be determined with certainty, and if it could, its exact situation cannot be fixed ; and it cannot even be proved whether the effusion is on the surface or in the substance of the brain. Mr. Erichsen, in his learned and elaborate ” Science and Art of Surgery,” relates two cases in illustration of these remarks, in both of which there was sup- puration of the brain in consequence of injury to the head, and both were fatal. In one case the trephine was employed by he late Mr. Samuel Cooper, but after death a large amount of thick yellow lymph was found covering both hemispheres, and here was also an abscess in the substance of the brain. In lie other case the trephine was not employed, but an abscess was found in the anterior lobe on the injured side, and there- 01 e if trephining had been performed it would have been useless. Mr. Erichsen alludes to a bold and, as it turned out, successful operation by the celebrated French surgeon upuytren, who, in a case of cerebral injury from accident, P unged a bistoury into the substance of the brain, and thus uckily relieved the patient of an abscess in this situation. A case which in its bold treatment and in its successful results 1Jjals that of Dupuytren has just been recorded by Mr. Hulke, the Middlesex Hospital, at a recent meeting of the Royal 1 edical and Chirurgical Society.* A boy struck his forehead gainst a fence, grazed the skin, and was momentarily stunned, e continued to work, however, for seven weeks, during which lrne he ]lac| some pajn jn ?}ie forehead, and then retching and ‘emiplegia supervened. The frontal bone was trephined at the at ot injury, and a small fissure was recognised in its outer >le. The dura mater seemed healthy. An aspirator-trocar ?mg pushed into the brain, pus rose into the syringe. The 1 scess was opened through the membranes with a knife, ln aU about three drachms of pus were let out. The rieur^j^ recoverec^ but lost the sight of both eyes by optic f ^ connexion with this subject I may allude to the inves- 1 ^’l 10ns now in progress with a view of determining the oca isation of the cerebral functions, and thereby of connecting c 6 existence of definite outward symptoms with local internal ^eie ral diseases or lesions. Interesting as these investigations enVlU evei7 Point ?f view, they will be eminently so if they det -tlle surSeon) in cases of local pressure on the brain, to th 6rmi?e on what point he should apply the trephine, and alUS Je^eve the sufferings of the patient. Some such cases are ‘ leady recorded by French surgeons, and it may be useful to abs 0n ?Specially the following, viz.: Broca, ” Diagnosis of an th’ ^ S1^uated along the region of language: trephining of nilr jfess” (Revue d’Anthropologic, 1876); Lucas-Champion- i . ‘ indications drawn from cerebral localisations for tre- ancPr^ ^le cranium” (Bulletin de VAcademie, 1876) ; Proust rrillon, ” Contribution to the study of cerebral localisa- tions” (Bulletin de VAcademic,, 1876). The views of these authors, however, are by no means undisputed even by their own compatriots, and I mention the matter only to draw atten- tion to a department of surgery and medicine, in connexion with physiology, which cannot fail to be attended, though per- haps only at some future day, by the most useful results. It is, as I have previously observed, very difficult, if not impossible, to distinguish, during life, the symptoms indi- cating inflammation of the brain itself from those denoting inflammation of the membranes; but it is utterly hopeless to attempt any diagnosis between the inflammation of the arachnoid membrane and that of the pia mater. These two last-named membranes are so intimately united together that any cause which gives rise to inflammation in one must necessarily affect the other. But the diagnosis of cerebral inflammation at all has been rendered more difficult than formerly in consequence of the development of our modern and more correct views of pathology, by which it is made manifest that many indications, supposed to denote inflammation of the brain or its membranes, are due only to irritation or to sympathetic disturbance of those structures. The more accurate views now entertained, for in- stance, with regard to typhoid or enteric fever, have already been briefly alluded to as proving that a great number of the cases formerly described as phrenitis, or cerebritis, or brain fever, really belong to the category of specific fevers. Such cases, then, when treated, as they formerly were, by copious depletion, including bleeding and purging, were regarded, if the termina- tion happened to be favourable, as the triumphs of the so-called antiphlogistic treatment; and when the result was unfavourable, it was considered that the treatment had not been sufficiently vigorous, and that enough blood had not been drawn.
I have previously shown that the cases to which the name cerebritis or phrenitis can properly and exclusively be applied, are very limited, and that this disease is really due to only a comparatively few causes.
Inflammation of the Arachnoid Membrane and Pia Mater. The pathological or post-mortem appearances of inflammation of the membranes of the brain are sufficiently well marked; and although they are often associated with those of inflammation of the brain itself, yet they are often capable of distinct limitation. But, again, in consequence of the advances made in modern pathology, it is very difficult to dissociate inflammations of the cerebral membranes from different diathetic conditions affecting the individual; or, in other words, it would be presumptuous to declare that meningitis is ever distinctly an idiopathic disease?that is to say, that it may arise in a person previously quite healthy and free from any constitutional taint. Scrofula, rheumatism, syphilis, are now each proved to penetrate into all he internal organs, and it would be perhaps erroneous to admit 1 hat meningitis exists independently of any of these conditions. However, the appearances after death in meningitis are often ( istinct, and although I do not attach much importance to the mere redness or vascularity of the membranes, yet the results of io inflammatory process may be traced in the presence of adhe- sions, and in the effusion of pus, serum, or lymph. The effusion ?t pus is rare, and when it is observed, it is generally in cases injury or accident to the head, and is then found on the surface of the dura mater. The effusion of serum is very common, but the amount varies exceedingly?from an ounce or Wo to several pints. It must be remembered that there is Naturally a small amount of serous fluid between the mem- .ranes, both of the brain and of the spinal cord, and this cncumstance should be taken into account in determining the appearances characteristic of meningitis. As a consequen&e of e morbid effusion the arachnoid membrane presents an opal- escent appearance, and the fluid runs out when an incision is made into the membrane. The effusion of lymph from the Membranes is very characteristic, and is an indubitable proof lecent inflammation of the arachnoid membrane. This is jsually found at the base of the brain about the commissure ? ? 16 ?Ptie nerves, the pons Varolii, and the medulla oblon- jVl a ‘ but; it is sometimes found in large quantities lying over !e upper surface of the brain or running;* along the course of >?e assure of Sylvius.
eff . n^n8’itis presents two stages?one of invasion, and one of usion ; but sometimes the first stage is insidious in its attack c the symptoms are consequently obscure. But in a typical ase the symptoms of the first stage are well marked, and when n all together they leave little doubt as to the nature of ie affection. The malady commences with rigors, there is tain ‘Pain in tlle llead’ ^tolerance of light and noise, and irri- . jy of temper. In children the disease often begins with violent scream or cry, the head is thrown in various direc- h?nf’ an^ ^ere is sawing of the air with the hands. The bfv,0^ head is increased, and the temperature, as observed hot thermometer, is notably augmented; the skin is dry and anl’k-1^ Pu^se is frequent and strong; the urine is scanty gh-coloured, and the bowels are constipated, or, if they In s*-??ls are pale-coloured and offensive in smell, a dition to these general symptoms, there are the special indications of contraction of the pupils and vomiting. These two last-named symptoms are of the highest importance, and when taken together are exceedingly significant. Each taken by itself is not so important. I have now a case under treatment where the pupil appears to be permanently contracted, and has been so, to my knowledge, for at least two years ; and as for vomiting, it is of course well known that this symptom may arise from a variety of causes quite independently of cerebral disease. But, in brief terms, when there are, together with general inflammatory and febrile symptoms, pain in the head, increase of temperatuie, diminished secretion of urine, absence of the specific characters of typhoid fever, constipated bowels, contraction of the pupils, and vomiting?there can be very little doubt that the patient is labouring under the first stage of meningitis.
After a time, however, these symptoms are replaced by others, the supervention of which tends to confirm the diagnosis. The inflammation results in the effusion of fluid in or upon the membranes, and the patient falls into a lethargic or comatose condition, from which he can be roused with very great diffi- culty, if at all ; the pulse is now full but slow, and the pupils are dilated?and this last symptom, following upon the previous ones, is but too sure an indication of effusion. But not only does this passive condition exist, but various movements of the muscles are observed, especially as the disease advances : there is often squinting, from irregular action of the muscles moving the eyeball; there are often convulsions; sometimes there is rigidity of one of the extremities ; and at last, involuntary dis- charge of the feces and the urine, jactitation, picking the bed- clothes, and other well-known fatal symptoms close the scene. The treatment of this terrible disease is too often unsuc- cessful, but, nevertheless, I am inclined to believe that remedial’ measures are sometimes of very great service, and that, even in apparently desperate cases, a cure may be occasionally achieved. Bearing in mind the diathetic conditions with which meningitis is very often, and indeed usually, associated, it is clear that the treatment must be directed in the first instance to the consti- tutional taint. Thus the rheumatic, scrofulous, and syphilitic diatheses respectively must be treated by colchicum, cod-liver oil and iron, and mercury and iodine ; but when the inflam- mation appears to be idiopathic?which is sometimes, though rarely, the case?the ordinary antiphlogistic treatment will be justifiable and is often successful.
I have given in a former paper (No. II.) a remarkable case, treated by myself, and which I believe to have been one of meningitis in an adult, and in which I practised bleeding to the extent of sixteen ounces with the best results. In this ease the intellect and the speech were impaired, there were convulsions of the limbs, the pupils were contracted, the pulse was full and strong, and the blood drawn was buffed and cupped. The bleeding was followed up bv the administration of calomel in repeated doses, together with saline purgatives, and in a fortnight from the date of the attack the patient was quite well and had no bad symptoms whatever. I attribute the successful result in this case to the early performance of blood- letting ; and I have given several instances, in the course of these papers, showing that this measure, adopted at the com- mencement of the attack, has often appeared to ward off the very serious termination of the disease.
Like the rest of the profession, I have renounced and con- demned, in a very great measure, the practice of bleeding’, but at the same time I still regard it as a very valuable method of subduing inflammatory action, especially when adopted at the very outset of the symptoms. In connexion with this subject, I cannot help adverting to the remarkable case recorded in my last paper (No. IV.), and related to me by the subject him- self, where an army surgeon, recently travelling on a scientific expedition under a burning sun in the desert of Arabia, and having no other surgeon in the company, was suddenly seized with symptoms denoting inflammation of the brain, and had the boldness and presence of mind to open a vein in his own arm, and with immediate relief.
In the early stage of meningitis, therefore, if the symptoms are well marked, if there be an absence of diathetic complica- tions, and if the patient be plethoric, as will be indicated by the pulse, I think that some kind of sanguineous depletion is justifiable?the manner and the amount being regulated by the age of the patient, the degree of toleration, and other collateral circumstances. In adults, bleeding from the arm may be piac- tised, or at least leeches may be applied to the temples ; in the case of children, the latter measure alone will suffice. At^ the same time the head should be kept cool by evaporating lotions, ice may be applied in a bladder, and the patient should be kept in a darkened room, and all noise should be excluded. The bowels should be opened by saline aperients, and calomel should be administered in repeated doses, either in the foim of pills or powders, or by placing the drug itself on the tongue. There cannot be any doubt as to the efficacy of this mercurial ju the cases to which allusion is now made, and more especially in the case of children. It is astonishing how well calomel is borne by this class of patients, both in this and in other dis- eases, and what large quantities may be given, and for a pro- 110 ON” PATHOLOGY AND TREATMENT OF CEREBRAL DISEASE. longed period, not only without bad effects, but with positive benefit. The milder forms of mercurial preparations, such as the hydrargyrum cum creta, are well adapted to the less serious maladies of children, but in the disease now referred to? namely, inflammation of the membranes of the brain?calomel is absolutely necessary, and may almost be considered a sheet- anchor.
By the adoption of the remedial measures now indicated? namely, moderate blood-letting, the use of calomel, and the administration of saline aperients?successful results may often be achieved, and I think it fair to conclude (although this is a matter which does not allow of demonstrative proof) that the supervention of the second stage may be averted.
If, however, the stage of effusion should be reached?as will be only too manifest by the entire change in the nature of the symptoms, the pupils being now dilated, the pulse becoming slow, and the patient comatose?the chance of recovery is very seriously diminished, although all hope must not be abandoned. All depletory measures are now useless, and the only favourable prospect is, that by certain well directed treatment the fluid which presses upon the brain may be re-absorbed and the healthy functions of the organ be restored. Although a suc- cessful result is somewhat rare under these circumstances, yet a sufficient number of well-authenticated cases has been recorded, and I myself have seen such an amount of benefit by the application of therapeutical means, that I think an effort should undoubtedly always be made to save the patient. The remedial measures should now consist in the application of repeated blisters to the nape of the neck, by which the absorp- tion of the effused fluids may be promoted; calomel should be freely administered, though in small doses, such as a grain, and for a considerable time; and iodide of potassium should at the same time be administered regularly three or four times a day, in doses of three or four grains or more. By this treatment the most satisfactory results have been obtained, and even in cases where the termination was eventually fatal, I have myself seen so much temporary benefit achieved as to justify the means employed and to encourage future attempts in the same direction.
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